CoinpltrrucTuts of t7tp, jCLubthov. 
INTERNAL URETHROTOMY: 
ARE THE BENEFITS TO BE DERIVED FROM IT, AS NOW 
ADVOCATED FOR THE RELIEF OF STRICTURE, 
COMMENSURATE WITH ITS DANGERS? 
BY 
AMBROSE T, B ANNTJCY Af D., 
ADJUNCT PROFESSOR OF ANATOMY IN THE MEDICAL DEPARTMENT OF T1IE 
UNIVERSITY OF THE CITY OF NEW YORK. 
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I). APPLETON <(: CO., Publisher*, 1, 3, & 5 Pond St., New Void:. INTERNAL URETHROTOMY: 
ARE THE BENEFITS TO BE DERIVED FROM IT\ AS NOW 
ADVOCATED FOR THE RELIEF OF STRICTURE, 
COMMENSURATE WITH ITS DANCERS? 
BT 
AMBROSE L. KANNEY, M. D., 
ADJUNCT PROFESSOR OF ANATOMY IN THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF THE CITY OF NEW YORK. 
IREPRINTED FROM THE NEW YORK MEDICAL JOURNAL, AUGUST AND 
. SEPTEMBER, 1880.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
1, 3, and 5 BOND STREET. 
1880. ARE THE BENEFITS TO BE DERIVED FROM IN- 
TERNAL URETHROTOMY, AS NOAV ADVOCAT- 
ED FOR THE RELIEF OF STRICTURE, COM- 
MENSURATE AVTTJI ITS DANGERS ? * 
Within the last few years the operation of internal ure- 
throtomy has, in the opinion of many prominent conservative 
surgeons, acquired an undue popularity. Despite the brilliant 
claims urged in its favor (and, if all that is claimed can be 
verified, they certainly are brilliant), and despite the long lists 
of patients who have been induced to undergo the operation 
(and the details of many have been published), the more con- 
servative authors, to whose judicious decisions too much 
weight can not be given, since they must always act as guides 
to the young and often to the old practitioner, fail, as yet, 
even in their latest works, to support or justify the operation, 
save in exceptional cases, whose alarming growth may well 
excite dismay. It seems to me that the time has come when 
the profession, who are too apt to leave what is old and well- 
proven for that which is novel and not proven, should review 
* Read before the New York Academy of Medicine. 4 
the grounds upon which internal urethrotomy has become 
popular, the evils which it aims to cure, and the dangers 
which accompany it; and that they should also accord due 
weight to the opinions of men whose views are entitled to con- 
sideration, before accepting unconditionally a means of sup- 
posed relief, which is attractive from its rapidity and ease of 
execution, but which is not always successful, and, in some 
cases, not without danger. 
Internal urethrotomy is not a new operation. From the 
time of Pare, cutting instruments have been described, and 
modifications of these primitive appliances have, from time to 
time, sprung into existence, each presenting some exceedingly 
slight difference from its predecessor, in accordance with the 
taste and fancy of its advocate. The only essential point of 
difference between them allows, however, of their general 
classification into two kinds of instruments, viz., those which 
divide the urethral wall freely, and those which do not injure 
it severely. 
It is not necessary to discuss here the relative merits of in- 
cisions from before backward or from behind forward, as a 
special aim of some instrument; nor to touch upon the fact 
that, by a previous stretching process before the incision is 
made, the certainty of division is made doubly sure. It is not 
the aim of this paper to discuss what is the best instrument 
for dividing a stricture, but to question the propriety of divi- 
sion, except under such circumstances as, in the general opin- 
ion of the best recognized authors, constitute a justifiable in- 
dication for the operation. 
Sir Henry Thompson,* in reviewing the efforts of Rey- 
bard, in 1855, to popularize incisions within the urethra, says : 
If the stricture be so confirmed that it will not yield to dila- 
tation when carefully applied, a slight notch will not facilitate 
its disappearance; and an extended section of the urethra, if 
required to effect that which other means have failed to ac- 
complish, permits the occurrence of internal haemorrhage and 
urinal infiltration, since the wound has no external outlet; a 
risk which we are not justified in encountering.” 
* “ Brit, and For. Med.-Chir. Review,” October, 1855. 5 
Professor S. D. Gross says : * “ All the methods of treat- 
ment by incision, however carefully or judiciously conducted, 
are liable to be followed by serious or even fatal conse- 
quences.” 
Professor F. J. Gant j* states in his last work: “ I very 
rarely find it necessary to have recourse to internal section of 
the urethra.” 
Professor John Ashhurst J says in his late treatise : “ Ure- 
thral fever is not an infrequent sequel of operations upon the 
urethra ”; and again : “ Gradual dilatation is by far the best 
mode of treating stricture in any instance where it is ap- 
plicable.” 
Mr. John E. Erichsen § says: “ Gradual dilatation is cer- 
tainly the most successful mode of treating ordinary strictures 
of the urethra. Internal urethrotomy is not free from danger. 
The so-called ‘urethral fever,’ if fatal, reveals one of two 
conditions, viz., pyaemia or acute interstitial nephritis. It 
rarely becomes necessary for a surgeon who combines patience 
and skill to have recourse to those more severe methods of 
treatment which have been unduly extolled and too often 
practiced of late years.” 
Mr. T. Holmes,| recognizing the danger of urethral fever, 
discusses its possible prevention by alcohol and laudanum. 
Mr. James Spence, of Scotland, says: “ Internal incision 
of strictures of the urethra has again become fashionable, and 
greatly to my regret. I can conceive no method more uncer- 
tain and dangerous. In any form of division from within the 
canal, the risks of bleeding and infiltration of the urine into 
the spongy texture of the organ must be very great, as there 
is no external wound.” 
In the “System of Surgery,” edited by T. Holmes, Vol. 
IY, p. 972, Sir Henry Thompson again says, speaking of 
internal urethrotomyNo one who is experienced iii the 
* “ System of Surgery,” Philadelphia, 1872, p. 823. 
f “ Science and Art of Surgery,” Philadelphia, 1878, p. 777. 
\ “ Principles and Practice of Surgery,” Philadelphia, 1878, pp. 921, 923. 
§ “ Science and Art of Surgery,” Philadelphia, 1878, pp. 855, 856, 719, 869. 
|| “ Treatise on Surgery,” Philadelphia, 1876, p. 795. 
IF “ Lectures on Surgery,” Edinburgh, 1876, p. 1072. 6 
surgery of the urinary organs can question that unfortunate 
events must sometimes happen.” 
Sir William Fergusson * makes the following statements: 
i( Like all cutting operations, internal urethrotomy is not de- 
void of danger. Deaths have been recorded, besides evils 
from shock, haemorrhage, and other annoyances. I can posi- 
tively state, from my own personal observation, that it is not 
always followed by entire relief from after annoyances, as we 
have been led to expect.”f 
It may be offered as an objection to the statements of au- 
thorities such as these, that writers upon general operative 
surgery are forced, by the responsibilities of their position as 
authors, to err on the side of conservatism; and that those 
who have more exhaustively studied the special department 
of urethral diseases would be our best guides in deciding the 
question. Let us see, therefore, how the statements of such 
authors compare with some of those previously quoted. 
In the last edition of Dr. Bumstead’s work, edited by Dr. 
R. W. Taylor,:]: the following passages may be found: “ Hae- 
morrhage is not infrequently an unpleasant accident following 
operations upon stricture. Internal urethrotomy is not free 
from the danger of haemorrhage for ten days after the opera- 
tion. Curvature of the penis is met with in many instances 
following internal urethrotomy of the penile urethra. It may 
exist to such an extent as to impair or entirely prevent sexual 
intercourse. The multiplicity of means devised to arrest 
haemorrhage is suggestive of the liability of its occurrence.” § 
“ If I had only a ‘ stricture of large caliber,’ presenting no ob- 
struction to the urine and occasioning no inconvenience, no 
argument drawn from possible ills in the future could per- 
suade me to be subjected to the knife, and what a surgeon 
would not have done to himself he has no right to recommend 
to others” 
In reviewing this work from which we have just quoted, 
* “ System of Practical Surgery,” London, 1870, p. 702. 
f The italics are my own. 
\ “Pathology and Treatment of Venereal Diseases,” Philadelphia, 1879, p. 
318. 
§ The italics are my own. 7 
“ The New York Medical Journal ” of February, 1880, 
says : “ It is to be hoped that the following words [those 
above quoted] will sink into the hearts of those callow 
young men who are itching to introduce a urethrotome into 
every urethra whose owner is so unlucky as to fall into their 
hands.” 
Sir Henry Thompson, although in a work published in 
1854,* states that “dilatation is the most desirable treatment 
to employ, whenever the case will admit of it ”; and he has not 
as yet receded from this view. 
Professor Samuel D. Gross, in a work renowned for its 
scholarly compilation,! states : “Notwithstanding the various 
attempts that have been made to supersede dilatation, and 
the reproaches that have been cast upon it by different writ- 
ers, it still maintains its place in the estimation of enlightened 
practitioners; and there can be no doubt that it is more fre- 
quently applicable than any other plan yet devised.” He 
has not in his later works, to my knowledge, materially altered 
his views. 
. Dr. J. W. S. Gouley, a careful and experienced operator, 
states in his work upon this subject: ! “ I only resort to inter- 
nal urethrotomy in intractable strictures of the ante-scrotal 
portion of the canal. . . . Success depends more upon the skill of 
the surgeon than upon the instrument he uses. Haemorrhage 
is apt to follow deep incisions ; likewise infiltration of urine, 
abscess, and ‘pyaemia may supervene upon the merest scarifi- 
cation.” § 
Professor William H. Yan Buren, in his late work, || thus 
expresses the results of his experience: “ Cutting operations are 
growing daily in favor, yet, in the case of uncomplicated stric- 
ture, no matter how tight it may be, provided it does not 
prove resilient and is not of traumatic origin, if any instru- 
ment at all can be passed, dilatation is still the best method of 
treatment.” 
* “ Jacksonian Prize Essay on Stricture of the Urethra,” London, 1854, p. 173. 
f “ Treatise on the Urinary Organs,” Philadelphia, 1855, p. 778. 
| “ Diseases of the Urinary Organs,” New York, 1873, pp. 83, 93. 
§ The italics are my own. 
| “ Treatise on the Surgical Diseases of the Genito-Urinary Organs,” Van 
Boren and Keyes, New York, 1874, p. 153, 8 
Mr. William Acton * concurs in these statements, as fol- 
lows : “ Dilatation is the plan of treatment the most generally 
applicable, and which most frequently succeeds.” 
Professor E. L. Keyes, in the latest work which has ap- 
peared upon this subject,f says : “ Deep - seated strictures 
should not be cut internally, for the double reason that, (1) 
Cutting in this region is a proceeding dangerous to life; (2) 
cutting in this region does not effect a radical cure.” 
It seems unnecessary to further quote authorities to sus- 
tain the first objection that I raise, viz., that the frequent em- 
ployment of internal division of strictures is unnecessary, 
since other means can be generally employed. Such universal 
condemnation of the unrestricted use of an operation that has 
long been before the profession, and which has had in the past 
its full share of criticism and support, would seem sufficient 
to the medical reader of the present day to establish this prop- 
osition, were not elements at work which have fanned the 
flame, and once more threaten the abuse of an operation which 
is valuable only within its proper limits, and consequent in- 
jury to many of its prospective subjects. Let us examiue, 
therefore, in discussing this question : 1. What are the ele- 
ments of its present popularity? 2. What are its dangers? 3. 
What are its benefits ? 
A. Its Elements of Popularity.—It would be an injus- 
tice to the valuable researches of one of our own city X to fail 
to recognize that largely by his efforts in the past twelve 
years has internal urethrotomy been pushed to the front in 
this country as an improvement upon dilatation in the treat- 
ment of urethral stricture. Too much credit can not be given 
to him who has done so much to prove that the normal ure- 
thral caliber has been greatly under-estimated, and that an ap- 
proximate relation exists between the circumference of the 
penis and that of its canal. He has shown great ingenuity in 
devising instruments ; and a proper appreciation of existing 
urethral conditions can perhaps be gained better by his methods 
* “ Treatise on the Diseases of the Urinary and Generative Organs,” New 
York, 1853, p. 96. 
f “ Venereal Diseases,” New York, 1880, p. 305. 
\ Professor F. N. Otis, “ Treatise on Stricture,” New York, 1878. 9 
than by those previously existing. I can not, however, refrain 
from quoting the following passage from a work which has 
lately appeared,* with which I am in the fullest accord : “ I 
have raised my voice for what it may be worth in protest 
against the views of the new school in urethral pathology, 
which seems to claim that every natural undulation in the tis- 
sues of the pendulous urethra is a stricture fit for cutting, and 
that all the ills of the genito-urinary passages may be ac- 
counted for by the existence of these undulations, and usually 
made to disappear when the latter are cut. The theories of the 
new school are as ingeniously perfect as the instruments which 
carry them out; but, unfortunately, its claims seem to leave 
out of view that the disease for which the patient seeks relief 
is only a symptom; and that such symptoms may be due to a 
variety of causes. What will cure a symptom in one case, 
will not necessarily do so in another. And a serious criticism 
upon the methods of the new school is that it does not gener- 
ally, in its list of published cases, give any prominence to those 
cases which have been cut without relief f of the symptoms 
complained of.” 
I can not myself agree with the advocates of this school 
that a meatus which is not accompanied by pockets on the 
upper or lower wall of the urethra should ever be divided to 
permit the introduction of instruments which shall correspond 
in point of size with the somewhat arbitrary measurement of 
the capacity of any individual urethra ; nor have I ever been 
convinced that a radical cure of the stricture is always in- 
sured by the urethrotome, or that the symptoms do not, in a 
certain proportion of cases, remain after the operation, unless 
treatment by other methods is used in conjunction. Unless 
these two latter tenets can be fully maintained, the urethro- 
tome must be considered as capable of being judiciously used 
only in a somewhat restricted number of cases. The chief ad- 
vocate of this operation has himself, I think, met with a few 
cases in latter years where his operation (performed by him- 
self) has been followed by a return of the stricture ; and many 
where certain symptoms for which the operation was performed 
were not relieved. 
* Keyes, op. cit. f The iralics are my own. 10 
The use of the dilating urethrotome has been popularized 
by the claim of its advocates that it surpasses in its results 
the treatment of stricture by dilatation, in the following re- 
spects : 1. That it accomplishes, what other operations do not, 
a radical cure of stricture ; '2. That it relieves certain symp- 
toms far more effectually and rapidly than any other method 
of treatment; 3. That it is easily and quickly performed, 
when the details in the use of the instrument have been mas- 
tered ; 4. That it is comparatively free from danger. These 
points summarize, in a general way, the main arguments in 
its favor which the profession are asked to accept; and it is 
not to be denied that the propositions, as above stated, have 
met with a more ready acceptance than the facts, in my opin- 
ion, seem to warrant. 
Within the last few years the chief advocate of this meth- 
od has been able to publish between six and seven hundred 
operations of his own (although details were given in only 
236 cases), and nearly as many more * which have been com- 
piled from the case-books of two or three of his supporters 
(Pease, Browm, and Mastin). 
Such an enormous number of operations—over 1,300—from 
so few sources, would in itself suggest that, if the operation 
has been justified, the general public has in the past been 
wofully neglected by the surgeons. But, when wTe take into 
consideration that the instrument makers are selling this in- 
strument to nearly every new graduate in medicine, w7ho are 
often only too anxious to test its merits and equal their prede- 
cessors in the number of cases reported, the conservative ele- 
ment may wTell question if by its indiscriminate use surgery is 
not rapidly being brought into disgrace, and if those wTho are 
now the advocates of the indiscriminate use of this operation 
will not, in time, regret the haste with which they accepted 
or prejudged its merits. 
B. Its Elements of Danger.—Internal urethrotomy has 
been followed, from the statistics of collected and reported 
cases, by the following bad results: 1. Death from uraemia ; 
2. Death from pyaemia; 3. Death from shock; 4. Infiltration 
of urine; 5. Peri-urethral abscess; 6. Severe haemorrhage; 7. 
* Italics my own. 11 
Cystitis ; 8. Epididymitis ; 9. Urethral fistulae ; 10. Deformi- 
ties of the penis ; 11. Impotence ; 12. Atrophy of the penis ; 
13. Gangrene of the penis ; 14. Prostatic abscess ; 15. Acute 
urethritis; 16. Gonorrhoeal rheumatism; 17. Phlegmasia alba 
dolens. 
Before considering these results in detail, let us fortify our 
opponents by the published results of their own cases, which 
are supposed to support their views, and encourage others to 
subject future patients to a like proceeding when any diminu- 
tion in the urethral caliber, no matter how slight, can be de- 
tected. Dr. Otis, in 1875, published his first hundred cases. 
An analysis of these cases shows the following accidents to 
have arisen: 
Haemorrhage in 4 cases. 
Rigors “ 6 “ 
Deformities of the penis from curvature “ 3 “ 
Prostatic abscess “ 3 “ 
Diphtheritic exudation “3 “ 
Retention of urine “ 1 case. 
Necessity for perineal section after operation “1 “ 
“ “ aspiration of the bladder “1 “ 
Acute urethritis “ 2 cases. 
Gonorrhoeal rheumatism “ 1 case. 
No deaths were recorded. 
In the second series of cases (one hundred and thirty-six in 
number), published in his work,* the following accidents oc- 
curred : 
Haemorrhage in 8 cases. 
Rigors or urethral fever “ 11 “ 
Suppression of urine “ 1 case. 
Deformity of the penis from curvature “ 6 cases. 
He also reports two fatal cases where the dilating urethro- 
tome was used in connection with perineal section, and two 
others where internal urethrotomy was alone performed. 
One of these patients died of pyelo-nephritis and renal abscess on the 16th day 
The second died of suppression of urine and uraemia on the 3d day. 
The third “ “ “ “ on the 6th day. 
The fourth “ “ “ “ on the 8th day. 
Professor Pease, of Syracuse, reports a freedom from ac- 
cidents which is rather remarkable, even when compared with 
* Otis, op. cit., pp. 311, 317. 12 
the cases above recorded, bat he still acknowledges to have 
had one severe case of urethral fever and two cases of severe 
haemorrhage. 
It may strike those who attempt to analyze the reported 
cases of Dr. Otis, Dr. Pease, Dr. Mastin, Dr. Brown, and 
other advocates of the dilating urethrotome, that haemorrhage 
is not more frequently reported, but a foot-note in Dr. Otis’s 
volume, on page 280, explains that “ haemorrhage is not enu- 
merated as one of the accidents, unless, in spite of ordinary 
measures used to control it, an excessive quantity of blood 
is lost.” (The italics are my own.) If “ ordinary measures ” 
mean the urethral tube, the cold-water coil, the perineal 
crutch and tourniquet, etc., perhaps to others unprovided with 
these appliances a haemorrhage might occasion anxiety, which 
to them would seem trivial. 
It seems also, from the published statement of Dr. Otis, 
page 277, that cases operated upon by him for other surgeons 
have not been included in his list of reported cases. This is 
to be regretted, as I have received from others during the last 
few years general statements of bad results, which are of 
course useless as scientific facts, but which should have been 
given to the profession, if the volume was to embody all the 
facts, and thus enable physicians to judge intelligently of the 
demerits as well as the merits of the operation. 
It would seem that I am not alone in this opinion. Dr. 
Sands, in a pamphlet (1879), facetiously remarked that “ it 
was sometimes hard to reach fatal or disastrous cases, which 
were often considered a kind of private property of the own- 
er.” In our city hospitals cases have occurred within the 
last few years which have been followed by serious conse- 
quences, if the personal statements of others can be relied 
upon, but I find no published record of many wdiose details 
would be of value. Dr. Keyes, in a passage previously quoted 
from his latest work, seems to convey the impression that, in 
his opinion also, the reports of the cases operated upon with 
the dilating urethrotome do not fairly represent the dangers 
which may ensue. Until more care is exercised in the record- 
ing of hospital cases, and until, in some way, they can be 
published in full for professional inspection, it will be more 13 
than difficult to accumulate accurate statistics of any of the 
later methods of treatment. It has proven difficult with my- 
self to find a sufficiently large list of cases upon which the 
dilating urethrotome has been employed, to properly verity 
the frequent occurrence of the other dangers which have been 
mentioned as liable to happen. But, as the new instrument 
only insures a more reliable and possibly as deep an incision 
as those of Civiale, Maisonneuve, Voillemier, Charriere, Bey- 
bard, Peters, and the host of others, the unfortunate results 
even of the distant past can still be justly regarded as a guide 
for the future; since no element lias been introduced by the 
“ new school ” to lessen the possibility of danger. 
Although, in these three hundred cases reported by Dr. 
Otis, but four cases of death have occurred, still fatal results 
have been known to follow this later method of treatment, in a 
relative proportion which is vastly greater, where the opera- 
tion has been performed by skillful hands. 
Professor Sands, of New York, in a pamphlet published in 
1879, says: “I have heard of a number of cases where death 
has resulted from the employment of the dilating urethrotome. 
... I can state with authority, however, that three fatal cases 
of operation with the dilating urethrotome have lately hap- 
pened in our city hospitals, two of which occurred last week 
in one hospital. ... In two of these cases death took place 
from pyaemia within a week of the operation. In the third 
case, death occurred from uraemia on the sixteenth day after 
the operation, which was performed for the division of an an- 
terior stricture which was so slight as to be detectable only 
with a bulbous sound, No. 21 F.”* 
Mr. Berkeley Hill f summarizes the results of sixteen cases 
operated upon by him with the dilating urethrotome as fol- 
lows : The operation was serious in two instances. One 
patient had alarming haemorrhage. Three had severe rigors. 
In eleven cases the gleet persisted. Abscess of the buttock ap- 
peared in one. Orchitis appeared in one. In only five was 
the operation successful. In four, bleeding continued for sev- 
eral days. 
* The italics in these quotations are mine, 
f “ The Lancet,” April 8, 1876. 14 
It is but just to Dr. Otis, as the chief advocate of this 
method, to say that he explained, in a later publication,* cer- 
tain facts which may have accounted for the bad showing, 
but, if the operation is unsafe in the hands of good surgeons, 
unless specially experienced in its performance, is it not proper 
that the general profession be warned against attempting it ? 
Let us look again at other results of this method, as re- 
ported, before we investigate the previous results of ure- 
throtomy. 
In Dr. Sands’s pamphlet f the following passage will be 
found: “ I have frequently seen the operation of slitting the 
meatus carried to such an extent that the patient was unable 
to project the stream of urine in a natural manner; and I 
know of a case in which an eminent surgeon was obliged to 
perform a plastic operation to restore a meatus that had thus 
been destroyed. I have seen, in consultation, persons who 
have suffered from troublesome haemorrhage, varying in dura- 
tion from a few days to a month, in consequence of having 
been cut with a dilating urethrotome.” 
In 1876, as I am informed, a case was operated upon in 
one of our hospitals, which resulted in internal haemorrhage, 
which completely filled the bladder, and the expulsion of 
eighteen ounces of clotted blood took place on the withdrawal 
of a catheter of large size, some days after the operation. The 
patient recovered, but the stricture returned within a few 
months. In 1870 I myself witnessed an operation in one of 
our hospitals, with which I was at the time connected, which 
resulted in gangrene of the penis, due to infiltration of urine, 
and which was followed by death.:{; In 1876 I performed 
division of a stricture which was too firm to admit of dilata- 
tion, and the patient died of total suppression of urine in 
sixty-seven hours after the operation. I had many months 
previously performed the same operation upon him without 
any bad symptoms following, but the stricture had returned 
to even a worse condition than when first seen.§ 
* “ The Lancet,” June 3 and 10, 1876. 
f “ A Reply to Dr. Otis,” New York, 1879. 
t “ Bellevue Hospital Reports,” 1870. 
§ “ The New York Medical Journal,” May, 1880. 15 
Dr. Banks, in his report of three fatal cases after attempts 
to pass an instrument through very tight strictures, attributes 
the accident chiefly to shock, since uraemic symptoms were 
absent; * but it is a question, as the instruments passed were 
of very small size, and therefore of necessity sharp at the 
point, if in at least one of the cases some injury was not done 
to the urethra differing but little from an incision. Within 
the last year I saw in consultation a case where atrophy of the 
penis and impotence appeared after internal urethrotomy, fol- 
lowed by severe haemorrhage; but I am not prepared to say 
that it was attributable to the operation, although no other 
cause could be ascertained, and the patient had, previous to 
the operation, been in good health, excepting in regard to the 
frequency of micturition.f He has since died of renal disease. 
In two fatal cases reported by Bumstead,J the strictures were 
situated at about four inches from the meatus, and death en- 
sued from septicaemia in four and fourteen days, respectively. 
In these cases the Otis urethrotome was employed. Dr. Brid- 
don § reports a case of death from internal urethrotomy, per- 
formed with the instrument of Maisonneuve, as a result of 
suppression of urine. Benal disease, however, existed prior 
to the operation. 
One of our leading surgeons lately lost a patient, in hos- 
pital practice, after internal urethrotomy. The details of the 
case have not been published. 
Another well-known surgeon of this city lost a patient in 
another hospital, after an operation with a Maisonneuve in- 
strument. M. Guyon, of Paris, in the published results of 
internal urethrotomy in 1876, 1877, 1878, reports one case of 
death in a total of fifty-two cases, but he has since reported a 
total of two hundred and fifty cases, with seven deaths. 
Mr. Prescott Hewett,|| in 1863, reported a case of death 
from suppression of urine, following instrumental manipula- 
tion which drew blood. Mr. Teevan reports, in 1876, three 
* “Edinburgh Medical Journal,” June, 1871. 
\ “The New York Medical Journal,” May, 1880. 
\ Op. cit., p. 809. 
§ “ The Medical Record,” March 6, 1880. 
§ “The Lancet,” 1863, vol. ii. 
T Ibid., 1876. 16 
cases of death in the Hopital Necker, following internal ure 
throtomy. Leroy d’Etiolles, in reviewing Reybard’s cases, 
reports having witnessed two fatal cases at the Hotel Dieu 
and one case of the most alarming haemorrhage, which caused, 
serious doubts as to the patient’s recovery.* Dr. Gouley re- 
ports a fatal case, and one in which thrombus of the iliac vein 
and phlegmasia dolens followed the operation of internal 
urethrotomy. Dr. Otis, f as before stated, reports four cases 
of death as occurring in his own practice. Three of the pa- 
tients died on the third, sixth, and eighth days after the opera- 
tion, of suppression of urine and uraemia, while one died on 
the sixteenth day of pyelo-nephritis and renal abscess. In two 
of these cases, however, perineal section was combined with 
the use of the dilating urethrotome; so that an additional 
source of danger existed. 
It seems, from collected statistics, that sixty-six deaths 
are already verified as the result of internal urethrotomy, and 
that the possibility of the other dangers enumerated as liable 
to follow this operation is supported as well by Professor Otis’s 
reported cases as by the opinions of those against whom the 
claim of prejudice might be urged. I can not refrain from 
quoting the following sentence from the article of Mr. W. 
Mitchell Banks,:}: commenting on the dangers of the use of 
instruments within the urethra : “ When a patient, the victim 
of some grievous malady which is hurrying him to certain 
death, prepares to submit to a hazardous operation lor its re- 
lief, both he and the operator have weighed the chances of the 
operation over and over again. If the operation succeed, it is 
a triumph to both; if it fail, the surgeon can console himself 
with the fact that he did all that his skill enabled him to do, 
while he may derive, from his very failure, practical experi- 
ence which may guide him to happier results in the future. 
But it is a very different matter when a man, perhaps in the 
prime of life, and, with the exception of a mere local ailment, 
in good health, lies down upon the consulting-room sofa or the 
hospital bed, submits to a comparatively simple operation, has 
* Wade, “On the Treatment of Stricture,” London, 1860. 
f Op. tit., p. 811. 
\ “Edinburgh Medical Journal,” vol. xvi, 1871, p. 1078. 17 
a rigor, and is dead within twenty-four hours. That such is 
not an overdrawn picture the case just narrated proves ; and 
the melancholy feature is that, in spite of all ordinary precau- 
tions, we can not always guard against such accidents.” 
I am well aware that such fatal accidents can not be used 
as evidence that the operation of internal urethrotomy should 
not be performed. All surgical operations have a percentage 
of risk that the patient and the operator should both appre- 
ciate. But the point which this portion of the paper aims to 
impress upon the profession is this, viz.: That the operation 
of incision into the walls of the urethra greatly increases the 
'percentage of danger, when compared with the results of dila- 
tation ; and that the proportion of those complications which 
have been enumerated to the total number of patients cut is 
relatively greater than is usually supposed. 
It is difficult to obtain the percentage of danger in the 
treatment of strictures bv dilatation, as any form of complica- 
tion is extremely rare—so rare, indeed, that the twelve deaths 
from catheterism, reported at different times in the leading 
journals, would he lost sight of in the thousands of cases in 
which relief has been afforded the patient without any un- 
pleasant consequenceshaving arisen. I can state that, within 
the last ten years, I have treated at least two hundred cases of 
marked stricture by dilatation alone, and that I have never 
known but five cases wdiere a chill, abscess, orchitis, or other 
complication occurred. Possibly my results have been un- 
usually fortunate, but I think the statistics, if all the cases of 
successful dilatation could be gathered together, would show 
the percentage of danger reduced almost to the minimum; 
that the process of dilatation, if gently and skillfully practiced, 
will relieve most of the cases; and that the symptoms will be 
arrested without anxiety to the surgeon or the patient. 
C. The Benefits Claimed.—From the published state- 
ments of the advocates of the dilating urethrotome, the follow- 
ing premises seem by them to be considered as fully proved : 
1. That “gleet is the signal which Nature holds out to 
indicate the existence of urethral stricture ”; and that by the 
removal of the cause the only means of radical cure of this 
symptom is insured. 18 
2. That certain obscure symptoms, among which may be 
mentioned neuralgic pains in the pubic region, the back, the 
rectum, the testicle, and the lower limbs, are reflex in charac- 
ter, and are likewise dependent upon urethral stricture, in a 
large proportion of cases. 
3. That all methods of treatment of urethral stricture save 
incision have been found worthless as a means of radical cure. 
4. That the dilating urethrotome does effect a radical cure 
of the stricture, and that the symptoms dependent upon -the 
latter are likewise relieved in the majority of cases. 
5. That the operation advocated is comparatively free 
from danger, and that the benefits derived from its use rec- 
ommend it to the medical profession, to the exclusion of the 
older methods of treatment. 
6. That the records of published cases in which the urethro- 
tome has been used support each and all of these conclusions. 
It is impossible, within the compass of one single article, 
to discuss whether the flrst three of these propositions can be 
fully established. The causes and treatment of gleet are ques- 
tions which to-day are certainly open ones, and cases are re- 
ported of its cure by other methods of treatment as well as by 
the use of the urethrotome. The flrst proposition, in itself, 
involves the great and undecided question of what constitutes 
a stricture, and until the profession can agree upon this point, 
it is useless to attempt to discuss it. Those who claim that 
the normal urethral caliber is not impaired, provided an in- 
strument corresponding to 23 or 24 F. can readily be passed 
to the bladder, and that all apparent constrictions detected by 
larger instruments are mere undulations in the urethral walls, 
not dependent upon disease, can unquestionably present cases 
not in accordance with this view. Thus, Sir James Paget 
says: “ Every year teaches me more and more plainly that a 
very large number of cases of stricture of the urethra are not 
really dependent on any flxed condition of the urethra, but 
are mere swellings of the mucous membrane.* Such an opin- 
ion from so prominent an authority can not be hastily set 
aside. 
The second proposition opens again for discussion the great 
* “Clinical Essays and Lectures,” London, 1875. The italics are my own. 19 
question of reflex irritation and its various manifestations. 
That such conditions do exist, no one at all familiar with the 
literature of the subject can deny, although “sexual hypochon- 
driasis’’ may account for a large proportion of imaginary 
symptoms, which are to be distinguished from those due purely 
to reflex irritation ; but, when symptoms referred to parts dis- 
tant from the urethra are interpreted as dependent upon ure- 
thral constrictions of large caliber, not impeding the flow 
of urine, and are made the indication for a cutting operation 
which is not infrequently followed by serious, complications, 
the advisability of such a procedure may well be questioned. 
Of the second series of operations reported by Dr. Otis (136 
in number), 78 were performed for the cure of gleet, and 48 
for the relief of reflex troubles. It inav well be asked, if self- 
questioning is of any value in determining our actions toward 
others, how many of us who are here assembled would have 
our urethra cut for pain in the back, pubes, perinseum, rectum, 
or legs, until we had exhausted every other means of relief 
which had ever proved successful in the cure of such condi- 
tions ? 
Let us see what have been enumerated as reflex troubles in 
59 cases of this character, appended to this paper,* where ac- 
cidents have followed the operation of internal urethrotomy : 
Frequent and painful micturition in 15 cases. 
Seminal emissions “ 4 “ 
Premature emissions “ 3 “ 
Neuralgic pains in distant parts “ 5 “ 
Imperfect erection “ 2 “ 
Spermatorrhoea.,.. “ 1 case. 
It may not seem out of place to ask if such conditions have 
not frequently been seen by many of ns, who have cured them 
by simple measures rather than by recourse to the knife. All 
these methods may have been tried even in these cases pre- 
vious to the operation, but no such statement is made, nor can 
I see how the cure reported of these symptoms carries any 
positive evidence either for or against the use of the operation 
in preference to other and simpler means of relief. 
The third proposition, which denies the possibility of cur- 
* As read before the Academy. 20 
mg stricture by any other method, is one well worthy of dis- 
cussion. To my mind, more importance lias been attached by 
the advocates of this new method of treatment to the possinil- 
ity of the return of stricture than the histories of cases seem 
to warrant. In a few occasional instances, strictures do mani- 
fest a quality which is called resiliency, and which is evidenced 
by a tendency to return to their former caliber almost at once 
after the withdrawal of a dilating instrument. Such cases as 
these, as is evident to any reasonable mind, can not be bene- 
fited by dilatation, and must continue to produce their own 
symptoms until by incision or rapture their elasticity is de- 
stroyed. Strictures of traumatic origin, which are usually 
indurated and cartilaginous in type, often fail to yield to the 
most persistent efforts to dilate them, and, even if fully dilated, 
are with difficulty kept from re-contraction by the occasional 
passage of an instrument. In the majority of instances, how- 
ever, the ordinary forms of stricture, which result from inflam- 
matory conditions of the urethra, are easily dilated, and can 
be kept free by the occasional passage of an instrument by the 
patient himself, in case a tendency to re-contraction is antic- 
ipated. From my own experience, and from that of others 
who have practiced this system of treatment in a much larger 
number of cases and for a much longer period of time, I have 
never had any reason to doubt that a certain proportion of 
cases have been completely cured by dilatation, while in others 
the tendency to re-contraction was so slow that the patients 
were relieved from all symptoms for a long period of time, 
even where instruments were not introduced at intervals to 
prevent the return of the trouble. 
The advocates of urethrotomy, however, lay great stress 
upon the annoyances which must arise from the necessity of a 
constant passage of instruments at stated intervals by the pa- 
tient or by the surgeon, and contend that a means, even if it 
has dangers, which will insure a radical cure, would be ac- 
cepted by intelligent patients in preference to a method of 
treatment which required future care and attention to the dis- 
eased part. This objection, to my mind, appears to be in op- 
position to reason, provided the patient feels assured that, by 
a process which has few if any dangers associated with it, the 21 
symptoms for which he seeks relief can be effectually con- 
trolled by the passage of an instrument at intervals of seven or 
fourteen days after dilatation is once accomplished. On the 
same ground, it might as well he argued that persons who did 
not desire the growth of a beard would prefer the operation 
of depilation to the occasional annoyance and expense of 
shaving. 
The aim of all forms of treatment is, principally, to relieve 
the symptoms which are distressing the patient, and I have 
never found, from personal observation, that patients would 
not willingly and joyfully accept a means of relief in which 
the dangers were slight and no privation from business was 
required, in preference to one where the complications might 
be distressing and where confinement to the house was an 
absolute necessity. Unfortunately for the sake of the argu- 
ment, the advocates of dilatation, not feeling the great neces- 
sity of convincing the profession of the possibility of a radical 
cure, have not reported as fully as might be wished the cali- 
ber of the strictures which they were called upon to treat and 
the results of a subsequent examination ; but I think it can 
be positively stated, that, in some instances at least, strictures 
of the urethra have, by constant dilatation, been entirely cured, 
through an absorption of the inflammatory products in or 
around the urethral walls, to whose contraction the urethral 
constriction was originally due. 
The fourth proposition, that the dilating urethrotome does 
effect a radical cure of strictures of the urethra, I am prepared 
to accept—with the proviso that this method, like the one 
whose merits have been previously argued, will also occasion- 
ally be found to fail in accomplishing permanent relief. I 
am inclined to think that, perhaps in a proportion of cases even 
larger than dilatation can present, prevention of re-contraction 
follows the use of the urethrotome; but even this admission 
hardly seems to me sufficient to justify the use of this instru- 
ment, except in such conditions as are associated with symp- 
toms which a prolonged and careful trial of the treatment by 
dilatation has failed to arrest. I do not think that any circum- 
stances, no matter how serious, should justify a surgeon in 
resorting to internal urethrotomy when the stricture is situ- 22 
ated more than four inches from the meatus, since external 
section affords a better prospect to the patient. In almost all 
the cases reported where serious consequences have followed 
the use of the dilating urethrotome, the situation of the stric- 
ture has been below that point. Rigors, severe haemorrhage, 
urethral fever, and urinary infiltration are much more liable 
to occur when an incision is made in the deep urethra than 
when it is made anterior to the peno-scrotal junction. 
Robert Wade * takes positive issue with the advocates of 
the urethrotome, in the following sentence : “ It is well known 
that internal division of strictures was fully tested in England 
by Guthrie and Stafford, who lately acknowledged its hazards, 
and were so much disappointed with the little permanent re- 
lief which it afforded, that they were ultimately induced to 
abandon the practice, except in cases of emergency. Should 
the views which I have advanced induce others to hesitate be- 
fore they resort to the more hazardous method of* treatment 
which has lately been too prevalent, it is to be hoped that my 
labors in this branch of the profession may prove useful in 
saving many patients from the risk incurred by them from 
operations not infrequently fatal, and which, I feel convinced, 
are seldom required.” 
The fifth proposition, that the operation with the urethro- 
tome is comparatively free from danger, has been quite ex- 
tensively discussed in previous pages of this article. It is, 
however, with great interest that I present, in addition to the 
statistics before mentioned, an analysis of the essay of Dr. W. 
Gregory,f which has created no little comment in some of the 
leading journals of Europe. Dr. Gregory, in summing up the 
cases of internal urethrotomy collected by him, says: “ In adding 
the total of the results obtained from different statistical reports, 
we arrive at a grand total of 872 cases, with 38 deaths; and, 
if the cases from the records of the Hospital of St. Andre be 
added, we have a total of 915 operations, with 46 deaths; giv- 
ing a mortality of five per cent.” In his paper I find some of 
the fatal cases which I report omitted, while, on the other 
* Wade, “On the Treatment of Stricture,” Preface, London, 1860. 
f “ De la Melhode Sanglante dans les R6trecissements de l’Urethre,” Paris, 
1879. 23 
hand, lie gives the records of many eases which it would oth- 
erwise have been impossible for me to reach. 
From the same essay other deductions may be drawn, as 
follows: 1. The proportion of fatal cases to the total of re- 
eorded operations with the urethrotome has been under-esti- 
mated by the profession at large, and almost equals that of 
perineal section ; 2. The other accidents which may accom- 
pany the operation are often most alarming, especially that 
of haemorrhage; and the statistics offered by European sur- 
geons show a much more serious list of dangers than the re- 
ported cases of some American surgeons would indicate ; 3. 
The comparative freedom from the dangers of haemorrhage 
and urinary infiltration presented by perineal section, and the 
nearly equal percentage of mortality with which the opera- 
tion of internal urethrotomy seems to be associated, are lead- 
ing the thinking men of our profession to question if internal 
incision within the deeper portions of the urethral canal should 
ever be performed. 
From a close analysis of those reported cases where the 
facts are given in sufficient detail to allow of any positive de- 
ductions being drawn, I summarize the results of internal 
urethrotomy as follows: 
In the 240 cases which Dr. Otis * reports as operated upon 
by himself, and in all but four of which full details are given, 
we find that 
Haemorrhage occurred in 5'5 per ceut. 
Rigors or urethral fever “ 7 “ “ 
Deformity of the penis from curvature “4 “ “ 
Death in about 2 “ “ 
In the 43 reported cases of the Hospital of St. Andre, the 
details of which are fully given by Gregory : + 
Haemorrhage occurred in 36 per cent. 
Urethral fever ; “ 59 “ “ 
Rigors “ 36 “ “ 
Abscess “ 9'5 “ “ 
Infiltration of urine “ 14 “ “ 
Retention of urine “ 16 “ “ 
Death in nearly 20 “ “ 
* Professor T. N. Otis, “Treatise on Stricture,” New York, 1878. 
f Op. cit. 24 
In the 68 reported cases of the Hospital of the University 
College, the details of which are also given by Gregory, we 
find that 
Haemorrhage (severe) occurred 
in 7 per cent. 
Urethral fever and rigors 
u 20 • “ “ 
Abscess (perineal) 
“ 11 “ “ 
Curvature of the penis. . . 
u 4 u « 
Abscess (lumbar) 
u u u 
Orchitis 
a 4 u u 
Pvelitis 
a g u a 
Cystitis 
“ 6 “ “ 
Death 
“ 5-75“ “ 
The fatal eases (sixty-eight in number) collected from the 
statistics of Dolbeau, Maisonneuve, Guy on, Voillemier, Gos- 
selin, Sedillot, Reybard, Barbosa, Tillaux, Labat, Sentex, Lan- 
nelongue, Otis, Bumstead, Van Buren, GoulSy, Stein, Denuce, 
and others, show the average proportion of deaths to be about 
5 per cent. 
The records of those cases where serious accidents or com- 
plications have followed the operation of internal urethrotomy, 
show a rapidly increased percentage of such accidents in opera- 
tions performed below three inches from the meatus. Cases of 
haemorrhage, where this operation has been done at the office, 
and the patients sent to their homes, are becoming so frequent 
in this city that surgeons are constantly having they* attention 
called to them.* 
The personal statements of some of our leading surgeons, 
lately made to me, confirm the experience of myself and 
others, who have been alarmed at the haemorrhage which some- 
times occurs; and several have assured me that, for this very 
reason, they now hesitate to cut unless compelled to do so. 
The occurrence of urethral fever seems to be much more 
frequent in Europe than in this climate; but rigors are a very 
common sequel of the operation, even in this country. This 
sequel may not always possess a great clinical significance, 
* After this article was written, an ambulance brought into one of our city 
hospitals a patient who was with some difficulty saved from death from htemor- 
rhage, where this operation had been performed in a dispensary, and the patient 
sent home without attendance. Had his condition not been accidentally discov- 
ered, he would have bled to death alone in his rooms. 25 
but I question it‘ a severe chill, when dependent upon a sur- 
gical procedure, does not always create anxiety in the mind of 
a careful surgeon, since it may indicate the commencement of 
some serious complication. 
The deformity of curvature of the penis is often spoken of 
by the advocates of urethrotomy as a trivial and temporary 
annoyance, and of but little consequence; but, in my experi- 
ence, it sometimes proves permanent, and always creates a 
feeling of annoyance and disgust on the part of the patient, 
which it is difficult to appease. I have collected from private 
case-books in this city the records of some 200 operations which 
have never been reported. I find by analyzing them that a 
large percentage of patients have been cut for what have been 
diagnosticated as reflex troubles, such as lumbago, sciatica, 
and plantar neuralgia; and that in most of the other cases 
chronic gleet was taken as the indication for surgical interfer- 
ence. In a remarkably small percentage of these cases was 
the contraction sufficient to impede the flow of urine or prob- 
ably to render it evident to the patient that a stricture ex- 
isted, unless first so informed by his physician. It is greatly 
to be regretted that, in the larger proportion of the cases which 
I have been able to reach, the details as to the situation of the 
stricture, its length and caliber, the severity of the symptoms 
complained of by the patient, and the previous methods of 
treatment employed for the relief of these symptoms, are 
either so given as to be worthless for comparison or are en- 
tirely omitted. 
In concluding this article, I present the following rules, 
which I consider as the proper guides in the treatment of 
uncomplicated urethral stricture: 
1. Seldom resort to the knife, except the stricture be of 
traumatic origin or resilient, or situated at the meatus. 
2. Never perform internal urethrotomy if the situation of 
the stricture be more than four inches from the meatus. (I 
question if three inches would not be a safer rule.) 
3. In strictures of the deep urethra, m case dilatation is im- 
possible, divulsion and perineal section are the two best 
methods of treatment. 
4. Dilatation, if carefully and judiciously used, will be 26 
found to he practicable in the majority of cases, and in many 
cases will entirely relieve all symptoms. 
5. Internal urethrotomy, if performed for the relief of 
“strictures of large caliber,” should he resorted to only when 
the symptoms presented by the patient have been treated by 
other methods without relief j and then only in the anterior 
four inches of the urethral canal. 
In support of my first rule, viz., never to cut internally if 
the stricture he situated more than four inches below the 
meatus, I present the following statistics as afforded by those 
of the collected cases where the full details are given. In 
Dr. Otis’s reported cases (two hundred and thirty-six in 
number) all the patients that had haemorrhage after the 
operation, with two exceptions, were cut below this limit; 
while rigors occurred only four times, curvature five times, 
and abscess twice, when the operation was performed in the 
anterior four inches of the canal. Should the rule be modi- 
fied to three inches, instead of four, the percentage of accidents 
would be found to be much smaller than that previously given. 
In the total of cases collected, urethral fever seems to occur 
in a large proportion of operations where the incision is made 
at a point more than three inches and a half from the meatus, 
and seldom to follow incisions in the anterior portions of the 
urethra. Infiltration of urine and abscess must of necessity 
occur in a larger percentage of cases in which the incision 
is made in the region of the bulb than of those in which it is 
made in the ante-scrotal portion of the canal. 
I can not agree with those who claim that incision of the 
upper wall of the urethra obviates the danger of infiltration 
or haemorrhage. It may possibly decrease the danger of in- 
filtration, but I can not see why an incision through the cor- 
pus spongiosum and possibly into the corpora cavernosa, near 
the point of union of the crura, should have any decided ad- 
vantage in respect to haemorrhage over an incision in the 
median line of the bulb. 
The other rules given for the treatment of stricture of the 
urethra differ but little from those advocated by most of the 
conservative surgeons whom I have consulted, and from whom 
I have quoted in this article; and they seem to me to be sus- 27 
tained by the results of those reported cases which have been 
previously analyzed. 
Finally, I trust that this paper, while plain words have of 
necessity had to be spoken, betrays no evidence of a spirit 
which is not that of a “ seeker after truth.” When new 
theories are advocated, and the profession is asked to accept 
new procedures as improvements upon well-tried methods of 
treatment, no replies can be made without constant refer- 
ence to the source of such new views, and a close analysis of 
the facts recorded. 
Gregor) 915 cases 
Otis* 214 “ 
From private case-books, about 200 “ 
From scattered sources (among journals and mono- 
graphs), about 100 “ 
SUMMARY OF CASES ANALYZED. 
* I find 100 of the cases reported by Dr. Otis recorded in Gregory’s “ Essay,” 
and the 214 cases enumerated above represent, therefore, only the remainder of 
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