THE 
OPERATIVE TREATMENT 
OF 
Strictures of the Male Urethra. 
BY W 
JOHN B. DEAVER, M.D., 
Philadelphia, Pa., 
Demonstrator of Anatomy and Lecturer upon Surgical Anatomy, University 
of Pennsylvania; Attending Surgeon to the German, Philadelphia, 
St. Agnes’s, and St. Mary’s Hospitals. 
REPRINTED FROM THE THERA PEl'TIC GAZETTE, OCTOBER is, iSqo. 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISflEk. 
1890. THE 
OPERATIVE TREATMENT 
OF 
STRICTURES OF THE MALE URETHRA. 
BEFORE describing the treatment of strict- 
ures of the male urethra, I think it well to 
mention their classification and location. 
The usual classification of strictures are as 
follows : 
i. The linear, bridle, pack thread, or val- 
vular. 
2. The annular. 
3. The irritable. 
4. The resilient. 
5. The stricture of large calibre. 
6. The stricture of small calibre. 
Strictures are also spoken of as permeable 
and impermeable, depending upon the degree 
of contraction ; permeable when an instru- 
ment can be passed through the stricture, and 
impermeable when the stricture will not per- 
mit the passage of an instrument, let it be 
ever so small. 
Location.—There has been a great deal of 
discussion as to the location of strictures of the urethra. Sir Henry Thompson, Treves, 
and Keys believe that the most frequent seat 
of stricture (two-thirds) is beneath the sub- 
pubic arch or at the bulbo-membranous junc- 
tion. Dr. Otis claims that the most frequent 
seat of stricture is about one-quarter of an inch 
within the meatus urinarius. In my experi- 
ence the majority of strictures occur about 
the middle of the pendulous urethra. 
The operations for stricture of the male 
urethra aiming for a radical cure, in my 
judgment, are gradual dilatation, only prac- 
tised as a preliminary procedure to dilating 
internal urethrotomy, external urethrotomy, 
and a combination of dilating internal ure- 
throtomy and external urethrotomy. 
In determining the operative treatment, I 
first learn the position of the stricture or 
strictures ; and, secondly, their calibre, this 
being most accurately as well as conveniently 
accomplished by the urethral metre. All 
strictures of large calibre, by which I mean 
those of eighteen millimetres and over in cir- 
cumference, when situated not deeper than 
four and a half inches within the meatus 
urinarius in the average-sized penis, and five 
inches in the unusually large penis, are cases 
for dilating internal urethrotomy. 
Strictures impermeable to the passage of 
instruments (filiform bougies, etc.) are cases 
for external urethrotomy or perineal section, 
depending upon their location. Strictures of 
small calibre, which cannot be dilated to eigh- 
teen millimetres by gradual dilatation, and 
situated within four and a half inches of the 
meatus urinarius in the average-sized penis 
and five inches in the unusually large penis, 
2 3 
are cases for internal urethrotomy, first using 
Maisonneuve’s urethrotome, with which the 
stricture or strictures are cut to twenty milli- 
metres, when, with the dilating urethrotome, 
the calibre of the urethra is easily restored. 
Gradual dilatation, by means of conical 
steel bougies, is the form of treatment most 
commonly employed by the great majority of 
surgeons, and for what reason I know not, but 
hope it is because their patients will not sub- 
mit to more radical measures, urethrotomy, 
which beyond any question of doubt, offers 
the only means of cure. It is true that 
gradual dilatation will temporarily relieve a 
stricture, but where is there a surgeon who 
would promise a cure by this treatment ? 
Except, perhaps, I will venture to say, in very 
recent strictures, as before organization has 
taken place : but these are so seldom seen 
before this process is complete, not having 
been the occasion of sufficient trouble to 
prompt the patient to seek the advice of a 
surgeon ; therefore they can practically be 
dismissed. With this form of treatment, the 
bougie becomes the patient’s constant com- 
panion, not for a short time, but for life. 
How common it is for the patient to be pre- 
scribed a bougie, and with one or two lessons 
taught how to use it, and is advised to pass 
it himself once every week, or perhaps every 
other week ; this, to say nothing of the ill 
effect accruing from this treatment, is quite 
enough to condemn it. Many of us have 
seen epididymitis, cystitis, abscess of the 
prostate, and prostatorrhoea, resulting from 
the passage of the bougie, both in the hands 
of the surgeon and of the patient. None of 4 
these troubles have I ever seen follow an in- 
ternal or external urethrotomy properly done. 
We will admit that in nearly all cases of strict- 
ure treated by gradual dilatation, whether the 
stricture be in the pendulous urethra or fur- 
ther back, the bougie is passed into the blad- 
der ; in fact, the instrument is forced into the 
urethra up to its hilt by depressing the handle 
well between the thighs, and is not spoken of 
as dangerous treatment when compared with 
urethrotomy. The mediate danger of this 
manner of treatment I am very certain is of 
considerable moment, while that of urethrot- 
omy is nil. 
There is no doubt that with a very small 
conical steel sound, unless the greatest care 
be observed when attempting to traverse a 
tight stricture, there is danger of making a 
false passage, this being more likely to occur 
when the stricture is located in the pendulous 
than in the deep urethra. To some this may 
seem an adverse statement, but when we re- 
call the fact that the surgeon has better com- 
mand of the deep than of the pendulous ure- 
thra, owing to the relation it bears to the 
anterior wall of the rectum, with the index- 
finger, in which (for practical purposes an- 
swering the part of a director) it can be 
positively determined whether or not the 
sound is following the proper course, it will 
be readily understood. I am always able to 
accomplish more with the conical steel sound 
than with the soft bougie. If from the history 
and examination of a case like the above 
I suspect there is a false passage, I make 
a urethroscopic examination, when, with a 
probe, I am able to determine positively. It may be very difficult to find the orifice of the 
false passage, owing to the presence of blood ; 
this can be overcome by swabbing the urethra 
with styptic cotton. 
Continuous dilatation, where a filiform 
bougie or a small catheter, if the stricture 
will admit it, is introduced into the bladder, 
and allowed to remain for some time; gener- 
ally two or three days, when these are re- 
placed by others of larger size, and so on till 
the stricture can be disposed of according to 
the operator’s preference,—this treatment is 
always followed by a strong tendency to re- 
contraction, to say nothing of its provoking 
suppuration and often ulceration of the walls 
of the urethra ; certainly three strong objec- 
tions. In the case of a tight stricture of the 
deep urethra (causing retention of urine) in 
a subject well advanced in years, and having 
every appearance of bladder- and kidney- 
disease, I have seen the urethra loaded with 
filiform bougies, and, after persevering for 
some time, the surgeon has succeeded in 
passing one through the stricture, allowing 
it to remain, congratulating himself upon the 
feat performed, this offering sufficient relief 
to the distended bladder till the stricture can 
be dilated to admit the smallest-sized cathe- 
ter. By this treatment it is a question how 
long it will be before the bladder is com- 
pletely emptied, to say nothing of the evil 
effects of the prolonged retention. These 
are cases in which I always practise and 
teach that external urethrotomy should be 
done, thus fulfilling every indication,—that of 
relieving the retention, dividing the stricture, 
and draining the bladder, all of which are 
5 6 
urgently called for, but especially so, in the 
event of existing organic trouble, beyond the 
urethra. 
The treatment by rapid dilatation and di- 
vision I do not approve of, as by either 
means we must necessarily occasion a lacer- 
ated wound, the latter being much less safe 
than an incised wound, like that made in the 
operation of internal urethrotomy. In oper- 
ations upon the surface of the body, we are 
careful to have our cutting instruments in 
such condition as not to do faulty work, 
knowing how union is interfered with when 
the edges of the wound are in any way con- 
tused or lacerated. Why, then, should we 
adopt an opposite course when doing a plas- 
tic operation, as it were, upon the urethra, to 
say nothing of opening up more than one 
channel by which the urine may find its way 
by infiltration, thus exposing the patient to 
unwarrantable risk ? For one who still be- 
lieves the above means of treating strictures 
of the urethra are preferable, safer, and there- 
fore more surgical than by internal urethrot- 
omy, to convince him he is wrong, I would 
ask him that he make a urethroscopic exam- 
ination, with the incandescent lamp urethro- 
scope (Leiter), of the portion of the urethra 
operated upon, when I am confident that this 
alone would forever disabuse his mind of the 
fallacy he has been laboring under, if not in- 
stilling into the minds of hundreds of medical 
students, to say nothing of the sequelae of the 
divulsion treatment. In a paper on the “Value 
of the Leiter Incandescent Lamp Urethro- 
scope in the Treatment and Diagnosis of 
Chronic Urethral Discharges,” I had the 7 
honor of reading before the surgical section 
of the American Medical Association, at 
Nashville, Tenn., May, 1890, and published 
in the Philadelphia Medical News of June 21, 
1890, I called attention to the disadvantage 
of this proceeding, illustrating my remarks 
by diagrams, which showed tabs of the torn 
urethra. The only circumstances under 
which I practise rapid dilatation or divulsion, 
but never carried to the extent of restoring 
the urethra at the seat of the stricture to its 
normal calibre, are when called to see a pa- 
tient with a stricture, simple or multiple, of 
small calibre, seated in either pendulous or 
deep urethra, causing retention of urine, and 
when a cutting operation is positively refused. 
Here I introduce the small-sized Thomson 
divulsor, if the stricture or strictures will ad- 
mit it, and stretch it to thirty millimetres. 
Not being able to engage a divulsor at once, 
I introduce a filiform bougie, and over this 
pass the divulsor. Immediately after the di- 
vulsion, a No. 20 soft catheter rendered asep- 
tic is passed into the bladder, and retained for 
forty-eight hours. The bladder is washed 
out through the retained catheter with either 
boracic-acid solution or a solution of bichlo- 
ride of mercury, 1 to 15,000, two or three 
times a day, depending upon the amount of 
cystitis present. The retention of a catheter 
in cases like the above I consider imperative. 
The treatment by internal urethrotomy is 
carried out in the following manner: The 
preparatory treatment consists in an exami- 
nation of the urine, both chemically and 
microscopically, when, if the case be a suit- 
able one for operation, the internal admin- istration of boracic acid, io grains, is given 
four times daily ; attention to the bowels, a 
laxative being given, if necessary ; irrigation 
of the urethra with a i to 15,000 solution 
of bichloride of mercury three times daily ; 
this to be instituted and pursued for four 
days previous to the operation. 
The technique of the operation is described 
in the report of the cases. The after-treat- 
ment consists in the internal administration 
of boracic acid and two grains of bisulphate 
of quinine four times daily for three or four 
days ; urethral injections of either boracic 
acid, grains 5, to 1 ounce of distilled water, 
or solution of bichloride of mercury, 1 to 
15,000, for one week, when, if there is still 
present some discharge, the urethra is exam- 
ined urethroscopically, and treatment di- 
rected according to the indications. The 
passage of a bougie of the calibre of the ure- 
thra at intervals of four days is continued for 
four weeks. The complications of internal 
urethrotomy usually described are hemor- 
rhage, extravasation of urine, urethral fever, 
spongio-corporitis, and abscess of the pros- 
tate. If the rules relative to the distance 
from the meatus in the division of strictures 
by internal urethrotomy be closely observed, 
and the retention of a full-sized aseptic soft 
rubber catheter in the bladder for twenty- 
four hours after the operation and the divi- 
sion made with the dilating urethrotome, 
hemorrhage to any extent should not occur. 
The superiority of the dilating urethrotome 
over Civiale’s instrument, the one so largely 
used, and all others of this class, a point 
which will be referred to later on, is the 
8 exactness with which the incision is made, 
and the depth of the incision required, owing 
to the strictured tissue being rendered tense 
(thinned out) by dilating it prior to cutting. 
By confining the incision to the strictured 
portion of the urethra, coupled with the in- 
troduction of the soft catheter, the likelihood 
of extravasation is prevented. If the precau- 
tions are taken as advised, to secure thorough 
asepsis, urethral fever will not occur. Curva- 
,ture of the penis to a slight extent will follow 
this operation in a small number of cases, I 
care not how carefully the operation is done. 
In this connection I can do no better than 
refer to the second series of cases, number- 
ing one hundred and eighty-six, reported by 
Professor F. N. Otis, where incurvation of 
the penis occurred as follows : 
Slight, and lasting for a short time only 3 
Slight, and lasting for one and a half months 1 
Slight, lasting four months 1 
Slight, lasting one year 1 
Total 6 
The treatment that will be found most sat- 
isfactory in this complication is massage and 
the local use of an ointment of mercury and 
belladonna. By retaining the soft catheter 
for twenty-four hours following the operation, 
retention is less liable to occur than if the 
urine be drawn. Spongio-corporitis I have 
never had follow the operation, and I believe 
when it does occur it is the result of faulty 
antisepsis. By confining the bougie, passed 
for the purpose of preventing recontraction, 
to the pendulous urethra, and the observance 
of strict asepsis, abscess of the prostate gland 
9 will not be met with. The advantage of the 
dilating urethrotome over all instruments for 
the internal division of strictures of large cali- 
bre of the pendulous urethra are the follow- 
ing : i, the adaptability to accommodate itself 
to a stricture of the size between twenty and 
forty millimetres ; 2, the exactness with which 
the stricture can be located and divided ; 3, 
the very small incision necessary for the com- 
plete division of the same, being able to ren- 
der the stricture tense ; 4, being able, with- 
out any question of doubt, to divide all 
strictured bands, the latter qualification par- 
ticularly not being possessed by any other in- 
strument. The adaptability of the dilating 
urethrotome to any stricture of the calibre 
between twenty and forty, holds the same re- 
lation to other instruments as does the ure- 
thrameter to bulbous bougies,—i.e., that the 
urethrameter will accomplish what will 
otherwise require a series of twenty-two 
bulbous bougies. In addition to being able 
to locate accurately a stricture in the pendu- 
lous urethra of the calibre of eighteen milli- 
metres and above, with the urethrameter, 
we are able to measure its calibre as well as 
its length, and by this means determine the 
length and depth of the incision required to 
divide it. I would not advise internal ure- 
throtomy in the case of a stricture of large 
calibre in one the subject of a hemorrhagic 
diathesis, of advanced kidney-disease, or in 
one advanced in life. In the case of a strict- 
ure of small calibre, where either of the above 
conditions are present, I do not think it pru- 
dent to adopt radical operative means, unless 
the stricture is the source of much trouble. 
10 If the patient is of a bleeding family, I would 
simply practise gradual dilatation, but other- 
wise would divide the stricture under cocaine, 
believing this preferable, under the above 
circumstances, to the administration of an 
anaesthetic. Strictures of small calibre in the 
pendulous urethra that cannot be dilated to 
admit the Otis urethrotome, but which will 
admit the filiform bougie of Maisonneuve’s 
urethrotome, can be divided by this instru- 
ment, thus allowing the passage of the dilating 
urethrotome, when it can be disposed of as 
an ordinary stricture of large calibre. This 
I find safe, and much more acceptable to 
the patient than an external urethrotomy. 
In all strictures of large calibre, whether 
made such by the preparatory urethrotomy, 
with Maisonneuve’s urethrotome or not, 
and situated not deeper than four and a half 
inches from the meatus in the average-sized 
penis, and five inches in the unusually large 
penis, I believe dilating internal urethrotomy 
to be not only the surest and the most speedy 
way of treating the same, but the only way that 
will offer the patient a means of permanent 
cure. 
The operation of perineal section and 
external urethrotomy can be done in one of 
several ways, the technique of which depend- 
ing upon the permeability of the stricture to 
the passage of an instrument. When the 
stricture will admit, it is the custom with 
many surgeons to introduce a guide (Gouley, 
Symes staff, or, if these be too large, a 
filiform bougie), in this way facilitating the 
operation. Should this not be feasible, a 
medium-sized staff or conical steel sound 
11 12 
is passed down to the face of the stricture, 
and the urethra opened by cutting down 
upon the point of the instrument as the guide. 
The stricture is then divided from before 
backward. My method of performing peri- 
neal section and external urethrotomy for 
stricture is without a guide, exposing the 
urethra behind the stricture by a careful dis- 
section, when it is opened and the stricture 
divided from behind forward. This is un- 
doubtedly a safer method—there being no 
question about finding the urethra if we are 
perfectly familiar with the anatomy of the 
part operated upon (which I maintain every 
surgeon should be)—than to cut down, being 
guided by so small an instrument as a Gouley, 
Symes staff, or a filiform bougie, engaged, as 
it is thought, in the stricture, but as likely to 
be in a false passage. Is not the recognition 
of the tissues a more reliable guide ? Excep- 
tions may be taken to the above when the 
perineum is extensively infiltrated with urine. 
I recall a case of traumatic stricture of the 
membranous urethra following a fracture of 
the ramus of the ischium, the result of direct 
force, which I operated upon in the Univer- 
sity Hospital two years ago. I am quite sure, 
if I had not operated in this way I would not 
have succeeded without at least endangering 
the life of my patient. This case made a 
speedy recovery, not having had a bad symp- 
tom. The urethra being opened and the 
stricture divided, a soft catheter is introduced 
into the bladder through the urethrotomy 
wound and retained. A drainage-tube, full 
size, is passed through the urethra to the 
urethrotomy wound, where it is brought out; this, with the catheter in the bladder, is al- 
lowed to remain four days. By means of the 
catheter and the drainage-tube, both bladder 
and urethra are kept aseptic by frequent and 
thorough irrigation of a solution of bichloride 
of mercury, i to 15,000. After the removal 
of the catheter and the drainage-tube, the 
treatment consists in passing a conical steel 
bougie of the calibre of the urethra through 
the meatus to beyond the stricture every third 
day till repair is complete. 
The terms perineal section and external 
urethrotomy have distinct meanings, the for- 
mer referring to a section of the urethra made 
from without and posterior to the perineo- 
scrotal junction, the latter to a section of the 
urethra anterior to this point. The only com- 
plication of any moment in a perineal section 
or external urethrotomy is hemorrhage, which, 
I believe, is less likely to occur when the op- 
eration is done by dissection, this enabling the 
operator to see and tie all bleeding points. 
In the event that the bleeding continues after 
the operation is completed and the patient 
put to bed, it can, in the majority of cases, be 
controlled by packing. Yet I recall one case 
where there was internal bleeding (into the 
pelvis), notwithstanding the above precau- 
tions were taken. What is the explanation of 
blood finding its way into the pelvis ? So long 
as the membranous urethra is not trespassed 
upon, there is no danger of bleeding taking 
place into the pelvis, blood being prevented 
from finding its way there by the attachment 
of the anterior layer of the triangular liga- 
ment (deep perineal fascia.) When the space 
between the anterior and the posterior layer 
13 of the triangular ligament is opened up, as 
must of necessity be done when dividing a 
stricture of the membranous urethra, a com- 
munication is established between the mus- 
cles (levator ani coccygeus and pyriformis), 
forming the floor of the pelvis and the pelvic 
fascia, which latter is continuous with the 
posterior layer of the triangular ligament 
(deep perineal fascia). The case above re- 
ferred to was one of stricture of the bulbo- 
membranous junction, for which I did a 
perineal section some years since, and where 
hemorrhage took place into the pelvis, form- 
ing a blood clot most pronounced in front of 
the bladder ; the clot underwent suppuration, 
causing septicaemia, from which the patient 
did not recover for three months. 
Case I.—-Internal Urethrotomy.—J. H., 
white, aged 32, was admitted to the male 
venereal wards of the Philadelphia Hospital, 
complaining of difficult micturition. Gave a 
history of several attacks of gonorrhoea. The 
stream of urine passed was small, and there 
was a gleety discharge. Examination of 
urine was negative. A No. 20 F. conical 
steel bougie could be passed with some diffi- 
culty, occasioning patient considerable pain. 
Examination of the urethra with the 
urethrameter showed its calibre to be forty 
millimetres, calibre of the meatus twenty- 
eight millimetres, and the presence of three 
strictures, respectively, three-quarters, two 
and a half, and three inches posterior to the 
meatus. The patient giving his consent to 
an operation, 10 grains of boric acid t. d. 
was given internally for five days previous to 
the operation. On October 4, 1889, he was 
14 brought before the clinic, and io grains of 
quinine were administered ; was anaesthe- 
tized, ether being used. The first procedure 
was the restoration of the meatus to the cali- 
bre of forty millimetres. Having located the 
anterior stricture, I then passed the Otis di- 
lating urethrotome, so as to engage it, and di- 
lated it until it met with resistance. The 
concealed blade was then drawn through the 
stricture. After division, was able to expand 
the blade up to forty millimetres, the normal 
calibre of the urethra. This procedure was 
repeated with each of the remaining strict- 
ures in turn. Having divided these, I then 
introduced the urethrameter down to the 
bulbo-membranous junction, when it was ex- 
panded to forty millimetres, and then easily 
withdrawn, all obstructive points having been 
divided. The urethra was washed out with a 
i to 15,000 solution of bichloride, a soft cathe- 
ter introduced into the bladder, which was al- 
lowed to remain for twenty-four hours. Before 
removal from the operating-table a one-grain 
opium suppository was introduced. His re- 
covery was uninterrupted, the temperature 
at no time reaching 990. A No. 40 F. bougie 
was passed every fourth day for four weeks, 
when, there being no longer any discharge, 
the patient was discharged cured. 
Case II.—Internal Urethrotomy.—S. S., 
transferred from the nervous to the surgical 
wards of the Philadelphia Hospital on Sep- 
tember 16, 1889, with the diagnosis of strict- 
ure. Had gonorrhoea fifteen years ago. For 
the last three years noticed his stream de- 
creasing in size. When admitted to the 
nervous ward a No. 15 F. bougie could with 
15 difficulty be passed. When referred to the 
surgical ward his urethra was gradually di- 
lated, until a No. 21 F. bougie could be 
introduced. 
Measurements.—Circumference of penis, 
three and three-quarter inches; calibre of 
urethra, thirty-five millimetres ; of meatus, 
twenty-three millimetres ; of stricture, twenty- 
one millimetres ; depth, three inches from the 
meatus. 
He was prepared by the routine adminis- 
tration of boric acid internally, 10 grains t. d. 
Previous to the operation 10 grains of qui- 
nine sulph. and grain of morphine sulph. 
were given. 
Operation, September 25.—Stricture cut as 
in Case I. Temperature before operation, 
99f° F.; after operation, evening, 98!° F. 
The night following the operation the pa- 
tient removed the catheter ; his temperature 
rose to ioi-|° ; catheter was reintroduced 
under antiseptic precautions ; quinine was 
administered. After this his temperature 
dropped to 101, and on the morning of Sep- 
tember 26 was 98|°. On the evening of the 
26th the catheter was again removtd by the 
patient, his temperature rising to ioi§°; was 
treated as on former occasions. After this 
no difficulty was experienced. One montli 
after the operation a No. 36 F. bougie could 
be passed with perfect ease. 
Case III.—Internal Urethrotomy.—S. T., 
white, aged 47, a hemiplegic, was transferred 
from nervous to surgical ward of the Philadel- 
phia Hospital for urethral treatment. The ex- 
amination revealed as follows : Circumference 
of penis, three and a half inches ; calibre of 
16 17 
urethra, thirty-four millimetres ; of meatus, 
thirty millimetres. One stricture was found 
three inches from the meatus. The patient 
had some difficulty in urinating, but not a 
great deal ; complained chiefly of reflex 
symptoms, which were thought to be due to 
the condition of the urethra. The patient 
having been prepared as in Case I., and the 
stricture and meatus divided in the same 
manner, a No. 34 F. sound was passed through 
the stricture without any difficulty. A cathe- 
ter was passed into the bladder and secured. 
An opium suppository introduced into the 
rectum and patient returned to bed. Same 
after-treatment given as in the two previous 
cases. Four weeks after the operation re- 
covery complete. 
Case IV.—Interno-External Urethrotomy. 
—J- W., aged 42, white, was admitted into 
the venereal ward of the Philadelphia Hos- 
pital suffering from periodical attacks of re- 
tention of urine, with a history of having had 
several attacks of gonorrhoea and a stricture. 
Had external urethrotomy performed some 
time since ; the wound was entirely healed 
at time of entrance into the hospital. On 
examining the case, a cicatrix was found in 
the perineum, corresponding to the site of the 
former operation. 
Measurements.—Circumference of penis, 
three and a half inches. Examination by 
the urethrameter gave a urethral calibre of 
thirty-three millimetres ; meatus, twenty-eight 
millimetres ; and the presence of two strict- 
ures in the pendulous urethra, situated two 
and a quarter and four inches posterior to 
the meatus, of the calibre of twenty-eight 18 
and twenty-six millimetres, respectively. The 
calibre of the stricture in the deep urethra 
was not measured. 
I explained the condition of affairs to the 
patient, and advised radical treatment, to 
which he gave his consent. An examination 
of the urine was negative. Boric acid was 
given internally for four days previous to 
the operation. The patient received io 
grains of quinine sulph. prior to the adminis- 
tration of ether. The strictures in the pen- 
dulous urethra was disposed of as in Cases I., 
II., III. I then divided the stricture in the 
deep urethra by perineal section. The in- 
cision began at the junction of the scrotum 
and perineum, and was continued backward 
about two inches, taking as my guide the 
perineal raphe, going through the cicatricial 
tissue resulting from the former operation. I 
found the landmarks in this case entirely ob- 
literated ; the perineum was infiltrated by the 
products of inflammation. Cutting through 
the cicatricial tissue, being careful not to de- 
viate from the median line, I readily exposed 
the urethra behind the stricture, which was 
opened and the stricture divided. An ordi- 
nary aseptic drainage-tube was passed through 
the pendulous urethra, and brought out at the 
perineal wound. A catheter was introduced 
into the bladder from the perineal wound, 
and held in position by a suture ; the pendu- 
lous urethra and bladder were flushed with a 
i to 15,000 bichloride solution ; the free ends 
of the drainage-tube were fastened together 
with a safety-pin. Iodoform was freely used 
in the perineal wound, which was then packed 
with iodoform gauze, an opium suppository 19 
introduced into the rectum, and an antiseptic 
dressing applied. Patient returned to bed. 
The packing was allowed to remain for three 
days ; when removed, the wound was free 
from pus and aseptic, the urethra and blad- 
der were irrigated, and the drainage-tube and 
catheter removed ; a No. 33 F. bougie was 
passed. This was repeated every third day 
until the wound in the perineum was en- 
tirely healed, which required six weeks, the 
drainage-tube and catheter only remaining 
in three days. Patient left the institution 
cured. 
Case V.—External Urethrotomy.—W. J., 
aged 17, white, was admitted to the surgical 
ward of the Philadelphia Hospital suffering 
from retention of urine. Gave a history of 
having fallen astride a rail when thirteen 
years of age. On entrance to the hospital 
an attempt to pass a catheter by my resident 
failed. Neither was he able to pass a filiform 
bougie. Failing myself to pass an instru- 
ment, I had the patient etherized. Under 
the influence of the anaesthetic I succeeded 
in passing a No. 12 conical steel bougie, 
French scale. As the patient desired per- 
manent relief, and the stricture (traumatic) 
was situated in the deep urethra, I performed 
perineal section. An incision, beginning at 
the junction of the scrotum with the peri- 
neum, was carried back in the median line or 
the perineal raphe for two and a half inches, 
when, by a careful dissection through the 
deep structures, the urethra, which was infil- 
trated to a considerable extent with inflam- 
matory material, was exposed. A small open- 
ing was now made in the urethra, through which a grooved director was passed into the 
bladder, from which passed a large amount 
of urine. The opening in the urethra was 
extended anteriorly through the stricture. 
A sound, No. 40 F., could now be passed 
through the urethra and into the bladder. 
From the perineal wound a catheter was 
passed into the bladder, which was held in 
place by a suture ; a drainage-tube passed 
through the urethra ; the wound thoroughly 
irrigated, dusted with iodoform, and packed 
with iodoform gauze; a suppository of 10 
grains of quinine and 1 grain of opium was 
introduced into the rectum, the wound 
dressed antiseptically, and the patient placed 
in bed. The dressing was allowed to remain 
for four days, when the packing with the 
catheter was removed, and both wound and 
bladder thoroughly irrigated with a solution 
of boric acid. A sound, No. 40 F., was 
passed with the same ease as at the time of 
the operation. The wound was again lightly 
packed and dressed antiseptically. The pa- 
tient was dressed every three days, and a 
No. 40 F. bougie passed at the time of the 
dressing. Five weeks and three days after 
the operation the wound in the perineum 
had entirely healed. There was no difficulty 
experienced in passing a 40 F. bougie. The 
patient was discharged cured. 
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