SOME REMARKS 
ON the 
Diagnosis id Treatment of Spasmodic Strictdrl 
BY 
JOHN BLAKE WHITE, M.D., 
PHYSICIAN TO CHARITY HOSPITAL. 
Reprinted from Journal of Cutaneous and Venereal Diseases, Vol. IV., 
June, 1886. 
NEW YORK: 
WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
1886. SOME REMARKS 
ON THE 
Dutisis m Imiim of Spasmodic Stricture. 
BY 
JOHN BLAKE WHITE, M.D., 
PHYSICIAN TO CHARITY HOSPITAL. 
Reprinted from Journal of Cutaneous and Venereal Diseases, Vol. IV., 
June, 1886. 
NEW YORK: 
WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
1886. SOME REMARKS 
ON THE 
WHO® Mil TIEAT1EMT (IF SPASMODIC SIMM. 
ORGANIC strictures of the deep urethra are very rarely met with, 
as all surgeons assure us, but contractions dependent upon irri- 
tation reflected from the anterior canal are of common occur- 
rence. The presence of a stricture in the pendulous urethra, or the 
existence even of a contracted meatus urinarius, often occasions, as a result 
of reflex irritation, a contraction at the membranous junction so resist- 
ant that a filiform bougie cannot be passed beyond it. 
Such spasmodic action of the muscular urethra may result from other 
causes than the existence of organic strictures in the anterior urethra. 
A spasm is occasionally produced in the membranous portion by the simple 
passage of an instrument along the urethra, which acts solely as an irri- 
tating medium to the mucous membrane, precisely as an irritation may be 
occasioned by highly acid urine. 
Voluntary retention of urine for a prolonged period is also capable of 
exciting spasm. Diseases of the rectum and all irritations about the 
anus, as well as derangements of the digestive or cerebro-spinal system, 
may produce urethral spasm. 
A slight urethral discharge is, generally, an early and constant symp- 
tom of stricture. Such a urethral discharge might arise from causes 
independent of stricture, but the continued presence of a gleet may be 
justly regarded as symptomatic of a contraction in some part of the 
urethra. 
Among other important symptoms of stricture may be mentioned a 
more or less frequent desire to urinate, associated with lumbar pain, 
sometimes extending from the back around both sides to the inguinal 
regions and down the scrotum, following the course of both ureters and 
the spermatic cord. Pain is also referred, occasionally, to the supra- 4 
White, The Diagnosis and Treatment of Spasmodic Stricture. 
pubic region, or in the perineum and along the urethra before, during, or 
after urination. 
A sharp pain is not infrequently experienced at the end of the penis 
after the bladder has been emptied. This is, I think, oftener observed 
when a spasmodic condition of the membranous urethra exists, or rather 
has a tendency to be excited to spasm as the result of a permanent 
stricture anterior to the bulb. 
The stream of water is more or less altered in size, momentum, and 
form. It may assume a spiral shape, may be expelled from the meatus 
in two or more distinct streams, or the patient may be obliged to make 
strenuous efforts to urinate, without avail. This symptom is more likely 
to be present when permanent strictures complicate the spasmodic, but 
the symptom may also be an indication of the latter condition alone. 
When urine manifests an ammoniacal condition, the presence of 
stricture may be suspected. A partial retention of the urine is thus occa- 
sioned by the incomplete emptying of the bladder, and the retained portion 
is prone to decompose, thus exciting troublesome cystitis if the obstruc- 
tion is not removed promptly. 
Prof. F. N. Otis has often demonstrated the frequency with which 
strictures of the deep urethra are found to co-exist with a contracted 
meatus urinarius only. They have been shown to be dependent not 
infrequently upon the presence of strictures of large or small calibre in 
the penile urethra. No surgeon merits more credit than Prof. Otis for 
recognizing and proving the correctness of these facts by the results of 
many such operations for the relief of spasmodic strictures. 
In the course of my experience I have met with not a few instances 
where a contracted orifice or stricture of large calibre situated in the penile 
urethra was the sole cause of what seemed to be an impassable stricture of 
the deeper portions of the urethra. 
Some eminent surgeons believe that, in accounting for deep strictures, 
the possible influence of spasm as an exciting cause does not as frequently 
■obtain as is claimed. My personal observations and experience have led 
me to think differently. The reflex character of such deep strictures is 
not so often recognized as its importance and frequent influence de- 
mand. 
The two following cases will afford good examples of the subject un- 
der discussion : 
Case I.—Julius A., aged 24 ; single. Has had repeated attacks of 
gonorrhoea, the last occurring about six months ago (October, 1885). At 
the time the patient was seen, there was some slight urethral discharge. 
Complained of pain on urination along the urethra and especially at the 
end of the penis. Passes a very small stream of water, with some effort 
at times. 
Upon examination, the circumference of the penis measured three and WHite, The Diagnosis and Treatment of Spasmodic Stricture. 
5 
one-half inches. The calibre of the urethra should therefore be 34 F. to 
represent the normal proportionate relation as advised by Dr. Otis. At 
an inch and a half from the meatus there was a stricture of 14 F. and 
one also at three inches of 10 F. The meatus itself was 24 F. In the 
deep urethra a stricture was discovered which resisted the passage of a 
filiform bougie. It was thought that the deep stricture was of reflex 
origin. Dr. Otis, who was invited to see .the case, was of the same opin- 
ion, and advised the division of the anterior strictures with the meatus to 
34 F., which was performed. The operation confirmed . the diagnosis 
concerning the deep stricture, as a 34 F. sound was readily passed into 
the bladder. The patient convalesced rapidly and satisfactorily. 
Case II.—Frank R., aged 26, single. Has had several attacks of 
gonorrhoea. After the last attack he experienced some pain on micturi- 
tion, especially over the suprapubic region and at the extremity of the 
penis. Sometimes he had difficulty in passing water, being obliged to 
make an expulsive effort to do so, and afterwards for a little while the 
urine would dribble away. He had found it impossible sometimes to uri- 
nate at the time he felt the inclination to do so, but never had retention, 
so that instrumentation became a necessary resort for relief. Has been 
suffering from a gleety discharge for a long while, and when he urinates 
the water flows out in several streams. 
An examination revealed a contracted meatus urinarius. The circum- 
ference of the penis measured three and one-quarter inches which would 
indicate a urethral calibre of 32 F. A stricture of 14 F. was discerned at 
three and one-half inches by Otis urethrometer and a filiform stricture 
in the deep urethra was also discovered. As in the preceding case, the 
deep stricture Avas thought to be spasmodic, and in accordance with Dr. 
Otis* advice, avIio also examined this patient, the meatus Avas enlarged to 
32 F., and Avith the dilating urethrotome the contraction at three and 
one-half inches incised to correspond Avith the normal urethral calibre of 
32 F. After the operation a 32 F. sound Avas passed without obstruction 
into the bladder, although a filiform bougie was arrested prior to the 
operation. 
These two cases, among a number of others in the experience of sur- 
geons, afford important examples of the fact that deep strictures are 
sometimes entirely dependent upon contractions in the anterior urethra 
and indicate the expediency of first removing the anterior obstructions 
before resorting to the more serious operation of external urethrotomy. 
I have thought that a deep stricture, when spasmodic, imparted a 
peculiar, elastic resistance to the expert touch when an instrument Avas 
carefully pressed against it, Avhich would tend to characterize the nature 
of such strictures, but, after all, the surest Avay of corroborating the diag- 
nosis Avould be an operative procedure, respecting the anterior contrac- 
tions, Avhen any exist, and afterwards carefully attempting to pass a full- 
sized sound. Unless the stricture tissue has been thoroughly divided, 
the spasm Avill not be wholly relieved, therefore due caution, to render the 
operation successful as to results, is advised by attention to the importance 
of a complete division of the anterior contractions. 6 
White, The Diagnosis and Treatment of Spasmodic Stricture. 
One of the above patients (Case II.) had two severe hemorrhages fol- 
lowing the operation—one the second day and the other the third day 
after, but they were readily controlled by the introduction and retention 
of an endoscopic urethral tube aided by pressure upon the perineal por- 
tion of the urethra. The urethral tube was worn for three days without 
causing any irritation worthy of notice. 
It is said that an important diagnostic feature of spasmodic stricture 
would be the suddenness of its appearance or the possibility of passing 
urine at some time previous to the attack during the previous twenty-four 
or thirty-six hours. I cannot agree with these views entirely, for I have 
seen patients suffering from organic strictures with the same experiences 
above noted. It may be, however, as stated by Rynd, that “ when there 
is complete retention of urine, and the patient applies, writhing and 
straining with painful and continued efforts to discharge the contents of 
the bladder and not a drop appears, the presumption is that he is suffer- 
ing at present from spasm, no matter what his other troubles may be.” 
In other words, spasm is almost always an element present, or likely to be 
present, when there is a contracted meatus or a stricture of any calibre 
along the pendulous urethra. Sometimes spasm is relieved by a warm 
sitz-bath, followed by a full dose of opium. The patient may be ether- 
ized and an attempt be made to pass a catheter if the symptoms are 
urgent. Should instrumentation be determined upon, I would advise the 
injection of a four-per-cent solution of cocaine before passing the cathe- 
ter, as the pressure of an instrument in the urethra may irritate the mu- 
cous membrane and aggravate the spasmodic condition to such a degree 
as to baffle the most skilful operator in its introduction. The sedative 
effect of cocaine in such emergencies is very positive, whether the 
spasm be due to irritation reflected by anterior pathological conditions or 
is purely idiopathic. 
I have seen the good effects of its use in both conditions, when at- 
tempting to use the catheter or pass sounds for diagnostic purposes. The 
use of this solution, however, with the ordinary relief which the patient 
may experience from this treatment can be only palliative and of tempo- 
rary duration, when an organic stricture complicates the condition of 
spasm. The only means of permanent relief must be the removal of the 
organic lesions, which should be done without hesitation when all other 
means of relief are without avail, and before the extreme measure of 
puncturing the bladder is resorted to. 
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