J^?> ySS .$^s&m^dbJ -v ■ xi-Mi>i '- x 00 ■. .€ ^oKf.XMi *,\*\ ;is pXTURE JTHRA MALE IT' r.. ^0#*»;F ;i. ;■ y. .;.. i. : xa • M fm 'A- ■■■t. 0™.' iJ NLfl DS1QTS73 1 3&QQQQ®erOQnQ'QQ^9t}OOQ®Q®Qp'S Surgeon General's Office i) ^QaOjjaG'QjQ'^CQ.GaCQjGQSQGQ^JOa NLM051095731 DUE TWO WEEKS FROM LAST DATE Jfll 2 5 1956 KC|3 1963 ■•-iBte.: ( 8 7 6 5 4 3 2 1 . O O O O O O O. O O O O O o o o . ; !666o66o660000 5 28 27 26 25 24 23 22 21 20 19 OOOQOOOOOO,, .1 , J APPROXIMATED TO O THE METRIC SCALE^\ , , , I , . ." , . . . . . J ^ | , | , | , | , | , I , I , I I I I I i I l I I I I » I I l I l 1 1 1 I I I I I I I I I I I I I I I I t I I I I I I I I I I 1 I I I I I I I 1 I I I 1 I I I I I I 1 I I 1 I I I I I 1 I I I I I l> / 17 16- 15 11 13 12 11 10 9 ~8 7 G 5 4 3 2 1~~^V !6ooooooooOOOO 40 39 38 37 36 35 34 33 32 31 'O OOOOOOOOO -- — METXLTC SCALE. U || | , 1 , | M I M ! I I I ! I I 1 I I I I I I M I I II I M I I I I I II l< 1 M ', I I II I I . I I I I ■ 1 I I I I I M 1 I I I I I I I I I 1 I M ■ I I I ■ ■ I II I I I I II I I I I 1 I I II II I I I I I I I I I I I I .1 I I I I 1 I I I ' I I 1 I lMl I I I I 1 lll.l L/ THE METRIC SCALE. STRICTURE OF THE MALE URETHRA ITS RADICAL CURE BY FESSENDEN N. OTIS, M.D. Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York ; Surgeon to Charity Hospital, and President of the Medical Board ; Fellow of the N. Y. Academy of Medicine ; Member of the British Medical Association ; etc. NEW YORK G. P..PUTNAM'S SONS 182 Fifth Avenue 1878 WT Copyright, 1878, By G. P. Putnam's Sons. CONTENTS. CHAPTER I. Chronic Urethral Discharges—Bulbous Sound—Varieties of Urethral Discharges— Pathological changes in Inflammation of Mucous Membrane—Causes of Per- sistence—Indications for Treatment—Application of Remedies—Follicular Sinuses—Treatment of Folliculitis—Specific Medicines—Granular Ure- thritis—Meatoscope—Applications to the Deep Urethra—Diagnosis of Stricture—Individuality of Urethra.—P. i—26. CHAPTER II. Retrospect, Strictures of Large Calibre—Diagnosis by Bulbous Sounds—Relieved by Divulsion—Incapacity of Instruments—Dilating Urethrotome.—P. 27-3S. CHAPTER III. Retrospect, Dilating Urethrotomy—Multiple Strictures—Details of Operation— Operation Repeated—Cure of Gleet and Stricture —Completeness of Results —Dr. Gouley's Urethrotome—Improved Urethrotome—Endoscopic Errors— • Granular Urethritis due to interference with Muscular Movements—Sugges- tions of Radical Cure.—P. 39-57. CHAPTER IV. Retrospect, Urethrotomy, External and Internal, for multiple and difficult Strict- ure— Its Advantages—Fourteen Strictures—Immediate Results—Erroneous Teachings—Dr. Curtis's Brochure—Sir Henry Thompson's Views—Normal Urethral Calibre—Gleet the Signal of Stricture—Calibre of Meatus, and Fossa Navicularis—Urethra-metre—Why Strictures Return—Recontraction may be Prevented—Strictures curable by complete Division.—P. 5S-S2. CHAPTER V. Retrospect, Van Buren and Keyes on Urethral Calibre—European Endorsement— Slight Strictures Important—Proportionate relations of Penis and Urethra— Stricture Tissue Resilient—Stricture never cured by Dilatation—Meatus no guide to the Urethral Calibre—For radical cure every fibre of the Stricture IV CONTENTS. must be Divided—Tabular Analysis of locality of Strictures—Accidents fol- lowing Operations—Accidents Rare—Table of Cases Cured—Table of Results in ioo Cases—Mode of Operating—Cold water Coil—Cause of Recontrac- tion—Statistical Tables.—P. 83-122. CHAPTER VI. Itinerary, Cure of Perineal Fistula—Mr. Coulson's Case—Mr. Teevan's Case— Traumatic Stricture with Fistulse cured by Internal Urethrotomy—Rela- tions of Gleet to Stricture—Mr. Henry Dick on the Pathology and Treat- ment of Gleet—Stricture the Cause of Gleet—Knowledge of Normal Cali- bre Important—Degrees of Gleet—Cause of Dribbling—Granular Urethritis due to Stricture.—P. 123-143. CHAPTER VII. Retrospect, Errors of English and French Schools—Dr. H. B. Sands on Gleet and especially its Relations to Urethral Stricture, a Discussion of Dr. Otis's Views—Dr. Sands on Urethral Calibre—Casts of Urethrae.—P. 144-166. CHAPTER VIII. On the Relations of Gleet to Stricture—Dr. Otis's reply to Dr. Sands—Discussion of Dr. Sands's Paper—Gonorrhoea not the chief cause of Stricture—Irritating Urine, venereal excess, Masturbation, etc., as causes of Stricture—Dr. Sands's and Sir Henry Thompson's Methods fail to detect the earlier Invasions of Stricture—Dr. Sands's Casts represent Abnormal Urethrae—Complete free- dom from Obstruction essential to perfect Micturition—Variations in size of the Meatus—Highest Normal Type of Meatus—Drs. Van Buren and Keyes on Strictures of the Meatus—Dr. Gouley on Proportion of Strictures at the Meatus—Slitting of Contracted Meatus not Irrational—Results of Contracted Meatus—Dr. Sands, Dr. Van Buren, Dr. Curtis and others on Urethral Cali- bre—Method of Determining Calibre with the Urethra-metre —Discussion by Dr. Bumstead, Dr. Peters, and Dr. Keyes—Table of Measurements of 100 Normal Male Urethrae.—P. 167-212. CHAPTER IX Retrospect—Clinical Lecture on Treatment of Incipient Stricture, by Otis's Op- eration, by Mr. Berkeley Hill, of London.—P. 213-223. CHAPTER X. Dr. Otis's Reply to Mr. Hill—Average size of Meatus in 100 Cases—Calibre of Spongy Portion —Strictures may recur when not completely Divided—Com- plete Division cannot be determined with certainty at the time of Operating —Mr. Hill's Accidents due to Errors in Operating—Curvature of the Penis very rare after Internal Urethrotomy.—P. 224-236. CONTENTS. V CHAPTER XI. Dr. Thos. R. Brown on Urethral Calibre—Dr. Gross confirms Dr. Otis's views in reference to Relative size of Penis and Urethra—Measurement of Foetal and Infantile Urethrae, by Dr. Brown—The Dilatation of Fossa Navicularis acquired, not congenital.—P. 237-247. CHAPTER XII. Report of thirty Operations for Urethral Stricture, Otis's Method, by C. H. Mas- tin, M. D.—Confirms Dr. Otis's Views.—P. 248-254. CHAPTER XIII. Dr. R. W. Pease's Report of Seventy-one Operations for Stricture by Otis's Method—Otis's Claims Confirmed—Synopsis of forty-five Cases.—P. 255-274. CHAPTER XIV. Memoir to the French Academy—Plan of M. Reybard—Otis's Straight Dilating Urethrotome—Safety of Dilating Urethrotomy—Hemorrhage Prevented— Smith's Penis Compressor—Perineal Crutch—Perineal Tourniquet—Otis's Bulbous Urethrotome—Urethral Fever—Suppression of Urine—Incurvation of Penis—Otis's Dilating Urethrotome for Diagonal Division—Spongio- corporitis.—P. 275-292. CHAPTER XV. Strictures of Large Calibre—Causing Cystitis, Perineal Abscess, Urinary Infiltra- tion—Quotation from Dittel-r-Reflex Irritations and Neuroses—Retention of Urine—Civiale's Views.—P. 293-306. CHAPTER XVI. Strictures of Small Calibre—Treatment Preparatory to Operating—Complica- tions—Strictures often Impermeable—Dilating Catheter—Re-examinations and Results.—P. 307-323- CHAPTER XVII. Conclusions, Table of 136 Cases, 2d Series—P. 324. LIST OF ILLUSTRATIONS. PAGE Bulbous Sound.................................................. 2 Syringe Nozzle................................................... 9 Meatoscope...................................................... 16 Short Meatoscope............................................... 17 Deep Urethral Syringe......................................... 19 Improved Bulbous Sound.......................................23, 136 Voillemier's Divulsor.......................................___ 32 Dilating Urethrotome........................................ 35 Gouley's Urethrotome.......................................... 50 Small Dilating Urethrotome.................................... 51 Improved Bulbous Sound........................................ 56 Fourteen Strictures......................................... 63 Vertical Section of Glans Penis........................... 76,161,177 Urethra metre.................................................. 90,136 Urethral Tube, for Haemorrhage.............................. 98 Small Dilating Urethrotome................................... 103 Bulb-pointed Bistoury.......................................... 104 Solid Sound, Short Curve....................................... 105 Urethral Casts............................................... i57>174 Straight Dilating Urethrotome................................ 278 Smith's Compressor............................................... 281 Perineal Crutch.................................................. 2S3 Perineal Tourniquet........................................... 285 Curved Probe Point for Straight Urethrotome................. 2S6 Bulbous Urethrotome.......................................... 2S6 Dilating Urethrotome.......................................... 3°9 STRICTURE OF THE MALE URETHRA; ITS RADICAL CURE. CHAPTER I. CHRONIC URETHRAL DISCHARGES. THE subject of Genito-Urinary diseases, and more espe- cially those forms of trouble known as Urethral Strict- ure and Gleet, have received much consideration from me for several years past. As my study and experience in these dis- eases have led me in a direction somewhat opposed to the views and treatment hitherto accepted by surgeons throughout the world, it appears to me desirable at this time to make a full statement of the course, progress, and results of my ob- servations and practice. As early as the year 1861, I had come to appreciate the fact that the ordinary elastic bougie, or any instrument of uniform diameter, might traverse a urethra without giving in- dication of Stricture at any point ; whereas, in the same urethra, with the bougie-a-boule (of M. d'Etiolles) of the same size, Stricture was, not unfrequently, made out with absolute certainty. Soon finding the necessity for an instrument of wider range and greater endurance than the bougie-a-boule of M. d'Etiolles, (which was made of gummed cloth, and rarely found larger than 21m. of the French scale,) I devised the bulbous sound. This was a simple metallic bulb of olive shape, attached to a slender copper shaft. Six of these instruments were constructed under my direction, by Hernstein & Co., Surgi- cal Instrument Makers, of sizes from 18 mm. to 30 mm. in 2 CHRONIC URETHRAL DISCHARGES. circumference, and, for convenience, screwing into a common handle. With the aid of these bulbs I was often able to detect localized points of contraction that had escaped recognition in examination with the smaller bulbs of M. d'Etiolles. At this early period (1861) my attention was attracted to the frequent association of a chronic purulent urethral discharge the bulbous sound. with localized urethral contractions of greater or less degree. The rebellious behavior of such discharges, under all then recognized modes of treatment, induced me to make this subject one of especial study for the following years and up to March, 1870, when I presented the results of my thought and experience in a paper read before the New York Medical Journal Association, and published in the N. Y. Medical Jour- nal of June, 1870, as follows : On Chronic Urethral Discharges. In the term chronic it is intended to include, not only those purulent or muco-purulent discharges from the urethra which occur as the sequelae of acute inflammations of the urethral mucous membrane, but all which, by their appear- ance and sub-acute character, resemble such discharges with- out regard to the time of their continuance. In considera- tion of the similarity between chronic urethral discharges, both as to their symptomatology and their chemical and physical constituents, and in view of their moral and social as well as the medico-legal relations, the importance of classi- fying such discharges in accordance with their etiology will, I trust, be admitted. By such an arrangement, they readily separate into three distinct groups : I.—The venereal specific. VARIETIES pF GLEET. 3 II.—The venereal non-specific. III.—The non-venereal. Under the head of venereal specific we then have— I. Gonorrhoea and its sequelae. 2. Chancroid. 3. Syphilis. Under that of venereal non-specific we have— 1. The menstrual fluid. 2. Vicious non-specific, vaginal, and uterine secretions. Under that of non-venereal— 1. Acrid urinary secretions. 2. Idiopathic inflammation of the prostate. 3. Mechanical injuries and obstructions and chemical irritants. 4. Cutaneous disease. The inclusion of gonorrhoea among the venereal specific causes of chronic discharge from the urethra is with entire acceptance of the fact, that no physical distinction has yet been drawn between an acute urethritis, caused by contact with gonorrhoeal matter, and one set up by the application of the purulent secretion of a conjunctivitis, or of a uterine catarrh, or by excessive coitus, or, in short, by any one of the causes which are set down among the non-specific class. Yet it is well known that a peculiar virulence does pertain to the purulent secretion of a gonorrhoeal urethritis ; that its contact with sound mucous membrane communicates, with almost positive certainty, an inflammation whose product is of similar virulence, and whose tendency is to run a prolonged course; while from all other causes to which a urethritis may be at- tributed, not only is the establishment of the disease most ex- ceptional, but, when it does so occur, it is of shorter duration, and, as a rule, of more benign character. That gonorrhoeal pus has the power, more than any other, of extending its degenerating influence beyond the immediate layer of epithe- lium in contact with it, also seems to me certain ; but, until a specific virulent principle can be found in it, we must be 4 CHRONIC URETHRAL DISCHARGES. content to accept the inflammation of gonorrhoea as a simple inflammation of unusually acute character. Yet, in a classi- fication based upon etiological considerations, the propriety of placing gonorrhoea among the specific causes of urethral discharge must, I think, be conceded. The organisms with which we have chiefly to deal, in considering diseases of the urethra, are mucous membrane, muscular and connective tissue, with their vessels and nerves. The mucous membrane which lines the urethral canal consists, like all other mucous tissues, of an epithelial structure, lying on a basement membrane ; the epithelium being of the strati- fied kind, and of varied character in different regions—the tessellated variety presenting in the anterior, the spheroidal and columnar in the posterior parts of the canal. Under- neath the mucous membrane is a thin layer comprised of muscular fibres and connective tissue, which is united to the tendinous layer of the corpus spongiosum by delicate mem- branous bands. It may be well to glance briefly over the pathological changes which are now recognized as taking place in inflam- mations of mucous membrane of the variety under considera- tion, viz., those protected by a stratified epithelium. All such in their normal condition present a lubricated surface— this lubrication due to a bland secretion from the mucous follicles. Under the microscope, this secretion is found to consist of mucosine in which are suspended mucous corpuscles and epithelial scales. When the membrane is subjected to irri- tating influences, the epithelial element in the secretion is increased, the epithelial cells are hurried from the surface before they are fully developed, their forms become rounded, and hence they are more easily detached, until, as the inflam- matory process progresses, the natural proliferation of epi- thelial structure becomes luxuriation (Virchow). Layer after layer is thrown off, less and less perfectly developed, losing more and more the characteristics of the true epithelial scale, until at length it has degenerated into the form recognized CAUSES OF PERSISTENCE. 5 as the pus-corpuscle, and the mucous secretion has assumed all the features of the purulent discharge. In their normal condition, mucous membranes secrete only sufficient fluid to answer the purposes of lubrication. All discharges from the urethra are then evidences of abnormal excitement—of imperfect cell-development—varying in de- * gree from the first stage of epithelial imperfection to complete purulent degeneration, and dependent upon exciting causes of the varied character indicated in the classification I have ventured to adopt. In the frequency of its occurrence, in the importance of its indications, in its pathological connections, and in its moral, social, and medico-legal belongings, the discharge arising from gonorrhoea and its sequelae ranks first in im- portance. We have at this time only to deal with chronic forms of disease as defined in the commencement of this article. Omitting, then, all consideration of the acute stage of gonorrhoea, I shall at once proceed to consider the con- ditions upon which a continuance of the chronic or sub- acute discharge may depend. These are as follows: I. An enfeebled condition of that portion of the mucous lining of the urethra which has been occupied by the acute in- flammation. The degeneration of epithelium set up by the acute disease is continued by enervation—a simple want of vitality in the tissue sufficient for a return to its normal func- tions. 2. The vitality apparently restored by appropriate local and general treatment ; the discharge, though in de- creased amount, still continues. Its continuance may depend on the localization of the disease in the deeper parts of the urethra, or in folds of membrane, or in mticous crypts or fol- licles zvhich have escaped local medication. 3. The continuance of the discharge may be due to granular ulcerations located at any point along the canal where from any cause complete exfoliation of the epithelium has occurred. 4. From altera- tions in the course and calibre of the urethral tube dependent upon pathological changes occurring during recent or pre- vious inflammations. These causes of the persistence of 6 CHRONIC URETHRAL DISCHARGES. a urethral discharge, with gonorrhoeal antecedents, I propose now to consider, and to indicate the remedial measures which in my own experience have proved most productive of benefit. When, after a longer or shorter time, the acute symptoms of an attack of gonorrhoea have subsided, and there remains simply a muco-purulent, painless discharge, examination should be carefully instituted, with the view of ascertaining the exact point to which the disease has extended, and, as nearly as possible, the pathological condition upon which the continuance of the discharge depends. This may be done in a rough way by pressing the walls of the urethra together and squeezing out the discharge from the meatus, making the pressure farther and farther back, until no more fluid can be made to exude. In the absence of any tenderness or uneasi- ness beyond the point so examined, you may conclude that the disease has not extended beyond that limit. If, in addi- tion, a fair-sized bulbous bougie fails to detect any special points of tenderness, it may be concluded that the difficulty is dependent upon the first of the causes mentioned, viz., a want of recuperative power in the epithelialstructure, and that there is sufficient of the gonorrhoeal influence to keep up an exagge- rated desquamative action, though not sufficient to excite acute inflammation. The additional fact that the membrane is kept constantly bathed in fluid, also retards the return to a normal condition by diminishing the cohesive power of the superficial cell growths. The indications for treatment then are, to apply such local means as are most likely to dimin- ish the excess of fluid, and to stimulate the membrane to a more complete performance of its functions. Solutions of the salts of zinc, lead, and iron, combining astringent and stimulating properties in various degrees, are found well calculated to meet this double requirement. Vegetable tonics and astringents are also of value. The more thoroughly the epithelial products in the discharge are degenerated, the more stimulating and astringent is the application re- quired ; so that, when the discharge is thoroughly purulent, APPLICATION OF REMEDIES. 7 the more stimulant salts, as the chloride, sulphate, or acetate of zinc, etc., will be found most beneficial; the more it approaches the mucous character, the more simply astringent should be the application. Under all circumstances, where a simple atonic condition perpetuates the discharge, no solu- tion of any sort should be used of a strength sufficient to produce a caustic effect. Stimulation alone is required, such as results from solutions of the sulphate of zinc, or the acetate of lead, alone or in combination, and of a strength varying from one to three grains to the ounce of distilled water. When the discharge is not wholly without pain, I am accus- tomed to add two or three grains of the extract of belladonna to the ounce. When the discharge is small in quantity and chiefly mucous, the acetate of lead, grains one to three ; the persulphate of iron, grains three to five; tannic acid, grains five to ten, are often promptly efficacious. The power of phenol (the so-called carbolic acid) to modify and arrest sup- purative action, wherever located, is now generally admitted. My own experience in its use in disease of mucous membranes has been considerable, and I have seen positive benefit in quite a number of cases where a solution of two or three grains to the ounce has been used ; but I have not employed it to any such extent as would at present warrant an expres- sion of opinion as to its real value. The recent statement of a contributor to the Cincinnati Medical Repertory, that he had used it in hundreds of cases of gleet with magical effect, suggests a prevalence of the disease in that region which is appalling; while an entire forgetfulness to cite the supposed pathological conditions in any case, would warrant a suspen- sion of judgment as to the accuracy of the recital. Other journals have presented testimony of its efficacy in the treatment of urethral discharges. The antiseptic and antipa- rasitic qualities of phenol certainly warrant an expectation of usefulness in discharges of a specific nature, and it seems to me-not improbable that it may come to be a valuable agent in the management of gonorrhoeal disease. The permanga- nate of potash, three to five grains to the ounce, has been 8 CHRONIC URETHRAL DISCHARGES. highly recommended in simple chronic gonorrhoea. I have used it in perhaps twenty cases, with the apparent effect of arresting the discharge for a short time, but have inva- riably been obliged to resort to other means to complete the cure. The mode of application of solutions to the urethral mucous membrane which I have been accustomed to employ is by injection with a hard rubber syringe, of the capacity of half an ounce, and constructed with a well- rounded extremity, so that it may be easily and painlessly introduced, and the meatus readily and effectually closed around the pipe after insertion. Inasmuch as it is desirable that the injection should be applied only to the diseased sur- face, the urethra should be closed by pressure with the thumb and finger at the point previously fixed upon as the depth to which the disease has penetrated ; with this precaution the danger (which is not an imaginary one) of establishing a new focus of disease by forcing the vitiated secretions into the deeper parts of the urethra, or even into the bladder is avoided. A very general impression exists in the profession that fluids are with difficulty injected into the deeper parts of the urethra by an ordinary syringe, and that to force them into the bladder, by that means, is a physical impossibility. The positive statements to that effect by various authors (Acton, Milton, etc.) would tend to confirm such a belief. Within the past two years I have had three patients who were able to inject their respective bladders by means of an ordinary Davidson's syringe, one of them throwing in a pint of water, in my presence, then emptying the viscus—refilling and discharging it three times in succession. I am, therefore, convinced that it is judicious to limit the distance we desire to medicate, by pressure on the canal at a given point. And I also believe that the whole diseased surface can usually be reached by a properly constructed syringe of ordinary size. After directing the patient to pass his water (for the purpose of cleansing the canal), the medicated fluid should be thrown in quickly, to avoid spasmodic resistance, filling the urethra to the desired limit, and allowing it to remain for from one to FOLLICULAR SINUSES. 9 three or four minutes. This procedure I am accustomed to have repeated three or four times in the twenty-four hours. If, notwithstanding the use of injections administered after the manner I have indicated, the discharge still contin- ues, though in decreased quantity, no other cause of failure appearing prominent, I am led to infer— That the medicating fluid does not reach all points of the diseased surface; that, from insufficient distention of the canal, portions between folds of the membrane, or in the sulci of some of the numerous follicles with which the urethral lining is studded, have escaped the topical application. For security against failure, I am accustomed to introduce the in- jection through a modification of the ordinary syringe, as repre- syringe nozzle (half size). sented in the cut. By means of this instrument the urethra is penetrated to the farthermost point of disease, dis- tended to its full capacity and thoroughly bathed with the contained fluid. No point or portion can escape the ap- plication, except it be located in the lacuna magna, or in some accidental follicular sinus. These exceptions I am in- clined to think are not very rare. Dr. Benjamin Phillips, in his treatise on " Diseases of the Urethra," states that he has found the continuance of a chronic gonorrhoea to depend upon the engagement of the lacuna magna in the disease, and. cites four cases of cure by slitting up the inferior wall of that sulcus on a director. I have met with two cases of similar character which were successfully treated by injections introduced by means of a blunted hypodermic syringe. Un- der the designation of '■'■follicular sinuses," I allude to little fistulous canals which are sometimes met with running out- ward from the urethra, and occasionally opening upon the surface of the penis. 10 CHRONIC URETHRAL DISCHARGES. I have a record of two and possibly of three such in- stances. The first, in a gentleman who presented himself to me suffering from a very scanty muco-purulent discharge of two years' standing, which, commencing as a gonorrhoea, had resisted much treatment. Close to the meatus—say a quarter of an inch—on the right side, two minute openings were vis- ible, each the size of a pin's-head, one above the other, and about one-fourth of an inch apart. The patient remarked that, after connection, he always noticed a little matter at these points. Examining the fossa navicularis, I found its floor occupied by a narrow superficial ulcer a third of an inch from the orifice and half an inch in length. Exploring the fistulous openings with a fine probe, I endeavored to find a communication between them and the ulcer of the fossa, but was unable to do so. I did find, however, a fine canal connecting the two abnormal orifices, which I slit up and cauterized. The ample meatus received a No. 20 F.* bulbous sound with ease, but was arrested at the point of ulceration, and would only allow the passage of No. 16. I slit the constriction, which extended the entire length of the ulcer, and passed a No. 20 Benique sound into the bladder without difficulty. Twenty days afterwards, the wound was ci- catrized, and the discharge had disappeared. I felt confident to the last that there had been a connection between the openings on the surface and the ulcer of the fossa, but failed to find it. Five years have passed since then, but the patient, who married about that time, has had no further urethral trouble. The second case was that of a young man from Omaha, who came to me presenting a pustule the size of a pin's-head on the right side of the meatus urinarius, midway of the glans, and about one-third of an inch from the labium. Believing it to be the result of a vicious connection four days previous (as it had quite the appearance of a follicular chancroid), I cauterized it with a fine glass point charged * Whenever the letter F occurs, following figures, it indicates the French measure, i. e. by millimetres in circumference. One millimetre equals ?V inch. TREATMENT OF FOLLICULITIS. II with nitric acid, and felt warranted in giving the assurance of speedy cure. Two days following, the patient presented himself, with the lesion cicatrized, but a similar pustule had developed about a quarter of an inch above the site of the first. Confirmed by this, in my view of the chancroidal origin of the difficulty, the second was likewise touched with the nitric acid. On the following day my patient again presented himself, announcing that the first pimple had again broken out, and that he also had the clap. Making pressure of the glans, a drop of creamy pus exuded from the meatus and also a minute quantity of the same sort from the two little orifices on the site of the pustules. Struck with the similarity in location and appearance of these little openings with those of Case I., I at once set about exploring them. A fine silver- wire probe passed readily into one and out at the other; the lower seemed superficial. Into the upper, however, I suc- ceeded in passing the probe nearly half an inch backward and upward on a plane parallel with the urethra. Feeling certain that a communication existed, through this sinus, with the urethra, I introduced as far as I was able the blunted point of a fine hypodermic syringe ; and, having previously insin- uated a bit of lint into the fossa naviculars, I injected a solution of indigo. After several unsuccessful trials, at last, on the withdrawal of the lint, it was found slightly but dis- tinctly stained with the indigo. Shall we infer in this case that the trouble was originally a simple folliculitis creeping along an accidental sinus—possibly producing it—opening on the surface of the glans, and finally breaking also into the fossa, or was it of gonorrhoeal origin, having its initial point in the external follicular opening, and after seven or eight days cropping out into the urethra? No solution of contin- uity could be detected in the fossa navicularis, nor was there much tenderness at any point. A ten-grain solution of the nitrate of silver was injected into the fistula, with the apparent effect of closing it entirely ; the passage between the two points was slit up and cauterized. The gonorrhoea (if it was a gonorrhoea) extended very little beyond the fossa of the 12 CHRONIC URETHRAL DISCHARGES. urethra, ran a very mild course, and ceased under astringent injections in about ten days. The third case was in a Mr. D., wrho came to me two years since, complaining of a little boil on his penis. Examination disclosed a small purulent-looking collection between the folds of loose tissue, a little to the right of and behind the frenum. Both the surrounding inflammation and the swell- ing were very slight ; there was but little accompanying ten- derness ; the deposit was covered only by transparent cutis. A slight touch with the bistoury caused it to discharge three or four drops of laudable pus. As there were no venereal antecedents in the case, I remarked that it was probably a little sebaceous follicle which had become obstructed, and that he would have no further trouble from it. Several weeks after, Mr. D. called to inform me that he was quite well of the boil, but that when he urinated the water came out of the side of his penis. On examination, I discovered a fine opening like a pin-hole at the bottom of a small, funnel-shaped depression on the site of the old difficulty. A fine silver wire probe readily penetrated it, parallel with the urethral canal, for about half an inch. Failing to find my way into the ure- thra by this means, I introduced the blunted hypodermic syringe, and, on driving in the piston, the fistulous communi- cation was demonstrated by free dripping of water from the meatus. The foregoing cases, taken together, appear to me to war- rant the inclusion of follicular sinuses among the possible causes of persistent urethral discharge ; and, although I find no mention made of such complications in the literature of urethral disease, I venture the opinion that analogous cases have occurred in the experience of many practitioners. In conjunction with the local treatment, the internal ad- ministration of such special medicines as are known by expe- rience to act beneficially upon diseased mucous tissues, espe- cially those of the urinary tract, is often advisable. The bal- sam of copaiba and the oil and powder of cubebs I have prescribed with benefit, but so often have succeeded in upset- SPECIFIC MEDICINES. 13 ting the digestive apparatus of my patients, without securing the desired result, that I now rarely recommend their use. Much more tolerable, and, in my experience, of much greater efficacy in such conditions, is the oleum santalum citrinum (the oil of the yellow sandal-wood), in doses of from ten to twenty drops, on sugar or, preferably, in capsules, three or four times a day. I have seen recoveries from its use in from three to six days, after the long and faithful employment of injections and other internal medicines had proved unavailing. Berkeley Hill, a recent English writer, speaks highly of this remedy, where it can be borne, and advises it in doses of from twenty to sixty drops, three times a day, remarking, however, that " it produces nausea and vomiting, like copaiba, though in less degree." The maximum dose I have ventured to prescribe has been twenty drops, and, in uncomplicated atony of the urethral membrane, always with good effect. A patient would now and then complain that the subject of sandal-wood fans was too often introduced in his presence to be quite agreeable ; beyond the odor, however, and its giving rise to occasional slight dyspeptic trouble, the remedy ap- peared unexceptionable. Recent chemical investigations* have demonstrated the presence of phenol in the aromatic oils, such as oil of thyme, fir, cinnamon, cubebs, sassafras, sandal-wood, etc., and they are now included in the class of phenols. Not a few of these, cubebs, fir, thyme, etc., have long had a reputation for usefulness in diseases of mucous membranes generally, and in gonorrhoeal disease in particular. Is it not possible, then, that the active curative property in each is due to the phenol of which the predominance in any one determines its superiority ? Further chemical re- searches in this direction may yet discover other and still more potent remedial agents for internal as well as local use, and aid in the simplification of our now too empirical and overburdened category of anti-blenorrhagic remedies. The muriated tincture of iron, in doses of from ten to twenty * See Squibbs's " Notes on the Phenols from Coal Tar," etc., in the Proceed- ings of the American Pharmaceutical Association, 1868. 14 CHRONIC URETHRAL DISCHARGES. drops, repeated three or four times a day, I have found of decided benefit in asthenic gonorrhoea, even when the patient does not present the usual constitutional aspect which indicates its use. Iron, in conjunction with cantharides (as recom- mended by Dr. Bumstead, page 90 of his " Treatise on Vene- real Diseases"), I have occasionally prescribed, with prompt beneficial results. In cases of long standing the discharge is often found to proceed chiefly if not wholly from the deeper parts of the urethra, the bulbous, and even the prostatic portion. Treat- ment in these need be in no wise different from that already indicated, except perhaps in the use of long pipe syringes, to secure with certainty application of the local remedial agents to the entire diseased surface. Wrhere the bladder evidently participates in the difficulty, as announced by uneasiness and aching in the supra-pubic region, with or without increased irritability of the vesical sphincter, and confirmed by the presence of pus in the urine drawn directly from the bladder, a daily washing out of this viscus with a solution of Squibbs's perchloride of iron, twenty or thirty drops to the pint of tepid water, has usually, in my hands, proved promptly successful in relieving the complication. In cases where the discharge persists, notwithstanding a faithful pursuance of the above plan of treatment, and no constitutional complications are recognized, I am led to sus- pect the existence of the third in the list of causes upon which a continuance of the discharge may depend, viz., a granular condition at some point or points in the canal, where, from an unusual activity of the morbid processes, the mucous membrane has been completely stripped of its epithelial cover- ing, the underlying tissue becoming involved in the inflamma- tory process, and ulceration results. At a certain stage in the declining inflammation, little irregular papillae organize and sprout from the plastic lymph which has been exuded to repair loss of tissue, and these papillae are called granulations. The tendency of loose cell-growth to condense into fibro-cellular tissue, which subsequently contracts and produces coarctation GRANULAR URETHRITIS. 15 of the urethral walls, renders the granular condition one of great importance, not only because it leads to Stricture, but because it is likewise frequently a source of free purulent se- cretion. The granular condition is usually indicated by a localized tenderness on pressure or on the passage through the urethra of a sound or bulbous bougie. These methods, of ascertaining the presence of such a complication are, however, liable to lead to incorrect conclusions, inasmuch as such tenderness may be produced by the natural obstructions to the introduc- tion of an instrument at the triangular ligament, the com- mencement of the membranous portion, and the neck of the bladder. Besides this, such granulations may exist, and yet, on account of the absence of nerve-structure in them, produce no decided sensation on the passage of instruments. In this dilemma we have fortunately another resource, viz., the ocular inspection of the entire surface of the canal by means of tubes of proper construction, which may be introduced into the urethra and illuminated, so that every important point is made visible to the careful observer. As far as known, the credit of first applying ocular in- spection to the diagnosis of urethral difficulties is due to Dr. J. D. Fisher, of Boston, who, in 1824, published, in the Philadelphia Joitrnal of Medical Science, the description of an instrument identical in all essential points with the en- doscope of Desormeaux. At present, however, the names of Desormeaux, of Paris, and Cruise, of Dublin (who improved upon the illuminating apparatus of Desormeaux's instrument), are alone associated with the endoscope. By their patient and careful observations and experiments, and by their large and valuable contributions to the pathology and treatment of urethral diseases through its use, they are entitled to stand eminent as authorities in that especial province. The endoscopic tubes of Desormeaux and Cruise were constructed of white metal, eight or nine inches in length. In using them I found a serious objection to the metallic surface, on account of the troublesome play of re- 16 CHRONIC URETHRAL DISCHARGES. flection along their interior; and, moreover, so great a length appeared unnecessary for examinations of the anterior portions of the canal. Tubes, varying from one and a half to eight inches in length, were constructed of hard rubber by Messrs. Tiemann & Co., under my direction. The smooth, black surface of these tubes, though requiring somewhat stronger light, was entirely free from reflections, and enabled me to define with much greater certainty appearances in the field or bottom of the tube. These were distinct under reflected sunlight, and also from that thrown out by Tiemann's mod- ified student's lamp, burning kerosene oil, with the addition of ten grains of gum-camphor to the ounce. The use of tubes of various lengths made it possible to bring the eye much nearer the desired surface, when it was located at any point anterior to the prostatic urethra, and proved, also, of further advantage in the greater ease with which the light was kept steadily on the field of the tube, and moreover, the shorter tubes perceptibly decreased the absorption of the luminous rays. Like Desormeaux's tubes, they were fur- nished with an entering shaft, to facilitate introduction into the urethra, and a mortice or cleft in the side, for the greater facility of making applications through them. For accuracy in locating any seat of trouble, they were graduated in one-half inches, and, to distinguish them, were called meat- oscopes. I have used these instruments exclusively for five years past, and believe I am able, through their assistance, to detect the more important tissue changes occurring in the urethral interior. Especially is the meatoscope valuable in diagnosis of the granular condition of the urethra, previ- ously mentioned. Introduced beyond the suspected point LOCALITY OF GRANULATIONS. 17 (the shaft being removed), a pencil of light is reflected, by means of a small concave mirror into and to the bottom of the tube, which is then slowly withdrawn. As the folds of healthy membrane roll symmetrically in toward the centre, the observer is able to note the exact point of de- parture from a healthy condition, and the character and ex- tent of the lesions. The favorite seats of granular ulceration of the urethra are in the natural expansions of the canal at the navicular and bulbous portions, evidently invited by the rich diffusion of crypts and follicles in the ample folds of those parts. Not seldom the difficulty, when occurring in the fossa navicularis, is occasioned by frequent and teasing contact with the point of the urethral syringe. No especial localizing cause being present, we should expect to find granular ulcer- ations of more frequent occurrence in the deeper portions of the urethra, on account of the preponderance there of the spheroidal and columnar varieties of epithelium, the cells of which, less easily detached, are also less readily reproduced than those of the tessellated kind. The location and nature of the diseased surface being determined, topical applications may be made through the reentered tube, by means of wire stylets armed with a bit of cotton or lint soaked in the fluid selected for use. I am accustomed to use for this purpose a solution of the nitrate of silver, of a strength, graduated in accordance with the sensitiveness of the parts, of from twenty to thirty grains to the ounce of distilled water, usually limiting the applica- tion to such an extent of surface as can be touched with the cotton at one time—the tube being held stationary. I have not unfrequently extended the application from one-quarter to one-third of an inch, sopping the surface as the tube is slowly withdrawn. I have not usually found it necessary to inspect the urethra under the light after having thoroughly 2 i8 CHRONIC URETHRAL DISCHARGES. located the diseased surface. Observing carefully the mark on the tube when the first application is made, it will usually be found that this portion is quite free from pain on the succeeding introduction of the tube, and that commencing sensitiveness indicates the point to which cicatrization has extended. At the first sensitive spot I repeat the application as before, advancing gradually, at each sitting, until the entire lesion is removed. Applications may be repeated once in from four to eight days. The field of the meatoscope should be carefully cleansed from any discharge that may be present, both in the preliminary examination and in that immediately preceding the treatment; this is easily effected by means of a bit of cotton twisted on one of the stylets. In some cases of granular urethra, I have used, instead of the foregoing plan, an injection of four or five drops of a solution of similar strength, (20 to 30 gr. to the ounce) with good results. For applications to the prostatic re- gion—less easily reached with the straight tube of the meatoscope—the use of a long curved syringe has appeared to me preferable. When pursuing this plan, for a long time I was in the habit of locating the prostatic region by the preliminary introduction of a catheter into the bladder, measuring back half an inch from the point where the urine entered the catheter at about the central part of the prostatic urethra, then transferring the measurement to an ordinary long curved syringe. I was thus enabled to apply injections with accuracy to the desired point. About a year since I had occasion to see a patient with Dr. James Bigelow, of Brooklyn, and applied an injection to the prostatic urethra, after the manner above described. The entire suc- cess of a single application in relieving the diseased condi- tion was so gratifying to the doctor, and the crude means through which it was accomplished so apparent, that he soon afterwards designed and presented to me a syringe-catheter represented by the annexed figure. W7ith this ingenious in- strument, both the measurement and the application are accomplished by a single introduction. The shaft of the APPLICATIONS TO DEEP URETHRA. l9 instrument encloses a double canal—one continuous with the barrel of the syringe, following the inner curve of the instrument, and terminating at the curved extremity of the shaft in a number of minute openings; the other continuous with the little branch-tube, and following the outer curve to the extreme end of the shaft. This (the catheter portion) is traversed by a wire which stops the opening at its extremity. On the introduction of the instrument, with the wire slightly retracted, at the moment of its entrance into the bladder a few drops of urine exude from the branch tube ; the wire- stopper is then pushed in, the instrument withdrawn half an inch, and the piston driven home. For all topical applications deep urethral syringe. to the prostatic urethra, this syringe-catheter has, in my ex- perience, proved admirably adapted. The last, but by no means the least important of the local conditions capable of prolonging a chronic gonorrhoeal dis- charge, is the alteration which may occur in the course and calibre of the urethral canal. Henry Dick, of London, who has written an elaborate monograph on the pathology of gleet, asserts that the continuance of a gonorrhoeal discharge may depend on deviations in the course of the urethra without con- traction of its dimensions. His conclusions were arrived at, by noticing, in cases where no actual disease could be detected and the discharge continued, that, on introduction of a sound, the flat handle always became oblique in the membranous portion of the canal; that wax bougies used for diagnostic purposes, when withdrawn, were crooked at that point, but without giving evidence of constriction ; and that these cases were cured by the systematic introduction of sounds. 20 CHRONIC URETHRAL DISCHARGES. I have seen cases which apparently presented all the above-named peculiarities, but I was, and am still, of the impression that the irregular, localized muscular action of the urethra produced the seeming deviation, and that the continuance of the discharge depended upon a lack of sup- pleness from general but superficial contraction or fulling up of the mucous membrane, which disappears, and along with it the discharge, on the return of the urethra to its normal dimensions. Most frequently, however, chronic gonorrhoeal discharges depend for their continuance upon positive and recognizable alterations in the. calibre of the urethra—contractures at various points of the canal—the legitimate sequelae of follicu- lar ulcerations. As the urine is propelled through the urethral tube, it impinges with more or less force upon any salient or con- tracted point. The column of fluid is arrested, and in propor- tion to the degree of arrest is the force of the blow upon the mucous surface at that point. More or less hyperaemia necessarily ensues, and a condition is soon established well adapted to prolong an existing gonorrhoea, or which, upon slight additional cause, such as venereal excitement, or even an unusually acrid condition of the urine, may result in the origination of a muco-purulent or a purulent secretion. We may hence affirm, as a most important axiom, that the slightest encroachment upon the calibre of the urethral canal is sufficient to perpetuate a urethral discharge, or even, under favoring conditions, to establish it, de novo, without venereal contact. It is in this way that gonorrhoeas occurring a few hours after exposure are generated; and it also explains the appar- ently unaccountable renewal of a urethral discharge after excitement, in individuals who have had no gonorrhoea] disease for years. Within the last two months, a gentleman, who (according to his own account) had lived virtuously for more than thir- teen years, consulted me in regard to a muco-purulent discharge FROM URETHRAL STRICTURE. 21 which gave him painful suspicion of the fidelity of his wife. I found, on examination, that it was dependent upon a Stricture at the commencement of the membranous portion of the canal which scarcely admitted a No. 3 bougie, and yet no suspicion of Stricture had before arisen. Some four years since, a young man came to me in great distress, requesting an opinion as to the probabilities of con- tagion from a muco-purulent discharge from which he was then suffering. He had a history of an acute attack of gonorrhoea a year previous, which was cured, all but an occasional very slight oozing of yellowish matter. This, after ten months' persistence, was pronounced innocuous by his medical adviser, whereupon, he went to Chicago and married. Three or four days later, finding his discharge in- crease, he left his bride and came to this city to inquire concerning the possibilities aforesaid. Examination in this case brought to light a narrow Stricture at the peno-scrotal angle, which had evidently perpetuated the discharge. In regard to the contagious property of such a discharge, I will simply state that, within the week he read me a letter from his bride, containing as classical a description of gonorrhoea in the female as I ever saw. It will be readily seen that the recognition of Stricture as a cause of the origin or the persistence of a muco-purulent discharge is of the utmost importance, involving, besides the discomfort of the local trouble, other issues of the gravest moment. While authorities differ as to the precise seat in which contractions may occur, all are agreed that their most com- mon location is at those points where gonorrhoeal inflamma- tion runs the highest and dwells the longest, viz., the bulbous and navicular parts of the urethra. The chief, if not the sole cause of these constrictions is the granular ulceration previously dwelt upon. The plastic lymph which is thrown out becomes organized, and finally condensing or cicatrizing, produces a narrowing of the tube to a greater or less degree, in proportion to the extent of 22 CHRONIC URETHRAL DISCHARGES. tissue involved, forming, in short, what we are accustomed to designate as Stricture of the urethra. I have already spoken of the difficulty of diagnosticating contractions by means of the ordinary sound or the flexible bougie. The fact that a No. 16 or even a No. 20 can be readily introduced, is no positive proof of its absence. A man may have a urethra of size No. 21, with a contraction at some point of half a line, which the instrument No. 20 will fail to announce. To obviate this source of error, Sir Charles Bell, many years since, invented the ball-probe, which consisted, as the name implies, of a slender rod surmounted by a metallic ball. Selecting one suited to the proportions of a given meatus, it was passed down the urethral canal until arrested by the Stricture ; then this, or one of a size just permitting its pas- sage through the contraction, was introduced through it, and allowed to remain for a few moments. On attempting to withdraw the instrument, the ball would be arrested at the posterior boundary of the Stricture, thus definitely locating its extent and position. Le Roy d'Etiolles improved the ball probe of Bell by substituting an acorn shape for the ball, and a flexible material for the shaft, thus facilitating its introduction, and adapting the shaft more readily to the curvatures of the canal. In my own practice I have given a preference to still another modi- fication which appears to me to combine the excellences of both instruments, viz., a metallic olive-shaped bulb, whose firm polished surface (like Bell's) glides more readily over the mucous membrane than the gum coat of d'Etiolles' bulb. The olivary shape, while entering as easily and defining with suffi- cient accuracy, is less painful on withdrawal than the more abrupt base of the acorn shape; and the small soft metal shaft unites great firmness with a degree of flexibility suffi- cient for ready alteration of its curve. The handle is per- forated throughout its extent, thus allowing it to be slipped forward on the shaft to the meatus, and screwed fast, so that, when the situation of the Stricture has been determined, it correctly registers its depth. In explorations of the urethra DIAGNOSIS OF STRICTURE. 23 with this instrument, I am accustomed to accept the meatus, if apparently of normal size, as a gauge of the urethral calibre ; that is to say, any instrument which will pass that orifice will easily traverse the entire canal if no abnormal condition is present. It should be borne in mind, however, that both ^— ' —^CS. w==== bulbous sound (improved), half-size. congenital and pathological contractions of the meatus are not infrequent. A bulb, with its shaft bent to correspond with the curve of an ordinary sound, is accurately fitted to the urethral ori- fice, then slowly inserted and pushed gently back until some resistance is recognized. Muscular contraction may arrest the instrument at any point along the spongy urethra, but, with a little delay, this will subside. As the bulb advances it may impinge upon the triangular ligament; tilt- ing the shaft upward will clear this point. Muscular con- traction will also usually occur at the commencement of the membranous portion and at the posterior part of the pros- tatic, gently overcoming which, the bulb slips into the bladder. This is the usual course of the proceeding when no contraction has been recognized. After allowing the bulb to remain in the bladder for three or four minutes, it is slowly withdrawn ; if contractions are present at any point, slight clinging or want of suppleness will indicate their locality, and, in moving the bulb back and forth, where resistance is appre- ciated, a diagnostic ridgy feel may be recognized. Should this proceeding fail in locating a constriction, I am then ac- customed to slit up the meatus freely, and repeat the opera- tion with the largest bulb that will enter the spongy portion. Failing with this, a full-sized meatoscope, without the enter- ing shaft, is introduced under the light, and slowly pressed back along the passage, carefully noting any paling or lack of flexibility of the membrane, at any point. Should this last 24 CHRONIC URETHRAL DISCHARGES. effort yield no evidence of undue condensation of tissue, I am forced to conclude that no contraction is present. Decided Stricture is not likely to escape notice; it is the slight diminutions of the urethral calibre that are usually overlooked, and which may keep up indefinitely a trouble- some discharge. Especially at or near the meatus is Stricture likely to elude observation, and, in my opinion, the occurrence of Stricture at these points has been greatly understated by authorities. Not only is the inflammation unusually acute at this extremity of the canal, but the irritation and even excoriation, which often result from the use of improperly constructed syringes, plainly increase the tendency to plastic effusions about the urethral orifice. I will cite a" single instance in point. A gentleman consulted me not long since on account of a muco-purulent discharge from the urethra, stating that he had never had gonorrhoea, nor any sus- picious exposure for many years. I found a decided contrac- tion at about a third of an inch from the meatus. On inquiry I ascertained that, in times past, when he was in the way of carnal communication with loose women, he was in the habit of using an injection of alum-water as a preventive of disease. The Stricture appeared in this case, (which I consider typical of a class) to be due to the teasing contact of the membrane by the point of the syringe. The presence of a warty or polypoid growth may interfere with the integrity of the urethral calibre—a complication which can be readily recog- nized by means of the meatoscope. The treatment of contractions of the urethral canal cannot be fully considered in the limited scope of this paper. I am in the habit of employing the usual methods, gradual dilatation, rupture or internal division, according to the in- dications presented in each case. Always bearing in mind the tendency of Strictures to recontract, I endeavor to leave the strictured part above, rather than equal to the normal size, using healthy portions of the urethra as the guide, and not the numbers marked on the sounds. The standard measure- ments of the normal urethra are very well to philosophize INDIVIDUALITY OF URETHRA. 25 upon, but, practically, we must recognize and respect a dis- tinct individuality in each case, irrespective of standards, or even of general physical proportions. A few days since I introduced with ease a No. 20 English sound into the bladder of a boy of sixteen, not overgrown. I have frequently seen adults whose normal urethral calibre did not apparently ex- ceed half that size. The not uncommon remark, that such- and-such a sized sound has been passed, and consequently no Stricture can exist, leads to frequent error. Engorgements of the urethral tissues occur readily after the discharge has nearly or entirely ceased. The introduction of a sound, or even the passage of urine, may cause the lips of the orifice to become suddenly florid, as though acute inflammation were present; evidently due to a want of contractility in the vessels of the part. Patients likewise complain of an aching sensation along the urethra, espe- cially in the perineal portion, where the deeper parts of the canal have been involved in the preexisting inflammation. For this condition I have been accustomed to make applica- tions to the relaxed membrane of equal parts of the sub- muriate of mercury and tannic acid, by dipping an undersized bulbous bougie in oil, then rolling it in the dry powder, pre- viously mixed, introducing the instrument with care until the bulb enters the bladder, then slowly withdrawing it with a twisting motion. Sounds with little cup-shaped depressions at their extrem- ity (designed by Dr. William H. Van Buren, of this city) are also valuable for carrying medicated unguents into the urethra. The judicious introduction of unmedicated sounds or bougies of large size is also beneficial. For the same purpose I have frequently applied free car- bonic-acid gas to the urethra, throughout its entire extent, by means of a flexible catheter attached to an India-rubber gas-receiver of two or three gallons' capacity. The receiver is placed in a chair opposite the patient. Passing the catheter down to the prostatic urethra, the stop-cock is turned, and pressure made upon the receiver by the knee of the operator. 26 CHRONIC URETHRAL DISCHARGES. The escape of the gas along the sides of the catheter, with a sputtering sound, announces the successful application of the gas to the entire mucous surface of the canal. The tonic and sedative effect of this procedure is prompt and curative in many case of abnormal sensitiveness of the urethra, fol- lowing chronic inflammation. CHAPTER II. RETROSPECT. T"N a careful perusal of the foregoing chapter it will be seen, J- 1st. That the subject of Gleet was entered upon with a general, if not a complete, appreciation of the causes which might be supposed capable of establishing and perpetu-. ating it. 2d. That an essential virus for its establishment was de- nied, and that its continuance was considered to depend upon pathological conditions, the result in every case of simple in- flammatory changes, complicated more or less by the anatom- ical peculiarities of the parts. 3d. That the diagnosis, in every case, was sought to be established through an acceptance of all the then recognized pathological processes associated with disease of mucous membranes, and by all the mechanical aids then in use, or which a critical study of the subject could suggest. 4th. That the treatment of Gleet was, at first, based upon the popularly accepted value of known remedial agents, gen- eral and local. 5th. That failure of treatment addressed to assumed pa- thological conditions, independent of mechanical interference with the functional integrity of the urethra, became gradually more and more apparent, until, on page 21 the mechanical obstacle was made to assume the first rank as a cause of gleet. 6th. That the slightest contraction of the normal calibre of the urethra was sufficient, not only to prolong a gleet in spite of treatment addressed to the inflammatory state, but " to establish it de novo without venereal contact." 7th. That the value of the bulbous sound was more and more highly appreciated and an improved form was presented, page 23. 28 STRICTURES OF LARGE CALIBRE. 8th. That the meatus urinarius was accepted as a guide to the calibre of the urethra when free from apparent contrac- tions, and even at that time the frequency of congenital and pathological contractions was beginning to be recognized. 9th. That a distinct individuality was claimed for every urethra, " irrespective of standards or even of general physical proportions " (p. 25). These positions, reinforced by the experience and earnest study of nearly two more years, were again brought to the notice of the profession in another paper read before the New York Journal Association, Nov. 24, 1871, and published in the N. Y. Medical Journal of Feb., 1872, entitled Remarks on Strictures of the Urethra of extreme Calibre, with cases, and a Description of New Instruments for their treatment, as follows: In a paper, which I had the honor to read before the N. Y. Medical Journal Association nearly two years since, I called especial attention to the influence of Strictures of large calibre in perpetuating a purulent urethral secretion, conclud- ing in the following terms : " We may, then, affirm as a most important axiom, that the slightest abnormal encroachment upon the calibre of the urethral canal, at any point in its course, is sufficient to perpetuate a urethral discharge, or even, under favoring circumstances, to establish it, de novo, without venereal contact." Since the foregoing aphorism was enunciated, my experi- ence has resulted in a daily-increasing respect for slight and usually unsuspected narrowings of the urethral calibre, as a cause of establishing local points of irritation along the course of the urinary tract. The following case presents a common phase of the diffi- culty alluded to: Mr. J. W. R., a surgeon, aged forty-eight years, came to me in June last, complaining of soreness and persistent ach- ing in the prostatic portion of the urethra, accompanied by a slight purulent discharge from the meatus. He had been a DIAGNOSIS BY BULBOUS SOUNDS. 29 subject of gonorrhoeal inflammation several months previously, and felt confident that this had resulted in the establishment of a low grade of inflammatory action in the prostate gland. With occasional suspicions of Stricture, he had attempted to verify them by the use of sounds. At one time No. 25, of the French scale, was passed into the bladder without obstruction, but, on other occasions, no larger than 20 could be introduced. He was, however, very positive that no organic Stricture existed, but that the irritation, caused by the passage of the instrument, excited a spasmodic contrac- tion of the membranous portion of the urethra, which arrested its progress. Attempting the introduction of a bulbous sound of as large a size as the urethral orifice would admit, viz., 27 F., I ascertained, that there was a Stricture near the meatus. The bulb fitted the opening, but refused to enter. After steady, gentle pressure, continued for three or four minutes, it suddenly slipped through a narrow Stricture about a quarter of an inch in depth. The bulb was then easily ad- vanced for two inches, when another obstruction was encoun- tered ; this gradually yielded for about an inch, after which the passage of the sound, onward into the bladder, was easy and natural. On the withdrawal of the instrument its bulb was arrested at a point 3^ inches from the meatus by a Stricture which presented a nearly uniform resistance for one inch, when it again glided smoothly outward until arrested by the pre- viously mentioned obstruction at the meatus. The handle of the exploring instrument was now permitted to fall, and dangled from the extremity of the penis, its bulb so firmly held by the Stricture that not a little traction was required to withdraw it. Here, then, we had a urethra, readily admitting the passage throughout its whole length of a No. 25 sound, of the French scale, and yet the presence of two decided Strictures in its course was positively demonstrated. The Stricture at the meatus was freely divided with the urethrotome of M. Civiale, and a No. 28 F. sound was passed 3° STRICTURES OF LARGE CALIBRE. through into the bladder. This operation was repeated, with increasing sizes, every third or fourth day, until a No. 30 F. sound was passed through the urethral canal, and was repeated at stated intervals for a fortnight. Still the purulent oozing, though slight, did not cease. Believing that the full size of the urethra had been reached, and that the continuance of the discharge was due to the long-continued engorgement of the mucous membrane adjacent to the Strictures, the use of the sandal-oil capsules was advised, under the influence of which it was hoped the trouble would soon disappear. The patient continued to take the capsules for a week, at the end of which time the discharge had quite ceased, but he still complained of uneasiness in the prostatic region, and still found shreds of mucus in his urine. Sound No. 30 F., of the Benique curve, passes quite readily, but the patient com- plained of unusual tenderness on its passage through the prostatic portion of the canal. From the locality and char- acter of his sensations, he was confident that his whole trouble was in the prostate. On the withdrawal of the sound, a little of a grey secretion was observed at its extremity, and which, under the microscope, was found to be largely puru- lent. This secretion, it seemed to me, had been brought from the prostatic portion of the canal. Examination per rectum revealed slight prostatic tenderness, but no hyper- trophy. Endoscopic examination, half an hour after urinat- ing, revealed nothing except a slightly congested condition of the mucous membrane in the vicinity of the previously mentioned points of Stricture, and the presence within the prostatic portion of the canal of the secretion previously ex- amined. With these evidences of the existence of a chronic prostatitis, I injected five drops of a solution of nitrate of sil- ver (grs. xxiv. to the ounce of distilled water) by means of Dr. Bigelow's prostatic syringe. Shortly following the injec- tion, and for five or six succeeding days, the patient expressed himself as having felt a decided improvement; he also reported perceptibly less fiocculi in the urine. Three injections, of the character previously used, were administered at intervals RELIEVED BY DIVULSION. 31 of eight days, but no further improvement resulted ; on the contrary, a slight reappearance of the discharge at the meatus, with an increase of the prostatic discomfort, had occurred about the seventh day after the first application of the nitrate of silver. , These symptoms again ceased upon the second application, but only to return at about the same time as on the previous occasion ; a like repetition of the advance and retrograde movement occurred upon the use of the third and last injection. Suggesting the possibility of a Stricture of large calibre still remaining, I introduced bulbous sound No. 28 F., and found that it accurately measured a Stricture, the posterior boundary of which was 3J inches from the meatus, and which had been previously dilated to No. 30 F., three degrees above the supposed normal size of the urethra as indicated by the size of the meatus. I then introduced the shaft of Voillemierand passed upon it the largest dilating cylinder, measuring thirty-two millimetres in circumference, and corresponding with about No. 20 of the so called American scale. Under this distention the doctor recognized distinctly the sensation of rupture at the point of constriction. But little pain was experienced during the operation, and only slight temporary discomfort followed it. This occurred at 8 P. M., November 10th. Since that time the patient has been en- tirely free from the old unpleasant sensations in the prostate, and also from any sign of discharge from the urethra; the only evidence of any trouble continuing, is the slight mucous flocculi that still appear in the urine. I have now under my care another case, Mr. A., aged twenty-eight, in whose urethra some half-dozen bands of Stricture from one-eighth to one-fourth ofaninchin breadth are present, anterior to the bulb. These have been dilated so that conical sounds from No. 28 to No. 30 F. have been passed with more or less difficulty, at intervals of from four to eight days, for nearly two months. A few days since I introduced Voillemier's divulsor with shaft thirty-two milli- metres in circumference (the largest attainable), and with but little more discomfort to the patient than that which had 32 STRICTURES OF LARGE CALIBRE. followed the use of the 30 F. soun 26 F. still defines the bands of Stricture very distinctly. Such a degree of resiliency, in my own ex- perience, is uncommon, although I have seen repeated instances where it was almost as great. On a former occasion, the im- portance of recognizing a distinct individuality, in every urethra, was insisted on, and likewise, the meas- urement of the calibre of each, not by any popular standard, but by the introduction of the largest- sized bulbous sound that would pass the uncontracted meatus. With this as a guide, the discovery of urethras presenting a calibre freely admitting a 30 F. sound will not prove of so rare occur- rence as at present supposed. Contractions at the meatus are a fruitful source of failure to appre- ciate abnormal narrowings of the urethra; the complete suppleness and resiliency of the tissues of the normal meatus is a good test of its freedom from organic Strict- ure, but congenital contractions, to a greater or less extent, are not unfrequent. Here, both the nat- ural suppleness and resiliency may be present, and the deformity may escape notice, unless carefully sought. Wherever a bulbous sound can, by a gentle pressure of three or four minutes' dura- d—yet bulbous sound No. voillemier's divulsor. INCAPACITY OF INSTRUMENTS. 33 tion, be made to slip into the fossae navicularis, and in the withdrawal is abruptly arrested, the indication for the free division of the meatus is positive; without it no efficient exploration of the deeper parts can be effected. The chief embarrassment which arises, after the demon- stration of these Strictures of large calibre, is from the lack of instruments of sufficient size to divide or rupture them. The largest divulsing instrument of Mr. Thompson, of London, will not expand to a size equal to more than 28 F. The largest capacity of Mr. Holt's instrument is not greater. My own Holt, purchased some years since, had only a divulsing capacity of 25 F. until I had a larger cylinder made, which brought it up to twenty-eight millimetres. The instrument of largest capacity for the internal division of Stricture is that of M. Maisonneuve, and, with the widest blade, this only cor- responds to a sound twenty-eight millimetres in circumference. It is scarcely necessary to call attention to the entire incapa- city of dividing or divulsing instruments to deal efficiently with Strictures occurring in urethras whose normal calibre exceeds their own measurement. The divulsing shaft of Voillemier, measuring thirty-two millimetres in circumference, and which is the largest instru- ment of any kind at present in use for operations on Strict- ure, failed to rupture the Strictures in the case of Mr. A., previously cited. Of what possible consequence, it may be asked, is the presence of a Stricture, of a calibre sufficient to permit the passage of a No. 32 F. sound, where the normal calibre of the urethra is evidently several millimetres smaller? Briefly, that experience has shown the power of such Strict- ures to keep up irritation, and even a purulent secretion, at various points along the urinary tract, as was the case in the instances just related. Simple over-distention of such Strict- ures, or of any Strictures, is at best but a temporary expedi- ent. Complete rupture or complete division is the only method by which the speedy return of a Stricture to its origi- nal point of contraction can be prevented. Every practitioner of much experience in operations for Stricture must have 3 34 STRICTURES OF LARGE CALIBRE. been struck with the lack of uniformity in results by any and every method, as shown by the return of patients for treat- ment, after variable intervals from the date of operation. Taking into consideration the difference in the regularity with which patients continue the use of dilating instruments after an operation, it is evident that data on this point must of necessity be very imperfect ; but I have noticed, in cases where no after dilatation zvas practised, more permanent results in operations upon tight Strictures than upon those of large calibre. This, it has seemed to me, was because the tight Stricture was more thoroughly ruptured or divided, and that the Stricture of large calibre was more likely to be simply over-distended or imperfectly divided, on account of its in- ferior density and greater dilatability, as well as from insuf- ficiency in size of the instruments employed. The great defect in all the means now in use for operations upon the variety of Stricture under present consideration, viz., those of large calibre, is their want of adaptability to the dimensions of the Stricture upon which operation is required. In operating on the flaccid urethra the amount of resiliency of the Stricture is undetermined ; the divulsing shaft is, there- fore, selected without exact data, and the size of the blade in the cutting instruments being left to conjecture, is liable to be unsuited to the case. In small Strictures a certain positive- ness of result is attainable, the Stricture is divulsed or divided to an extent sufficient to relieve present emergency, but there is no assurance that the rupture or the division has been complete, and, unless this result is attained, the return of the Stricture to its former dimensions is certain, and likely to be speedy, unless combated by the regular and frequent use of suitable dilating instruments. I would not be understood as at all undervaluing the great advantages, nay, blessings, that have resulted, and must continue to result, from the intelligent use of the admirable instruments of Maisonneuve, Holt, and others. In their prompt and ready relief of close Strictures they leave little to be desired, and must always occupy a prom- inent place in cases of emergency, when the chief consideration DILATING URETHROTOME. 35 is to relieve a threatened or actual retention of urine. I simply hold that there is an uncertainty in the extent of their action ; uncertainty as to whether or not the Stricture has been com- pletely divided, or whether other tissue, besides that involved in the contraction, has not also been divided or otherwise in- jured ; and that, in Strictures of large calibre, they are, as at present constructed, often entirely insufficient. With the view of supplementing these important defects, I have de- signed the accompanying instrument, which was manufactured very perfectly by Messrs. Tiemann & Co., 6y Chatham St., under my direction, and especially intended for operating upon the Strictures of Mr. A., in whose case the 32 F. shaft of Voillemier was used without effecting their rupture. The instrument, which I term the Dilating Urethrotome, consists of a pair of steel shafts (A & B, Fig. 1), connected together by short pivotal bars, on the plan of the ordinary dilating urethrotome. parallel ruler, as shown in the expanded instrument, at Fig. 2. Its expansion and contraction are effected by means of a screw which traverses the handle connected with the lower shaft and is moved by means of the finger-button (C). Attached to the distal end of the screw is a pair of short, curved, regis- tering arms, seen at D, Fig. 1, which ride through grooves on either side of the shafts (A & B), and are marked, on one side, with the divisions and corresponding figures of the American scale, on the other with those of the French, in millimetres. Connected with the screw in the handle, the 36 STRICTURES OF LARGE CALIBRE. rise and fall of this register indicate exactly the degree of separation of the shafts, and consequently the precise progress of the dilatation. Upon the inferior shaft (B) is engraved a scale of inches and quarter inches, by which the depth of its introduction into the urethral canal may be noted. Up to this point the instrument is simply a divulsor, and may thus be used by introducing it into the urethra until its distal extremity is beyond the supposed point of Stricture; the finger-button (C) is now turned, dilating the instrument, until, if considered desirable, the Stricture is completely ruptured. The upper bar of the instrument, which is hollowed out, is traversed by a urethrotome (Fig. 3),* the distal extremity of which terminates in a little metallic knob or indicator, (F, Fig. 3); by the metallic handle (G, Fig. 1) of the canula of the urethrotome, it is moved, at will, through the entire length of the shaft (A) of the divulsor; a small button-screw (H), secures the canula at any point. Running through the canula, and attached to the handle (I), is the staff of the urethrotome, terminating in a thin, narrow, spring blade, which, when at the extremity of the canula, is concealed in the deep groove which extends on its superior aspect through its entire length. On withdrawing the handle of the urethrotome (I), (its canula being fixed firmly at any given point by the button-screw,) (H), the spring blade (J, Fig. 1) rises out of the groove by means of a little elevation on its floor, rides over it, displaying the full width of the blade (from one to two lines) for half an inch, when it again drops down, and is concealed in the groove of the canula. The instrument, with its contained urethrotome, having then been passed down beyond the supposed or known point of Stricture and dilated until the Stricture is made tense, the button-screw (H), is turned, releasing the canula, which may then be drawn carefully outward until the knob or indicator at its extremity is arrested by the Stricture. The canula is then advanced about half an inch and secured by a turn of * This form of urethrotome, with concealed spring blade, was invented by M. Ricord, of Paris, and presented to the profession some years since. DILATING URETHROTOME. 37 the button-screw (H); a rapid movement of the handle (I), of the urethrotome outward brings its blade up through the Stricture from behind forward, incising it almost instan- taneously, and passing down again into its concealment. The finger-button at the extremity of the handle of the divulsor is then turned, and the instrument again dilated sufficiently to ascertain whether or not the Stricture is completely divided : if not, the knife may be passed down, from before backward, completing the operation. Should other Strictures be present, the use of the indicator, the urethra being kept tense, will reveal the exact locality of each, and the blade may be applied as required. The especial advantages claimed for this instru- ment are, that it first makes the Stricture tense, thereby es- tablishing it as a fixed point; that it is capable of being adapted to Strictures of any size within its compass ; that it accurately defines their locality and extent; that it attacks a tense instead of a flaccid Stricture, and hence, that its work is approached with confidence ; that its incisions are made with ease, at a predetermined point, depth, and extent, instan- taneously, and with the slightest possible discomfort to the patient; and, lastly, that it combines great strength with ease and simplicity of manipulation. Since the completion of the instrument, four weeks ago (May, 1870), I have operated with it on six cases of Stricture in the ante-bulbous portion of the urethra, with complete success and satisfaction in every particular. Its compass is from 23 F. to 34 F., corresponding to 13 and 21 of the English scale. Messrs. Tiemann & Co. are confident of their ability to make one of similar pattern which shall range from 23 F. down to 18 F., corresponding to 13 and 9 of the English scale, and so curved that it may be readily applied to the deeper portions of the urethra. But it is for operating upon Strictures of large calibre that this in- strument has been designed, and, except in such cases, especial superiority over others in use is not claimed.* It will, how- * The only dilating urethrotome of which I find any record is that of M. Rey- bard (Traite Pratique des Retrecissements Du canal de l'Uretre, par M. le Dr. Reybard, Paris, 1843, p. 205). The principles on which the instrument of M. 38 STRICTURES OF LARGE CALIBRE. ever, I think, prove a valuable aid in completely restoring the natural calibre of urethrae that have been imperfectly operated on by other instruments. Reybard was constructed required long and deep incisions of the urethral canal, in consequence of which " the instrument, never extensively used, has fallen into disuse " (Thompson on Stricture of the Urethra. Third edition. London, 1869. P- 235). CHAPTER III. RETROSPECT. THROUGHOUT the period covered by the preceding chapter, it will be seen, 1st. That there was a steady progress of the mechanical views in regard to the nature and continuance of gleet. 2d. That the meatus was practically rejected as a guide to the normal urethral calibre (p. 32). 3d. That the incapacity of all the then known instru- ments for dividing or divulsing urethral Strictures was demon- strated (p. 33). 4th% That complete sundering of Stricture was necessary to prevent speedy re-contraction (p. 34). And hence, that an instrument of wider scope and more certainty in action was required. 5th. That to fill these indications my first dilating urethro- tome was invented, and presented to the profession as the- oretically capable of completely dividing Strictures of large calibre. The apparently successful practical application of the instrument in six reported cases was not deemed sufficient to warrant more than a casual mention, and this but as an incentive to a more extended trial of its qualities. During the succeeding year (i870-'/i) my experience in the use of the dilating urethrotome had extended to the divis- ion of fifty-seven bands of Stricture in twenty-seven patients. In every case the presence of long standing gleet was associ- ated with the Strictures. In every case, cure of the gleet fol- lowed rapidly on the removal of the Strictures and in five cases complete absorption of the Stricture tissue was found to have occurred, a fact verified by the distinguished surgeons mentioned on pages 48, 49. These results, so remarkable and 40 DILATING URETHROTOMY. opposed to the teachings of all authorities and experience, were accepted with reserve by other surgeons who were prac- tically cognizant of their truth, and not less so by myself, final judgment being deferred until a larger experience should have accumulated. They were however deemed so important that it was thought advisable to present the subject up to that date, to the Medical Society of the State of New York, to- gether with a new form of dilating urethrotome adapted for use in Strictures of smaller calibre. Accordingly at the Feb- ruary meeting of that Society in 1873, I read the following paper: On Strictures of the Urethra. Results of Operation with the Dilating Urethrotome, with Cases. In a paper read before the Medical Journal and Library Association of the city of New York, and published in the New York Medical Journal of June, 1870, especial attention was directed to the influence of Strictures invading but slightly the calibre of the urethral canal, as a cause of puru- lent urethral discharges. It was then claimed that " the slightest abnormal encroachment upon the calibre of the ure- thra at any point in its course is sufficient to perpetuate an existing urethral discharge, and even, under favoring condi- tions, to establish it, de novo, without venereal contact." Through an article published in the same Journal, in Feb- ruary, 1872, this position was reenforced by the results of a further experience and study of the subject. A number of cases were then cited, where a chronic purulent urethral dis- charge was associated with, and apparently dependent upon, the presence of one or several distinct bands of Stricture, and where, on account of the large calibre of the Strictures, the use of the largest divulsing instruments of Thompson, Holt and Voillemier, had proved ineffectual in rupturing them. The entire incapacity of those instruments, as well as of the cutting instrument of M. Maisonneuve, was demonstrated by actual measurements which proved the divulsing capacity of the largest instrument of Thompson to be no more than CASE OF MULTIPLE STRICTURES. 41 17 English, or 28 millimetres in circumference ; that of Holt, as usually constructed, about the same ; that of M. Voillemier 19^ English, or 32 F. ; while the cutting instrument of M. Maisonneuve, with widest blade in use, did not exceed a ca- pacity of 21 millimetres in circumference (corresponding to 11-| of the English scale) ; and this blade had been objected to by eminent surgeons on account of its extreme dimensions. Among the cases presented in proof of this alleged inca- pacity was one of Mr. A., in whose urethra some half a dozen bands of Stricture were present, anterior to the bulb. The history of this case is as follows : Mr. A. came under my observation November 22, 1865, having a chronic urethral discharge, following a gonorrhoea contracted a few months previous. He had used various in- jections, which failed to afford more than temporary relief. Examination revealed a decided contraction of the meatus, which was at once freely divided with Civiale's urethrotome; after which, under the use of astringent injections, the dis- charge soon ceased, and he had no further trouble until May 20, 1867. At this time, after an impure connection, the puru- lent discharge re-appeared. Again treated with mild injec- tions, and full sized sounds, the discharge ceased on the eighth day. June 29, 1868, he again presented himself with a return of the discharge, which, being submitted to treatment of the same character as before, disappeared, but more slowly, only ceasing on the 22d of July. Remaining well up to June 7, 1871, he returned with the same difficulty. Endoscopic tube No. 20 F. was passed easily down to the bulbous portion of the canal. On withdrawal, the urethra was found generally congested, presenting at several points a sensitive, granular surface. Bulbous sound No. 22 F. met with slight resistance at an inch from the meatus, and also at the sensitive points beyond. On withdrawal, the bulb was firmly held at an inch and a quarter from the meatus, when a Stricture, one-fourth of an inch in breadth, was positively defined. This Stricture was incised with a narrow, straight bistoury, and the granular points were submitted to applications of a solution of nitrate 42 DILATING URETHROTOMY. of silver through the endoscope. Under this treatment the discharge diminished, but did not cease entirely, although the granulations had disappeared, and the mucous membrane was of nearly uniform color throughout the straight portion of the canal. Gradual dilatation was then made, and treatment by injections and medicated bougies, resorted to at regular intervals, combined with the internal use of cantharides and iron, and later with the oil of the yellow sandal-wood, until August 14, 1871, by which time the calibre of the urethra was brought up to No. 30 F. The 30 F. bulbous sound was then used, and by its aid a Stricture one inch from the meatus was recognized (on the original site), and passed with some difficulty. No. 28 F. bulb detected the same obstruction, and, being carried to the deeper portion of the urethra, on with- drawal, five other bands of Stricture were defined : one at four and a half inches from the meatus, one at four, one at two and a half, one at two (each about a quarter of an inch in breadth), and another, of nearly half an inch in breadth, at an inch and a half, and separated by but a narrow interval from the one previously operated on at one inch from the meatus. No 30 F. conical sound was then passed down through all, immediately after which No. 28 F. bulb was again passed, which on entrance and withdrawal, again positively defined all of the above mentioned Strictures. This was on August 14, 1871. I then introduced the divulsing instrument of M. Voillemier, and drove the largest shaft (No. 32 F.) rapidly down through all. The resistance to its passage was not sensibly greater than that previously found in passing No. 30 F. sound. After the operation and at the same sitting, No. 28 F. bulb was again introduced, and still distinctly defined all the strictured points ; even No. 26 F. bulb indicated the points of contraction. Having thus failed to rupture the Strictures with the largest instrument available, and finding that the largest blade of the urethrotome of M. Maisonneuve could only reach to the calibre of No. 21 F. and the patient continuing unrelieved of his discharge, I devised an instrument for the DETAILS OF OPERATION. 43 purpose of effectually dividing the Strictures, upon the pres- ence of which I confidently believed the persistence of the discharge to depend. This was presented to the profession, in an unfinished state, at a meeting of the Medical Journal and Library Association, November 24, 1871, after a brief allusion to the salient features in the case of Mr. A., just cited, as the one for the complete division of whose Strictures it had been contrived. This instrument, which I have termed the Dilating Urethrotome, I had the pleasure of presenting to the Association after having tested its efficiency in the case above related, and in the treatment of other Strictures of large calibre. On the morning of the 12th of January, 1872, adapting this instrument to the calibre of Mr. A.'s Strictures, and hav- ing made such tension as the patient could comfortably bear, I drew the blade of the urethrotome through the anterior Stricture, one and a half inch from the meatus, cutting from behind forward, then giving the dilating screw half a turn more, I incised it from before backward, closed and withdrew the instrument. On examination of the result with the 30 F. bulb, no resistance in entrance or withdrawal could be detected at the site of the Stricture. The patient averred that he had not experienced the slightest pain on the passage of the knife ; the subsequent haemorrhage was very slight, and ceased in a few moments. Mr. A. then went down to his business. He called on the following morning, and stated that he had accomplished his usual work on the day previous and had had no discomfort since the operation, except a slight smarting on urination. On the nth of February I operated in the same manner on the second anterior constriction, with the same result as in the first. On the 24th of February, examination showed a complete freedom from obstruction at the points previously incised, and an entire absence of the purulent discharge. At this date, I operated on the two succeeding Strictures—one at two inches and one at two and a half—and the patient was 44 DILATING URETHROTOMY. directed to use the 30 F. sound daily until no bleeding followed. On Monday, March 4th, the remaining Strictures, at four inches and at four and a half, were divided, and the cut sur- faces kept asunder, by the occasional introduction of a sound, until March 11, 1872, subsequent to which date no treatment of any kind has been resorted to. Early in October last, seven months from the date of the last operation, Mr. A. called to consult me in regard to a difficulty unconnected with his genito-urinary apparatus. On inquiry, I ascertained that he had had no evidence of any-trouble with his urethra since his last visit, on March 12th. In a careful examination of his urethra with No. 30 F. bulbous sound, I was now una- ble to detect the slightest contraction or lack of suppleness at any point. Case II.—November 16, 1871.—Mr. M. S. came to me with the following history: Had gonorrhoea first ten years since ; was treated without injections ; disease lasted several weeks. A couple of years subsequent to this he had a whitish discharge from his urethra, which he first noticed shortly after connection with a woman who had scarcely completed her menstrual period. The difficulty was quite painless, but lasted noticeably for four or five months. One year after, or seven years ago, he had what was supposed to be a fresh attack of gonorrhoea, in which the inflammation ran very high, and lasted for several weeks. In this seizure he was treated by injections, in addition to internal remedies. A gleety discharge followed the acute symptoms, and lasted for a year, when a third acute attack occurred. To this last he paid no especial attention, until inflammation of the left testicle supervened and confined him to his bed for several weeks. From that time he received occasional treatment for a gleet, which still annoyed him, but he never obtained more than temporary relief. On one occasion, following a connec- tion, severe irritation at the neck of the bladder was set up, which, after a few weeks, appeared to yield to homoeo- pathic treatment, and left him with his old gleet which con- OPERATION REPEATED. 45 tinued with slight variations up to November 16, 1871. On this date I examined his urethra ; meatus apparently healthy and of normal calibre—No. 28 F. Bulbous sound No. 20 F. revealed a Stricture one and a half inch from the meatus, exceedingly sensitive, and bleeding freely at the slightest touch. November igth.—Conical sound No. 21 F. was passed under protest, on account of the sensitiveness of the part; free bleeding again followed. February 2\th.—Occasional introduction of sound since the last record has relieved the sensitiveness and tendency to haemorrhage, and raised the calibre up to 23 F. Bulbous sound again used, and showed the Stricture at one and a half inch from the meatus to consist of three distinct bands close together—the first one-fourth inch in breadth, the second half an inch from it, of about same breadth, and the third separated from it by scarcely a quarter of an inch. The dila- ting urethrotome was then introduced with the blade, set for the posterior Stricture, expanded up to 26 F., which was all the patient would bear, and the Stricture was incised from behind forward, and also from before backward, without moving the instrument. It was then closed and set for the anterior Stricture ; this was also divided, the instrument closed and withdrawn. The patient remarked that the pain of the entire operation was not sensibly greater than that following the first introduction of the sound. The incision bled quite freely, but the haemorrhage, under gentle pressure, soon sub- sided. The results of the cutting were not then examined. February 2jth.—Examination with No. 27 F. bulb showed resistance, on entering upon the site of the second Stricture. On withdrawal, a narrow band was found remaining ; this was cut, March 8th, after the manner of the previous opera- tion, and No. 27 F. bulb passed beyond the site of the Strict- ures, until, at three inches from the meatus, another narrow band was discovered, and at four inches still another. Al- though these last Strictures were distinctly appreciated by the patient as well as by myself, he expressed an unwilling- 46 DILATING URETHROTOMY. ness to submit to any further interference until he could ascertain whether or not the previous operations would give him relief from his discharge. March 23d.—Patient has introduced No. 27 F. sound past the seat of his anterior Strictures at intervals of a day or two since his last visit, as directed by me, in order to maintain the complete separation of the previous incisions. This was advised to be continued until no oozing of blood followed the use of the instrument. The locality of the wounds made in the previous operation was examined through the endo- scope, and healing was seen to have been complete, but the discharge was still present. At this time, by the patient's request, the dilating urethrotome was introduced, dilated to No. 27 F., and the deeper Strictures were again examined and readily defined by means of the indicator attached to the ex- tremity of the canula in which the blade of the urethrotome runs. The instrument was then adjusted for the posterior Stricture. This was rapidly incised on its superior surface. Setting it again for the anterior band, a like incision was made through it ; a turn of the dilating screw giving no pain to the patient was the evidence that the division of the Strictures had been complete ; but the patient, fearing an imperfect result similar to that occurring in the first opera- tion, requested that the Strictures might be incised on the inferior surface also. Seeing no objection to this, I did so, measuring their locality from the outside, as they could no longer be distinctly defined by the indicator. The incisions on the superior aspect of the urethra were attended with but little haemorrhage, but those on the inferior surface were fol- lowed by copious bleeding, which was only controlled by the introduction of a large flexible bougie. Removing it after an hour, a gush of blood followed. It was then readjusted and retained by a bandage, for the night. The following day, on removal of the bougie, blood again flowed freely. A hard rubber tube was then introduced, through which the patient could urinate. This was worn constantly for the three suc- ceeding days. No. 28 F. sound was then introduced with ease, CURE OF GLEET AND STRICTURE. 47 and patient directed to pass it upon himself daily for one week, since which time I have not treated him for his Strict- ures. The gleet disappeared, without other care, in about a fortnight after the last cutting, and he has remained free from it up to the present time. I made a careful exploration of the urethra of this patient in the early part of October last (1872), nearly seven months from the date of the last operation, with No. 28 F. bulbous sound (the previously noted calibre of the meatus), and was unable to detect any remains of Stricture at any point. Case III.—Mr. J. C. came under my care in July, 1870, with the first attack of gonorrhoea, which lasted for two months, under a combined treatment of copaiba and injec- tions. Subsequent to this, from drinking much beer, he had several returns of the discharge, which readily disappeared under the use of mild injections. In July, 1871, a profuse, painless purulent discharge followed a suspicious connection. This resisted the usual local means, but was controlled by large doses of the oil of the yellow sandal-wood (twenty drops three times a day), but reappeared on the withdrawal of the remedy. Examination, December, 1871, revealed a congenital contraction of the meatus, admitting only 16 F. I cut it with Civiale's Urethrotome, and introduced 24 F. Examination with the endoscope showed two broad inflamed and granular surfaces, involving the entire circumference of the urethra, at about two inches and five inches from the meatus. These were treated by the application of a 30-grain solution of the nitrate of silver through the endoscope, at intervals of three or four days, for about a month. Under this treatment the mucous membrane was apparently restored to its normal condition, the discharge ceased, and the patient was believed to be cured. Within a few weeks, however, after a debauch, the difficulty returned, and continued, without treatment, for several months. January, 1872, he presented himself with a scanty, thin, purulent discharge. Examination detected Stricture at two inches from the meatus; No. 24 F. bulb passed it with difficulty, and on withdrawal was sharply and firmly 48 DILATING URETHROTOMY. held. Passing the instrument farther, another band of Strict- ure was recognized at four and a half, one at four and three- quarters, and one at five inches. The anterior Stricture was then divided by the dilating urethrotome, and 30 F. sound passed easily through. This instrument was directed to be passed daily until healing of the wound was complete. March 30th, some discharge, though thin and scanty ; no obstruction to passage of 30 bulb through site of anterior Stricture, but it was arrested at 4% inches. The dilating urethrotome was then introduced, and the three posterior bands previously described were dilated and cut above and below; after which operation 30 bulb passed without hinderance through all. Patient directed to use 30 F. sound, until no bleeding ensues. After this time I lost sight of this case, until January 30, 1873, a period of ten months, when, accidentally meeting him, I requested an opportunity of ascertaining the results of the operations. He stated that the discharge continued for about six weeks after the last operation, and that he had had none since, although he had drunken very largely of beer, which had, previous to the operations, always brought back the discharge. Examination with bulbous sound 30 F. failed to detect the slightest trace of a Stricture in the course of his urethra. No. 31 was also passed and withdrawn without de- tecting any unevenness in the urethral walls at any point. In connection with the three cases above cited, it seems proper for me to state that, with the consent of the gentle- men operated on, I invited several prominent surgeons of the city of New York to meet them at my office on the 20th day of December, 1872, for the purpose of critical personal exami- nation of the results of operations with the dilating urethro- tome. Dr. Henry B. Sands and Dr. Robert F. Weir made the examination in the first case, that of Mr. A., with No. 30 F. bulbous sound ; in that of Mr. S., the second case, with No. 28, and completely confirmed my impressions as to the entire absence of any abnormal condition in the urethra in both cases. Again, on the first day of February, 1873, the three cases above related, together with that of Mr. WO (op- COMPLETENESS OF RESULTS. 49 erated on in May, 1872, for two Strictures, one at one-third of an inch from meatus, and one at an inch and a half)— making in all four cases (comprising originally eighteen bands of Stricture) were critically examined at my office by Drs. J. W. S. Gouley, Thos. T. Sabine, and Fred. D. Sturgis, of New York, and Dr. F. D. Lente, of Cold Spring, New York. The examination of Mr. S. (previously examined by Drs. Sands and Weir) was made with the bulbous sound No. 28 F. In this case there had been no abnormality at or near the meatus, and 28 had been accepted and registered as the nor- mal calibre of his urethra before the operations were made. In the remaining three cases the 30 F. bulb was first used, and afterward No. 31, without detecting in either case any obstruction or unevenness in the course of the urethra, either in the insertion or in the withdrawal of the instrument. I have now operated with the dilating urethrotome on 58 bands of Stricture, presenting in 27 patients. The presence of long standing gleet was the cause of their seeking relief in every instance. And in every instance, with one exception, the gleet had disappeared within 24 hours as the shortest and one month as the longest time after the final operation. The exception was in the case of J. C, case third reported, where frequent indulgence in venery and alcoholic stimulants was kept up throughout the treatment. This list, moreover, in- cludes four cases where a Stricture was left uncut in the curved portion of the urethra beyond the reach of the instrument as then constructed. In no case was any after-dilatation practised by me or by my direction, subsequent to the healing of the incisions. In one case a gentleman, who had for years been in the habit of occasionally passing a steel sound, continued to do so every two weeks for a couple of months succeeding the divis- ion of his Strictures ; but finding, as he said, " not the least resistance," he abandoned its use. With the exception of the operation in Mr. S., which was followed by a troublesome haemorrhage, nothing has occurred in any case to interfere with the regular habits or occupation of the patient. The 4 50 DILATING URETHROTOMY. dilatation is capable of being made so gradual that no shock is experienced from that cause, and the tension falling solely on the Strictures, renders them almost and often wholly in- sensitive ; thus the incisions are virtually painless. I have, therefore, in no case preceded or followed the operation by the administration of quinine or morphine, as has always been my habit when employing the instruments of Holt, Thomp- son, and Maisonneuve. During the frequent use of this form of dilating urethrotome, the objections which have suggested themselves are—I. Its large size, it being of a circumference of 23 millimetres, equal to 13 of the English scale, when closed, and not capable of material reduction. 2. That it is incapable of being used in the curved portion of the urethra. Recognizing the importance of combining dilatation with division in the treatment of urethral Strictures, and apprecia- ting the defects in my instrument, my friend, Dr. J. W. S. Gouley, of New York, contrived an instrument, with expand- ing springs, intended to remedy these defects. Dr. Gouley's Dr. Gouley's Dilating Urethrotome. instrument possessed the great advantage of having a circum- ference of no more than 12 millimetres, equal to No. 5 of the English scale ; but it was open to the objection that, on account of the elliptical shape which the dilated springs necessarily assumed, the tension on the Stricture might be easily lost by slight slipping of the instrument, when failure in complete division of the Stricture would inevitably result. To avoid the possibility of such an accident, and to reach the deeper portions of the urethra, I devised the instrument which I now present. This specimen, also constructed by Messrs. Tiemann & Co., is equal in size to 13 millimetres, or 5£ of the English scale, and is capable of material reduction. IMPROVED URETHROTOME. 5 I Its mechanism is exceedingly simple. The principle of its action being that of the parallel ruler, expanding by means of a screw at the handle, is the same as that upon which my Small Dilating Urethrotome. original instrument is constructed. The cutting apparatus is also virtually the same. An independent rod, terminating in a blunt elevation, plays the part of the bougie-a-boule for the detection and location of the Stricture points. In order that it may readily be passed down into the curved portion of the urethra, its shaft, which terminates in a copper probe-point, may be easily adapted to the curves of the deeper portions of the canal, and also enables the operator to arrange it for cutting at will upon either the superior or inferior aspect of the urethra, and, when straightened, can be used as well for operation upon Strictures in the straight portion of the canal; a movable hard rubber slide marks the required depth of in- sertion. Its efficiency was demonstrated at my office, January 29, 1873, in the presence of Dr. F. D. Sturgis, of New York, by the complete division of a Stricture of a previously ascer- tained breadth of three-fourths of an inch, and situated one and three-fourths inch from the meatus ; the calibre of the canal was thus raised from 23 to 28 millimetres by a single passage of the knife. This instrument has an expanding power up to 40 F. In the above recital of my experience with the use of the dilating urethrotomes, it will be observed that two somewhat novel ideas are suggested—1. That a very considerable num- ber of cases of chronic urethral discharge are dependent upon the presence and influence of comparatively slight contrac- tions of the urethral calibre; and 2. That the complete division of the cicatricial tissue producing such contractions may be followed by an entire absorption of the cicatricial, or t,2 DILATING URETHROTOMY. stricture tissue, and this quite independently of the long- continued use of sounds insisted on by all authorities as necessary to prevent re-contraction of the Stricture. Now, in regard to the dependence of chronic purulent secretion upon interference with the calibre of the urethra, it may be stated that, in order to effect a complete emptying of its contents after micturition, a complete and healthy action of the mus- cular layer surrounding it must occur. The presence of any condition which interferes with this, necessarily produces irregular and imperfect emptying of the urethra ; its acrid contents are retained for a time, and to a degree, sufficient to become a cause of irritation. This, it will readily be seen, may occur from such a slight plastic infiltration as simply interferes with the suppleness of the tissue without interference with the normal calibre of the canal. Thus Strictures, dilated even beyond the normal size of the ure- thra, still may give rise to an irritating influence upon the mucous lining of the canal. When, besides, there is an actual narrowing in the course of the urethra, " the urine impinges with more or less force upon the contracted point, the column of fluid is arrested, and in proportion to the degree of arrest is the force of the blow upon the mucous surface at that point ; more or less hyperaemia necessarily ensues, and a condition is soon established well adapted to prolong an existing gonorrhoea or gleet, or upon slight ad- ditional cause, such as venereal excitement, or even an unusu- ally acrid condition of the urine, to result in the establish- ment of a muco-purulent or a purulent discharge without antecedent contagion." In claiming the general dependence of chronic urethral discharges upon disturbance of the urethral calibre, I am not unaware of the importance attached by many specialists to the presence of local points of granulation, or papillary hyper- trophy, along the course of the canal. Accepting the views of Desormeaux, Cruise, and others, I have, in days past, been a firm believer in the value of the Endoscope for defining those points with certainty by ocular inspection ; and in ERRORS THROUGH THE ENDOSCOPE. 53 the efficacy of local treatment by strong solutions of the nitrate of silver applied to the granulated surfaces through the Endoscope ; but I have, of late, so frequently observed the same appearances, and by means of the large bulbous sounds have been able to detect bands of Stricture underlying them, and further, have seen the granular condition of the mucous membrane promptly disappear upon the complete division of the Stricture, without any other treatment, that I have come to look upon the Endoscope as a mischievous invention as used for the relief of chronic urethral discharges. The improvement and often apparent cure, which I have seen resulting from local applications through the Endoscope, has proved fallacious, for slight and often unrecognized causes have determined the return of the difficulty. I therefore now venture the opinion that localized granular urethritis will be found to result from interference with the muscular move- ment or with the calibre of the urethra in every instance. And now, as to the second point. No one could have been more surprised than myself, when, on my quite acci- dental examination of the urethra of Mr. A., in October last, I found that complete absorption of the cicatricial tissue had occurred. The interest excited by the apparent result of complete division of the Strictures in this case, (which, it will be remembered, was the one in which six distinct bands of Stricture were present before the operations, and whose case was cited before the New York Journal Association in November, 1871), induced me to seek an examination of patients where like operations had been performed at or near that time. This resulted in the collection of five other cases, making six in all—four of which, with an aggregate of seven- teen bands of Stricture, were examined by committees of surgeons especially skilled in urethral diseases. In cases Nos. I., II., and III., the final operation was performed in March, 1872, and the results examined in the first two in October, 1872; the third, January 31, 1873. Case IV., ope- rated in June, examined in November; Case V., operated in April, and examined in October; Case VI., operated on in 54 DILATING URETHROTOMY. July, and examined in November. In all these, an entire absorption of the Strictures was absolutely demonstrated. The above list includes all the cases in which I have, thus far, had an opportunity of instituting a final examination. Quite a number of those operated on came from a distance, which fact, and the indisposition of Stricture patients to dis- close their places of residence, have prevented an extension of the list. The generally-accepted view of authorities, in regard to the results of operations upon Strictures of the urethra by any other method than that by the dilating ure- throtome, is, that there is a liability to relapse, and that, as a rule, unless dilatation, by the occasional passage of a full- sized sound, is kept up indefinitely, recontraction of the Stricture is likely to occur. In consideration of the fact that, by every other method except that by combining incision with dilatation, the opera- tion is upon a flaccid urethra, with no accurate guide to the necessary correspondence between the size of the operating instrument and the Stricture, and that there are many Strict- ures of larger calibre than can be sundered by the largest instruments in general use, it may be justly inferred that the Strictures operated on by such means are, as a rule, not com- pletely ruptured or divided—that the Stricture is still left in its continuity, and hence the frequency of relapse. If, on the contrary, the Stricture is completely sundered at any point, and by subsequent dilatation a space is filled in with new material, when contraction takes place—as cicatricial tissue is certain to do—this contraction naturally takes place at the expense of the weaker new formation, resulting, as it seems to me, in a wider separation of the sundered ends, the irrita- tion consequent upon contraction of the calibre of the canal, and the retention of the irritating secretions, thus decreasing, hence, the reenforcement of the Strictures, by additional plastic material, diminishes, until, by the natural tendency to absorption of foreign or superfluous tissue, the Stricture- tissue gradually and completely disappears. Should this view of the modus operandi of the complete absorption of the MULTIPLE STRICTURES. 55 Stricture, after complete division, not prove satisfactory, the profession are invited to suggest a more plausible explanation of the fact, which, it seems to me, must be accepted in regard to the six cases, (for the most part aggravated examples of their kind) which I have had the honor to report to this Society. In the cases brought before you it will have been remarked that the occurrence of several distinct bands of Stricture in the same urethra is asserted. On this point Sir Henry Thompson, on " Strictures of the Urethra," London edition, page 68, remarks ; " Occasionally several separate Strictures may be observed in the same subject. John Hunter records six, Lal- lemand seven, Colot eight, Du Camp four or five, Leroy d'Etiolles (inventor of the bulbous sound) eleven, and for the most part in the spongy portion of the urethra." Three or four are as many as Sir Henry Thompson has been able to discover. Among the patients which I have operated on during the past year there were present six in two cases, five in three, four in one, in three cases three, out of twenty-seven cases observed. Dr. Gouley has recorded four cases with four Strictures in each, and over twenty cases, in each of which three were distinctly defined with the bulbous sound. The rarity of the occurrence of multiple Strictures in the same urethra, as reported by authorities, is, I am sure, due to an imperfect method of examination. The use of the ordi- nary sound is quite valueless in the attempt to recognize or define slight contractions of the urethral canal, which often readily dilate to its normal calibre, while they can be perfectly demonstrated by a bulbous sound two or three sizes smaller. I have frequently met with Strictures which could not be ap- preciated during the passage of a full-sized bulb, but which, after being allowed to remain for a few moments, was per- ceptibly arrested at a point of Stricture on its withdrawal. I may then state it as my conviction, that the bulbous sound is the only instrument which can be relied upon for certain diagnosis of Strictures of large calibre. For explorations of 56 DILATING URETHROTOMY. the straight portion of the urethra, I prefer the metallic olive- shaped sound; for the curved portion, the olive-shaped gum bougies. Contractions at the meatus, either congenital or resulting from disease, are of frequent occurrence. Civiale recognized this fact, and is said to have " divided the meatus in nearly three thousand cases, with the best results." Dr. Gouley states that he has divided over two hundred. By this simple operation I have many times relieved chronic discharges and inflammatory troubles of the urethra and bladder, which had resisted every other method. When such contractions exist, there can be no efficient explora- tion of the urethra previous to complete division, whether the contractions be cicatricial or congenital. Any resistance to the withdrawal of any bulbous sound which can be intro- duced through the meatus, is positive evidence that an ab- normal contraction is present sufficient to render nugatory a thorough examination of the deeper portions of the ure- thra. Bearing this fact in mind, and appreciating the value of the full-sized bulbous sound as a means of diagnosis, I be- lieve that the detection of important urethral contractions will be vastly more frequent, and that complete division of such contractions will result in the relief of much annoyance and suffering from gleet, urethral and vesical inflammation, and irritation, which cannot be permanently removed by any other means. The metallic, olive-shaped sound, with a small, flexible shaft passing through a perforated handle, to which a thumb- IMPROVED bulbous sound. screw is attached for fixing it at any desired point (see Fig.) is one of a set which I have used very frequently for the last twelve years, and has proved in my hands superior to those of any other form or material in use for examination of the straight portions of the urethra, on account of the com- plete ease of its introduction and withdrawal, and of the ex- SUGGESTION OF RADICAL CURE. 57 actness with which it defines and measures every degree of Stricture. Its value is also enhanced by its freedom from lia- bility to injury by use or time. For the relief of close Strictures requiring immediate op- eration, on account of retention of urine, or where, by reason of irritability or extreme density, such Strictures are not sus- ceptible of being sufficiently dilated, the instruments and methods of Maisonneuve, Holt, and Thompson are, and I believe must always remain, of inestimable value. Although inadequate for complete and permanent restoration of the .urethral calibre, yet, the immediate emergency being relieved, the remaining disability, I am hopeful, may be removed at leisure, by the supplementary use of the Dilating Urethrotome, and thus the continued, often uncertain and perilous, use of sounds or bougies, now required after the ordinary operations on Strictures, be virtually abolished. CHAPTER IV. RETROSPECT. THE foregoing paper was received by the Society with amiable attention, but called forth no discussion. On its publication in the New York Medical Journal for March, 1873, it elicited no expressions of opinion or interest in the leading medical periodicals at home or abroad. The claim of curing gleet by division of Strictures, often not appre- ciable by straight bougies or bulbous bougies of the ordinary sizes, and, still more startling, the suggestion of the radical cure of Stricture were too improbable to warrant public con- sideration. As time went on however, an increasing experience steadily strengthened my convictions on all the important points claimed. In addition to these I recognized more and more the necessity of ascertaining the normal calibre of the urethra in every case associated with urethral or vesical irritation ; and also, the utter worthlessness of the meatus urinarius, as a guide to that calibre. The bulbous sounds, of which I had found a necessity of increasing the size up to 34 mm. were efficient explorers where the meatus urinarius was large, but were rendered useless for exhaustive examination, in all other cases, until after division of the urethral orifice. Gradually I became convinced, that the nearer the meatus urinarius corresponded in size with the urethra behind it, the more nearly it approached the highest perfection, and that the fossa navicularis was the result of forcible dilatation, caused by a contracted meatus, (p. 33). To measure the urethra, independently of the size of the orifice, seemed a great desideratum, not alone for detection of contractions or Strictures, but to harmonize the many con- flicting statements by authorities in regard to the normal NEW OPERATION. 59 urethral calibre. During the latter part of the year 1873, I devised an instrument which I termed the Urethra-metre, which promised to settle all the vexed questions in regard to urethral measurements. For the purpose of presenting this instrument to the profession (p. jy), and of discussing the views of Sir Henry Thompson (p. 70, et seq.) in regard to the methods of examination of the urethra for Stricture, and to combat what I believed to be a grave error of the English and French schools, in claiming an average standard for all urethrae, and still further, to demonstrate the possibility of the complete cure of Stricture (p. 81), I read a paper before the N. Y. Medical Journal Association in February, 1874. This was published in the N. Y. Medical Journal for April, 1874, as follows : Urethrotomy, External and Internal combined, in cases of multiple and difficult Stricture; with Remarks on the Urethral Calibre. In the early part of the year 1872, two cases of urethral Stricture presented in my service at the Strangers' Hospital, which were decided to be appropriate cases for the external or perineal incision, from the fact that the first was the sub- ject of impassable Stricture at the bulbo-membranous junction, and that the second was suffering from a long, close, per- ineal Stricture, admitting only the finest whalebone filiform bougie, and also further complicated by the presence of several perineal fistulae. The method of operation differed in some respects from that usually performed. The prac- tice approved by authorities in such cases is to cut down upon a sound or other instrument which has been introduced through or down to the point of Stricture, and then from without to incise freely all Stricture-tissue until an instrument, sound or catheter, of the supposed normal dimensions of the urethra, can be readily passed through the urethra into the bladder. In the cases above alluded to, the modification of this procedure consisted in making the external perineal incision in great measure subsidiary to the operation of inter- 60 URETHROTOMY, EXTERNAL AND INTERNAL. nal urethrotomy. This plan was determined on for the first case, with the idea of including in the same operation several i Strictures which were present in the straight portion of the ! urethra, as well as the impassable one for which the perineal incision was demanded; and for the second, to avoid the necessity of laying open the scrotum in the division of the long Stricture, which was found to pursue a tortuous course through a mass of indurated tissue traversed by the perineal fistulae. The preliminary steps in this modified operation were taken as if the ordinary perineal section had been contem- plated. An incision was then made down upon the anterior face of the Stricture, aiming to enter the urethra by as small an opening as possible, and through this opening, as a new point of departure, the endeavor was made, in the first case, to introduce a fine, soft, filiform guide through the posterior Stricture. Succeeding in this, the staff of Maisonneuve was entered at the meatus, and passed down through and past the perineal incision into the bladder; blades of the instru- ment, Nos. 2 and 3, were then slid down the staff in succes- sion, cutting on the superior wall of the canal and dividing all remaining Strictures. A large silver catheter was then passed into the bladder. In the second case the same plan was pursued, with like result, as far as the contraction posterior to the incision was concerned, and a large bougie was passed from the incision into the bladder; but there still remained the long and close Stricture anterior to the perineal opening. A filiform guide was then passed from the meatus urinarius through the urethra and out of the perineal incision; the staff of the instrument of M. Maisonneuve was then screwed upon it and also passed through the urethra and out of the incision ; this was followed by the blades Nos. 2 and 3 in succession ; after which a full-sized catheter was passed through the entire urethra into the bladder. The result of these operations proved highly satisfactory in both the cases alluded to, detailed accounts of which were published in the New York Medical Record of April 15, 1873. ITS ADVANTAGES. 61 Among the advantages which it seemed to me might be legitimately claimed for this modified perineal section, were —i. That it methodically included in the same operation all points of Stricture in the urethra, with only a limited division ot the external urethral walls, and yet one sufficiently exten- sive for the free discharge of urine and of the fluids resulting from the operation. 2. That all divided Strictures, anterior to the perineal opening, were protected from contact with the urinary secretion after operation ; thus obtaining the advan- tages of each operation, viz., external section and internal urethrotomy, and at the same time lessening the disadvanta- ges if not the dangers of each as separately performed. With the view of illustrating still further the value of the procedure above described, and in order to call your attention to some important imperfections in the modes of procedure ordinarily pursued in the treatment of urethral Stricture, the following case is presented : On the 31st day of July last, Mr. W. C. H., merchant, aged thirty-three years, presented at my office, with the history of a gonorrhoea thirteen years previous. This was severe in its accession, and, through the aid of strong injections, continued in a highly inflammatory stage for fully one month. It was supplemented by a free, almost painless muco-purulent dis- charge, which, in spite of a variety of treatment, internal and by injections, continued, in a greater or less degree, through all the succeeding twelve years and up to the present time. He had his first trouble in urination seven years ago, after excess in wine.and sexual indulgence. This resulted in an attack of retention of urine, which was relieved after several hours' effort on the part of the surgeon, by the introduction of a flexible filiform catheter. From that time he had frequent- ly been obliged to resort to the introduction of the catheter, but had never since suffered from retention. For the last two or three years he had been troubled with occasional attacks of intermittent (urethral?) fever, but was not aware that he had ever been exposed to any malarial influences. He passed his water guttatim, but says that, occasionally, 62 URETHROTOMY, EXTERNAL AND INTERNAL. he passes it in a fine, short jet, and that his condition in this respect has not varied materially for the last five years. Examination showed the external genito-urinary apparatus fully developed ; penis in flaccid condition, three inches in length, and three inches in circumference; from this I esti- mated the normal calibre of the urethra to be No. 30 F. Bulbous sounds detected a Stricture at the meatus, extending one one-third of an inch, measured by No. 22 F.; one at one inch, No. 19 F.; one at two inches, No. 15 F.; one at three inches, No. 10 F.: six distinct bands from three inches to four and a half, defined by No. 8 F.; beyond four and a half inches, No. 1 filiform passes to six and a quarter inches; |- m. whale- bone, closely hugged, is finally arrested at seven and a quar- ter inches. Examination of the urine shows freedom from albumen, an occasional pus-globule, a few epithelial scales from the urethra and bladder, but none from the ureters or pelvis of kidney. No casts. The foregoing measurement of Strict- ure and condition of urine were reviewed from time to time without the appreciation of any marked changes, and with no further progress toward entering the bladder up to No- vember 4, 1873. On this date an operation was decided upon. Present Dr. George A. Peters, Dr. George W. Ives, the patient's family attendant, and Dr. J. De Forrest Wood- ruff. As the initial step in the anticipated operative procedure, ten grains of quinine and one-quarter grain of morphine were administered. The patient was then placed under the influ- ence of ether, and the calibre and location of each of the Strictures were verified (as compared with the measurements already given) by the use of bulbous sounds and bulbous filiform bougies. It was then decided that the modified perineal section was indicated as affording promise of most rapidly and certainly restoring the urethra to its normal calibre. No. I whalebone filiform bougie was passed down to six and a quarter inches, beyond which it could not be persuaded. With this as a guide (which was skillfully managed by Dr. FOURTEEN STRICTURES. 63 Peters), I made an incision from a point just behind the scro- tum to within an inch of the anus, cutting carefully down in line with the centre of the sub-pubic arch, until I came squarely upon the whalebone guide. At this point in the operation the knife was laid aside, and with No. 1 silver grooved-probe, entering the urethra through the incision from before back- ward, I passed it readily into the bladder. I then introduced the staff of the urethrotome of M. Maisonneuve alongside ESTIMATED NORMAL CALIBRE OF URETHRA the probe into the bladder. A slight pressure accomplished this, when the probe was withdrawn, and the largest blade of M. Maisonneuve (capacity 22 F.) was passed, distinctly ar- rested at three points on its course, and,on withdrawal, a 20 F. catheter was introduced. No urine flowed, although the end of the instrument was felt to be free in the bladder. This was withdrawn and found to be obstructed by a clot, but contained urine. No. 24 was substituted, with precisely the same result. It was then concluded that the curved catheter passed up above the line of urine present. No. 24 straight catheter was then substituted, and the clear urine flowed freely through it. The straight catheter having been 64 URETHROTOMY, EXTERNAL AND INTERNAL. closely embraced on entering, indicated some persistence of Stricture. I then introduced a straight, probe-pointed bis- toury along it, and incised dense cicatricial tissue for fully an inch; withdrew the catheter, and passed No. 31 F. steel sound through the external incision back into the bladder. The next step in the operation, after thoroughly incising the Stricture at the meatus, was the passage of the \ mm. fili- form whalebone guide through the urethra, from the meatus down to and out of the perineal opening, then sliding down upon it the staff of a Maisonneuve (which was perforated at the extremity for this purpose),* it finally emerged from the perineal incision. The smaller blade of the urethrotome was then driven slowly down the staff, arrested abruptly at each Stricture, and required all the force which could be used without bending the shaft of the knife, before its passage through the spongy portion of the urethra could be effected. This was followed by a blade of the second size, with much the same results. A passage of the third and largest blade was then attempted, but this, after passing with great diffi- culty, through each of the Strictures, up to three inches, was finally arrested at that distance. After a thorough trial, in which I was efficiently supported by Drs. Peters and Wood- ruff, it was found impossible, on account of the density of the opposing Strictures, to divide them with this instrument. The staff of Voillemier's divulsor was then introduced through the Strictures and out of the perineal opening, and rapid divuision made with the largest shaft (No. 30 F.). On examining the results of this last procedure, it was found that 28 F. bulbous sound was arrested at two inches. No. 26 passed, and defined the posterior face of the Stricture at two and a half inches; the same instrument was arrested again at four inches, finding slight resistance for half an inch, then passed freely down to the perineal incision. The (my) small dilating urethrotome was then introduced through the posterior Stricture, turned up to 30 F., and the narrow blade of the instrument drawn through it. This urethrotome was then adjusted to the * The filiform traversing the entire length of the staff. IMMEDIATE RESULTS. 65 anterior Stricture, which was in like manner incised from four inches to four and a half (i. c., about one-half inch). No. 31 F. steel sound was then easily passed down through the entire urethra into the bladder; thus evidencing—as much as the introduction of an ordinary steel sound can do—complete division of all the Strictures. The patient rallied quickly from the effects of the ether, having been under its influence just one hour and three- quarters. The haemorrhage occurring during the operation was slight, only two superficial vessels requiring ligature. At the end of a half-hour there was not the least oozing from either the wound in the perinaeum or from the meatus; there was no complaint of pain subsequent to the anaesthesia; and, as I was leaving him, he emphatically expressed himself as feeling " bully." From the date of the operation, November 4th, until the ioth, the patient, who was seen daily by either Dr. Ives or myself, had not the .least untoward symptom. He had an average pulse of y6, and temperature not above 98f°. His urine, over which he had complete control, was passed entirely through the perineal opening for the first three days, after which a small portion found its way through the anterior section of the canal. A conical steel sound, No. 24 F., was now (six days after the operation) passed through the extent of the urethra, and followed easily by Nos. 25 and 26 F. A slight gush of blood followed No. 26 F., but stopped in a few moments. On the 12th passed Nos. 28 and 30 F.; patient, as on the previous occasion, doing well; says he has not had an ache or a pain since the performance of the operation. Haemorrhage occurred on the next day, following the act of micturition ; this was evidently from about the middle of the spongy portion. Dr. Ives was called; eight or ten ounces of blood were lost before it was completely arrested. 14///.—Tenth day after operation. Wound in perinaeum closing healthily; passes water about equally through it and through the urethra anterior to it ; feels well, eats well; walks about his room, or sits in his arm-chair, with equal 5 66 URETHROTOMY, EXTERNAL AND INTERNAL. comfort. No further instrumental procedure was had until two weeks subsequently (December 28th), when he called at my office, saying that he felt quite well in every respect, that his stream was full size, and that only a few drops came through the perineal opening; he had gained several pounds in weight, and was looking in good condition. Examination of the urethra detects a recontraction of the Stricture at one and a half to two inches from the meatus, 17 F. ; rest of canal appa- rently clear. Ordered ten grains of quinine. December 4th.—Pass 17 F. easily, then 19 F., which was closely hugged. 6th.—Find the Stricture at from one and a half to two inches composed of two firm bands close together ; introduce small dilating urethrotome ; expand it to No. 28 F., with difficulty, on account of the great density of the Strictures ; draw the blade of the urethrotome through them from behind forward, and pass 26 F. conical sound readily down into the bladder. No. 26 F. bulb passes down .to the membranous urethra and returns, without giving any positive evidence of further recontraction at any point. Patient took ten grains quinine, and then started for home, three miles distant, in the cars, with directions to keep quiet for the remainder of the day. Two days subsequently (December 8th) patient reports that there had been no haemorrhage, no disturbance nor dis- comfort whatever following the operation, except slight smart- ing on urination : pass 25 and 26 F. conical sound with ease. gth.—Patient calls to say that he had a smart chill, fol- lowed by fever and sweats, coming on about five hours after the introduction of the sound yesterday. Ordered five grains quinine to be taken three times a day. 12th.—Patient reports himself in good condition, having had no further trouble; a few drops of urine still exude from the perineal opening during micturition, but he passed per urethram a full and comfortable stream ; 28 F. passes readily through the entire urethra. 1 $th.—Perineal incision completely closed; discharge EXAMINATION BY COMMITTEE. 67 quite gone ; patient makes a full and satisfactory stream ; repeat passage of 28 F. 22 H M o 61541 Gonorrhoea- 10 11 12 13 33 Gonorrhoea several times during the last ten years. 27jGonorrhcea sevei years previous. 24 30 46 Gonorrhoea. Gonorrhoea four years previous Gonorrhoea nine years ago. Gonorrhoea twelve years previous. G onorrhoea twenty years previous. 1 in. 29 34 £in. 33 33 3Jin. 20 31 1 in. 19 1| in. 19 Meat. 20 32 i in. 23 37 1 in. 28 1+in- 28 2^ in. HO 3 in. 30 3£in. 30 4 in. 28 4* in 28 5£ in. 28 Meat. 23 £ in. 26 34 2* in. 26 Meat 22 31 29 34 Gleet......._.....______Gleet Gleet for five years. Frequent and painful mictu- rition. Pain in perineum Gleet. Irritation in urethra Frequent micturition. Gleet Granular spots in urethra. Painful erections. Pain in perineum, left hip over the region of left kidney. Frequent micturition. perfect erections. Im- Cure, complete in two weeks. .. Cure in two weeks. Perfectly well one month after opera- tion. Cure Slight gleety discharge remain- ing ten days after operation Not since heard from. Thirteen months after operation no recontrac- tion. One month after operation no recontraction. Three months after last oper- ation. No re- con traction. Perfectly well One year after operation. No recontraction. Granular spots disappeared after operation. Painful erections still persist. Immediate relief of pain in per- ineum, hip and back. Cure. One year after operation. No recontraction. Sexual power perfect. O STATISTICAL TABLES— Continued. O oo Cause and date of 14 45 Gonorrhoea fifteen years previous. Several times since. 15 42 Congenital con- traction. 24 Gonorrhoea four months previous Masturbation____ 18 25 Gonorrhoea one half a year pre vious. 19 48 Gonorrhoea twen- ty years pre- vious. 1 k in. 1| Meat. Meat. 18 11 in. 29 2} in. 24 2i in. 2'i 3} in. 23 1 in- 20 Meat. 30 32 34 21 Condition at date of Operation. Gleet for twelve and a half years. Irritability of vesical neck Imperfect erections. Gleet. Frequent micturition. Gleet. Imperfect er- ections. Gleet. Frequent and painful mic- turition. Pain in perine um. Gleet. Frequemt seminal emis- sions. Incomplete erec- tions. Weekly semi- nal emis- sions. Gleet. Frequcn I seminal emissi o u s Imperfect erections. Accidents after Opeiation. H e m o r - r h a g e controlled by tube. Results. Cure of gleet in one month. Curva t u r e of penis during erections. Cure. Recontraction three times Perfectly well two and a half months after last operation. Cure. No re-examination after one month Cure of all trouble____________ Cure. Four re-contractions with partial return of symptoms. Final cure after last operation ten months ago. Cure______...........------- Seven months after operation no trace of stricture. 20 25 Gonorrhoea three 2 Hin. 23 31 | years previous. 6 in. 21 21 25 Gonorrhoea one and a half and one year pre-vious. 4 2 in. 4^ in. 4^ in. 5 in. 24 24 24 24 30 22 20 Gonorrhoea. Mas-turbation. 2 iin. U m. 24 24 30 23 30 Gonorrhoea ten years previous. 3 I in. 2* in. H in 31 31 31 31 24 50 Gonorrhoea thirty and twenty-five years previous. ] i in. 18 29 25 54 Gonorrhoea______ 2 i in. 3 in. 16 26 31 26 40 Gonorrhoea twelve years previous. 5 i in. 2 in. 2± in. 2j in. 2} in 20 28 28 28 28 31 27 35 Masturbation____ 4 Meat.. \ in. 1 in. 2 in. 19 19 27 27 31 2S IT Masturbation____ 3 i in. 2 in 3J in. 20 22 22 32 29 40 Gonorrhoea three years previous. 1 1 i in. 36 38 Gleet lasting one year Gleet.........______ Gleet................ Gleet.....____ Painful and frequent mictu rition. Gleet. Irritability of vesical neck Gleet. Frequent and painful mictu rition. Chronic discharge from the urethra. Frequent and painful mictu- rition. Frequent micturition. Sense of foreign body just be- hind the meatus, causing great nervousness. Gleet. Gleet. Gleet. Gleet. Gleet. Gleet. Gleet Gleet Chills... Prostatic abscess Cure of gleet. not divided. Cure---------- Deep stricture Cure. Remains perfectly well two years and three months after last operation. Cure______________________ Cure. Recontraction after six months. Second operation. Relief, which after two years remains permanent. Cure, which remains complete three years after last operation. Cure________________________ Discharge disappeared. Cure. Cure within two weeks. Ten months also two and three years after op- eration. No recontraction. One year after operation no recontraction. Six months after last operation, no recontrac- tion. Recontraction at meatus. None of deep stric- tures. Four mos after operation. No recontraction. Nine months af- ter operation. No recontrac- tion. £ STATISTICAL TABLES— Continued. 30 31 32 33 34 19 19 24 Cause and Date of. Gonorrhoea two years previous Masturbation. Gonorrhoea. 25 Gonorrhoea s i x years ago. Fre- quently since. 29]Gonorrhoea six months previous 3 o 1 u tw -£ OJ o CC O £ Hi o 1 in. 25 31 2£ in. 31 3 in. 26 3£ in. 22 3£ in. 31 4 in 31 5* in. 27 iin. 26 32 Meat. 2 Cure________________________ Relief for three months. Re-turn of symptoms. Recon-traction discovered. Second operation. Partial return ol symptoms four months after. Immediate relief of spasmodic stricture, under other care Pros, abscess reported ten days after. Cure________________________ ter operation. No recontrac-tion. Perfect-ly well at date, January,1875. Immediate relief of all symptoms connected with the urinary organs. Tolerance of diure-tics re-established. operation. No recontractioD. 35'4 6 [Gonorrhoea. 30 38 f lonorrha-a s i x years previous. 37 41'Gonorrhoea six ! . years previous. 3S 47 Gonorrhoea twelve years previous. 39 40 41 28 29 Gonorrhoea six and five years previ- ous. Gonorrhoea seven years previous. Gonorrhoea_____ II tin. 19 in. 26 2 in. 30 Meat. 1 iu tin. Meat.. 1 in. 1J in 2 in. 2| in i in. Meat.. 2i in. 3£ in H in. Memb. port. 31 32 30 32 34 Frequent and painful mic iPainful erec- turition. Pain in should-| tions. ders, knees, legs. Painful erections. Painful micturition. Gleet. Gleet. Unpleasant sensa- tion in testicles. Frequent micturition. Irri- tation in deep urethra. Had been treated for deep stricture. Frequent and painful mic- turition. Gleet. Weak- ness. Gleet. Spas modic stric- ture. Gleet........ Gleet. 30,34 Gleet 32|Frequent and painful mic- turition. Gleet. Fre- quent attacks of retention of urine. Gleet- Gleet. Reten- t i o n of urine. Diphtherit- ic exuda- tion ou s u r face of wound at meatus after first operation Uretnrai fe ver Hwem or rliage causiu< retention and neces s i t a t i n g perineal incision and aspira- tion of the bladder. Recontraction of stricture three times. Last operation about a month ago. Perfect relief after each operation, until re- contraction occurred. Cure of troubles within a month. Gleet, etc. Cure of gleet and the nervous trouble in testicles. Cure. 32 passes with ease into the bladder after division of the meatus. No re examin- ation after two weeks. Cure of gleet and frequent mic- turation. Cure of gleet for one month, when patient aquired a fresh gonorrhoea. Recovery with thirty f. calibre. To continue use of sound as recontraction at some point had taken place. Further operation deferred. O .....""" M X ___ _ _ c R e-e x a m i ned ^ two weeks af- M ter operation. O No recontrac- <-) tion. > Three months g after opera- en tion recon- q traction at >r| meatus. No trace of deep strictures. Recontrac ton slight after one month. H X > en H o H a STATISTICAL TABLES.— Continued. to 3'J 24 Cause and date of. 3 a 3 .e 6 0 1 3 1 1 I w "3 "3 o o t-1 a -CE o 35 1 2 a: t3 o £ o s Condition at date of Operation. a _o "5 "H. a o O c _o }i O i. .£> 1 1 2 1 1 Accidents after Operation. Besnlts. a o a a a M w Follicular ulcera-tion. Masturbation____ Gonorrhoea s i x years previous. i in. F r om Meat to 1 in. 2% in. 2| in. iin. Meat.. 28 13 26 23 28 23 32 32 34 31 Frequent painful micturi-tion. Pain in thighs, knees and legs. Frequent and painful erec-tions. Very severe pains in thighs and feet. Ex-treme sensitiveness of glans penis. Excessive sensitiveness of glans. Frequent micturition_____ Frequent seminal emissions. Urotliral fis-tula. Urin-ary abscess over right cms penis. Freq'ent sem i n a 1 emis-sions. Pre-mature dis-charge o f seminal fluid Retention of urine re-peatedly. S pasmodio stricture at m e m b ran ous portion. Immediate relief of all reflex troubles. Cessation of semin-al emissions for one month. Return of trouble. No re-ex-amination. Cure. Immediate relief fol-lowing operation. Urinary abscess healed in ten days. Perfectly well four months after operation. No re-examin-ation. Cure of sensitiveness of glans, and consequent relief of sem-inal trouble. Cure. Perfectly well four months after operation. 46 47 48 49 50 51 21 28 25 Gonorrhoea three 5 and a half years and also two months previous Gonorrhoea s i x years previous. Gonorrhoea ten and also seven years previous. Gonorrhoea five years previous Gonorrhoea twelve years previous. 62 Gonorrhoea forty- one years pre- vious. 721 Masturbation. Meat. 2 n. 21 n. 1 n. Meat __ 1 n. 2 n. 2* n. 1* n. 4 n. 4+ n. * n. H n. n n. 3 n. 4 n. Mea 2* n. 2* n. 3 in. Meat.. Meat. 2 ii Meat. 2$ in. 3J- in. 26 36jGleet.........______ 26 26 26 30 22 32 22 30 30 30 30 30 20 28 20 20 27 27 23 32 26 30 31 22 32 2SJ33 30 28 28 34 Gleet, lasting six years____ Gleet for seven years_____ Gleet................... Gleet................... Frequent micturition. Frequent micturition, fol- lowed by severe pain in back and soreness in ure- thra. Gleet. Gleet. Gleet. Gleet. Gleet. Fre- quent erec- tions. Uri- nary sinus near mea- tus. Spasmodic stricture at in e m bran-! ous portion, dilated for, twenty yrs. Weekly semi- nal emis- sions. Pri-i apism. I Hemorr'age controll'd by tube. Cure of gleet within two weeks. Re-examination three weeks after operation. No recon- traction. Cure. Cure. Cure. Cure of gleet. Sinuses healed. No re-examination. immediate relief followed oper- ation. Intervals between mic- turition, eight hours. One month after operation, relief permanent. No recontraction. Relieved from frequent mictu- rition and priapism lor about three weeks. Return o! trouble. No re-examination. Three weeks af- ter operation. ^ o recontrac- tion. One and two and a half years after opera- tion. No re- contraction. Seven months a ft e r opera- tion. No re- contraction. Three months after last op- eration. No re-contrac- tion. STATISTICAL TABLES— Continued. J 1 f1 £ c I 3 a Cause and "E *E u 0 Condition at 9 Accidents a n m date of a C after Results. — 3 0 'E Operation. •2 O Operation. c3 u t>. rn U t. q; s "3 3 £ ft E c 61) 0 * < 25 'A *A 20 S<3 30 0 'A M 53 Gonorrhoea ten years previous. 5 H in. 3 b'nds Gleet. Irritable bladder... Gleet_______ 2 Cure____________________ thirteen 44 in. months after 2 buds 27 operation cure still per-fect. 54 -- Gonorrhoea______ 8 Meat. 2] in. 22 22 31 Gleet Gleet....... 5 Chills (slight). Cure____________________ Thirteen months after last ope- 2* in. 26 Curva- ration. No 2| in. 24 ture ol r e - c 0 n trac- 3 in. 30 penis du- tion. 3j m. 30 ring erec- 4^ in. 24 tion. 5 in. 24 55 -- Gonorrhoea two and also one and 3 2f in. 3^ in. 29 27 30 Gleet....... 5 H e m 0 r -hage not Cure.........9._________ One year after last operation a half years pre- 2k in.|27 very se- no re-contrac- vious. v e r e . C 0 ntrol-ed by tube. tion. 56 -- Gonorrhoea five and two years 1 fin. 24 30 Gleet Gleet........ 2 Half a year af-ter last oper- previous. ation no gleet no re-contrac-tion. 57 23 58,30 Gonorrhoea one year previous. Gonorrhoea. 5!) 27 Gonorrhoea. GO 32 Gonorrhoea ten years previous Masturbation. 61 40 Gonorrhoea twelve years previous 10' Meat. 24 '{ in. 22 1 in. 31 \k in. \\ in. 1J in. 22 31 40 2 in. 33 2i iu. 3£in. 4|in. Meat. 37 37 37 21 H in. 18 Meat.. Meat... i in. 24 22 26 40 Gleet...................Gleet 30 30 30 30 Pain and uneasiness in peri- neum and glans penis. Gleet. Profuse purulent discharge, caused by in tercourse. Gleet... Frequevit micturition. iu penis. Gleet. Pain Great nerv- ousness. Gleet. Spas- modic stric- ture a i me mbran- o u s p o r- tion. Fr e que n t sem i n a 1 e m i ssions. Nervous- ness. Gleet, Gleet. In- tense pain f o 11 owing s e m i n a I emissions. Cure of gleet. No re-contrac tion at any point after six months. Contracted another gonorrhoea. Freedom from symptoms fol- lowing each operation, and continuing from one to two months. Cure, remaining complete one year after the operation. Cure of gleet within two weeks. Married at the end of one month. Re-examined two months after. No return of trouble. Cure. Relief of pain and fre- quent micturition. Cessation of discharge for three mouths, when it returned, and also the frequent micturition. Re- contraction found. Second operation followed by renewed relief, which continued for six months when he contract- ed a fresh gonorrhoea. Six months after last operation no re-contrac- tion. Six months after the operation no recontrac- tion. Two months aft- er operation. No recontrac- tion. STATISTICAL TABLES.r-Continued. C\ 62 63 Cause and date of. 45 Gonorrnoea cwice 34_.......-....... 64|50|Gonorrhcea twenty five years pre- vious. 65,37 Masturbation Meat... i in i in. Meat. 1 in. 3 in 3} in. 2S 33 15 34 30 30 38 34 34 34 Condition at date of Operation. Irritability of bladder. Pain alter connection. Pain in back, hypogastrium. groins, testicles, innei aspect of thighs and knees Irritability of bladder. Gleet for five years. Constant desire to urinate Burning in penis. Pain at meatus, iu back hypo- gastrium, right testicle and legs. S p a s m o die stricture at m e mbran- ous portion Double hydro cele. Fre quent sem- inal emis- sions. Gleet. No erections; no venereal desire for four months Accidents after Operation. Results. Diphther- itic exud- a t i o n . A c u t e urethritis Immediate relief. Recontraction after two months. Return of trouble. Second operation followed by relief, which was permanent six months after operation. Immediate relief of pains. Dis- appearance of hydrocele with in a month. Two recoutrac- tions with returnof Symptoms Third operation followed by relief, which continues one year after operation. Cure; return of symptoms five months after first operation. Relief of pains. Patient stil under treatment three weeks after operation. Six months after operation. No recontraction. Two and a half years after second opera- tion, remains perfectly well. G6 67 59 47 51 52 31 35 32 29 28 Gonorrhoea first t w e u t y-n i n e years previous. Several attacks since. Gonorrhoea twenty five years pre-vious. Gonorrhoea twenty years previous. Gonorrhoea_____ Gonnorrhcea four times ; last at-tack three years previous. Gonorrhoea______ Gonorrhoea seven years previous. Several times since. Gonorrhoea three months pre vious. Paraphimosis Oc-cidental. 4 2 1 2 i 2 2 4 i in. H in. 3^ in. 4_-in. i in two bands. Meat. 3£ in. 5| in. Meat. 2 in. deep. £ in. Meat. 3 in. iin. 2k in. l|in. 24 in. 2|in. 2f in. 20 20 20 15 28 21 til til til 25 34 19 26 29 16 21 21 21 34 32 34 30 34 38 30 31 Frequent and painful mic-turition. Stranguary. Pain in perineum, above pubesaud in groins. Frequent and painful mic-turition. Small stream. Micturition every hour____ Frequent micturition. Pus in urine. Difficult micturition. Blood in urine. Urine in drops. Pain in back. Gonorrhoea acute for five months. Gleet _......._........._ Cystitis------ 68 69 70 Loss of sexual power. Subpubic and perineal fis-tulse. 71 7? Gonorrhoea. . Gleet....... Gleet. Spas-modic stric-ture. Retention of u r i n e . G leet. 73 Gleet______.....________ 74 Gleet.................... [Immediate relief of pains and stranguary. Pus iu urine diminished. Frequent mic- turition persists. Still under treatment. Cure_______________________ Diphther itic de- posit. Immediate relief of frequent micturition. Recurrence of erections. Patient still under treatment. Relief of symptoms_________ Cure of symptoms. amination. No re-ex Immediate relief to acute symptoms. Still under treat- ment. Relief of discharge. Slight re- contraction alter one month, Relief of spasmodic stricture Slight discharge remains. Relief of symptoms. Two months af- ter operation, no recontrac- tion. Recontra c 11 o n after one month. Recontra c t i o n at meatus. None of deep stricture. Three months after opera- tion found contraction at three inches. a M H 33 5- > C en H 1—1 o H a w STATISTICAL TABLES—Continued. 00 40 29 77 38 78 54 79'40 Cause and Date of. Gonorrhoea seven years previous. Gonorrhoea two years, also two months pre- vious. Gonorrhoea thir- teen years pre- vious. Gonorrhoea four- teen years pre- vious. Gonorrhoea twelve and also one yr. previous. 2 3 55 o O L. fc*. _J s C3 O » 1-1 1 Meat. 1 iin. 1 Meat. 2 3k in 6 in. 1 i in. 28 26 24 31 33 Condition at Date of Operation. 26 .. ill 21 34 Difficult micturition, fol- lowed by pain in urethra. Gleet. Burning in urethra during micturition. Pain in back. Gleet. Frequent micturition. Pain in deep urethra and tes- ticles. Nervous feeling in thighs and legs. Burn- ing of hands and feet. Frequent and painful mictu- rition. Frequent and painful mictu- rition. Pain at glans penis. Purulent urine. Burning in urethra dur- ing seminal emissions. Accidents alter Operation. Chills. Eesults. Cure- Cure. Cure. Perfect relief. Cure________ 8040 81 82 3 83 51 84 54 85 Use of syringe to prevent gonor- rhoea. Gonorrhoea r e peatedly. Gonorrhoea fifteen years ago. Sev- eral attacks since. Use of powerful injec- tion. Congenital con traction. Gonorrhoea twen ty and also eight years previous. 1 Meat. -- Gonorrhoea five months pievi ous. 22 30 Frequent micturition 20 i in. 2 in. 2|iu. Meat. in. Him 28 20 31 30 Frequent and painful mictu- rition. Pain in groins extending to feet. Peculiar motion of testicles, causing great suffering. Frequent micturition. 20 31 24 2|-in. 28 Meat._ 16 30 Frequent and painful nic turition. Pain in penis, testicles, thighs, peri- neum. Long attacks of retention of urine. Gleet. Chronic cystitis. Gleet....._......._ Cystitis. Fol hcular infil- tration of urine into the perine- um. Deep, spasmodic stricture. Peculiar movements of testicles, causin great suf- fering. Cystitis. Gleet. Gravel. Ret ention of urine pre- viously. Gleet.....___ 3Urethritis followed by gleet. lasting 4 months. Relieved of frequent micturition for two years. Return of same trouble. Recontraction found. To be operated on again. Division of meatus and incision into perineal abscess, followed by immediate relief of symp- toms Cure of cystitis in two weeks without other treat- ment. No subsequent re- examination. Reflex movements ceased after operation, also pains. Eight months after operation return of trouble. No re-examina- tion. Perfect relief for one year. Re- turn of symptoms. Second operation followed by urethri- tis and gleet. Third operation followed by complete relief. which after eighteen mouths remains perfect. Cure. One month after first operation, re-contraction. Re- division of stricture at meatus. Relief. Perfectly well three months after, as reported by his physician. Cure____.____________________ R e c o n t raction found after two years. O W d M O o > m W c/i O a *j w H > r1 en H O H a K VO STATISTICAL TABLES.— Continued. 86 22 Cause and date of 87 89 90 Gonorrhoea five years previous. Gonorrhoea twenty and inree years previous. Gonorrhoea____. Gonorrhoea ten years previous. Gonorrhoea twenty years previous. i in. 2i in. 2J iu. 1 Jin. 22 28 2 J Meat. 3 in. Meat. 31 Condition at date of Operation. Occasional increased fre quency of micturition. Return of gleet after eacl venereal indulgence. Gleet for two years_______ Gleet____................ 34 Several attacks of retention of urine. Treated for deep stricture. Trouble refer- red to neck of bladder. Red u n dent prepuce C i rcumcis Gleet Gleet. Gleet. spasm. S t r icture. Ret ention of urine. Accidents after Operation. Gonorrhoe- al rheu matism. Pros tatic abscess. Results. Gleet ceased for six months. Then he had a fresh gonorr- hoea, followed by gleet. Cure. No return of trouble six months, also one year after operation. Cure of gleet. No return when patient was seen last. Cessation of gleet for three months. Recontraction at three inches and return of discharge. Still under treat- ment. Complete relief. After division of meatus thirty-four sound passed into bladder. Passed out of observation one week after operation. « Six months after operation re- contraction at meatus. None of deeper strictures. Recontraction at three inches six months af- ter operation. 91 92 93 94 4 7 jGonorrhoea twenty five years pre. vious. 34 47 10 Gonorrhoea ten years previous. Gonorrhoea twenty years previous. Balanitis 95 50 Gonorrhoea twenty years previous. 90 97 27, Masturbation. 27 Gonorrhoea seven years ago. Sev- eral attacks sub- sequently. 2 i in. 28 37 two bands. 1 i in. 27 31 7 Meat. 24 31 1 in. 22 3\ in. 15 four bands. membr portion lilifb'm 1 Meat. 12 22 2 i in. 27 32 2k in. 30 1 Meat. 30 38 2 iin. 20 31 1 in 19 Frequent micturition. Gran- ular urethra and great sensitiveness of urethra Frequent micturition. Sense of fullness in urethra. Highly spasmodic condi tion of urethra. Frequent micturition. Two Retention attacks of retention of urine. Small stream. Granular urethra. Incontinence. micturition. of Frequent|Phymosis cir- cumcision. Frequent micturition. Pain and tenderness in hypo- gastnum and back. Small stream. Dribbling. Frequent micturition. Sense of wetness about glaus. Dribbling. Frequent and painful mictu- rition. Pain in penis, perineum, rectum. Con- stant desire to defecate. Frequent sem- inal emis- sions. Postatic e n - largement. Cure. Immediate relief to fre- quent micturition. Urethral trouble disappeared without further treatment. Cure of frequent micturition and abnormal sensations in uretlna Relief of all symptoms which continues. Cure. Immediate relief of in- continence. Return of incon- tinence. Recontraction. Re- division of meatus. Perfect relief of incontinence up to date. Immediate relief of symptoms, which continues up to date. Cure. Remains perfectly well eight months after last opera tion. Recontraction with re turn of symptoms twice. Cure. Relief of all symptoms for two months. Recontrac- tion with return of symptoms Second operation followed by relief, which after ten months remains perfect. Two months af- ter the opera. tion no recon- traction. Three months afterlast oper- ation. Eight months af- ter last opera- tion no recon- traction. Ten months af- ter last opera- tion, norecon- traction. STATISTICAL TABLES— Continued. a U c £ 33 Cause and date of. 02 C c s 3 cn >. "3 o Hi o 'E c 3a 22 19 15 e O) £ 30 Condition at date of Operation. a p "8 75, a o g a u c-c t-B 3 2 Accidents after Operation. Results. 3 | 98 Gonorrhoea thir-teen years pre-vious. 14 Meat. 1 in. 2 in Gleet. Retention of urine. Urine in drops. Gleet. Reten-tion. Chills after introduc tion of in- Complete relief of symptoms External and internal opera-tions combined. Recontraction of two strictures to 24. 3 in. 10 strum'ts. 3 to ^ 4iin [ 6 j 8 bandsj 4.1 to 1 2bds ^ 1 99 30 Gonorrhoea------ 8 6rto 1 7iin [ 3bds j 31 Gleet for two years_______ Gleet....... 3 Cu r vature of penis Cure of gleet_______________ One vear and a iHin [ half after op- 3bds f 0 during e ra t ion, no 3£ in. 25 erection. recontraciion, 2 in. 26 Disap- except at two 100 30 Gonorrhoea ten years previous. 2 2| in. 3| to 4 Meat.. G_-in. 20 17 30 Frequent and painful mictu-rition. Gleet. Gleet_______ 0 peared after one year. Cure________________ _______ points, be-tween three and four ins. One year and a half after last operation, no recontraction. Total number of operations, 203 CHAPTER VI. ITINERARY. ABOUT three months after the presentation of the forego- ing paper to the State Medical Society, I made a voyage to Europe with my family, stopping incidentally in London. Not hitherto satisfied with the mechanism of the urethrametre I availed myself of the exceptional skill of Messrs. Mayer & Meltzer, Surgical Cutlers to the University Hospital College of London, to substitute steel springs for the jointed arms. By this improvement the instrument was rendered more val- uable through increased accuracy and freedom from points / of friction. The dilating urethrotome was also improved at that time, concealing the blade by dropping it into a groove at the end of the instrument. Presenting a letter to Mr. Berkeley Hill, from my friend Dr. Bumstead, I was cordially received. I soon found that Mr. Hill was au courant with my published views and in general harmony with them. By his invitation, on the 7th of July, 1875, I delivered a clinical lecture at the University College Hospital, embodying my peculiar views on urethral Stricture with practical demonstration, before a large body of students and medical men. A report of this lecture, by the late M. Victor de Meric, may be found in the London Lancet of July 24th, 1875. I called upon Sir Henry Thompson, author of several works on genito-urinary diseases, and perhaps the greatest accepted living authority on all such matters. My previous published criticism of his teachings on urethral Stricture, (p. 69, ct scquitur,) while purely impersonal and scientific, did not lead me to expect a cordial acceptance of my views. They 124 CURE OF PERINEAL FISTULA. were made the subject of some discussion, however, and sub- sequently I was afforded an opportunity, through his polite invitation, of witnessing several operations by him, on Strict- ure, and for vesical calculi, on private patients. The results of the Stricture operations as well as of the discussions which followed them were not productive of a satisfactory settle- ment of the grave points of difference which were known to exist between us. Through the courtesy of Mr. Alfred Cooper, Mr. Walter Coulson and Mr. W. F. Teevan, eminent surgeons in London, and connected with the Lock Hospital and St. Peter's Hos- pital for stone, I operated on several cases of urethral Stricture and demonstrated the capacity of my different in- struments in each of those hospitals, and in St. Peters, and in each case operated on, the proportionate correspondence between the urethral calibre and the circumference of the flaccid penis was proved. One case was met in Mr. Coul- son's service at the Lock Hospital, where the circumference of the flaccid penis was 10.6 centimetres (4^ inches). After the division of an anterior contraction, I passed a solid steel sound, No. 40 F. through the entire urethra without the least force. This instrument was withdrawn by Mr. Coulson, who then expressed his conviction that the normal portions of this canal had not been over-distended by the introduction of the sound No. 40, i. e., of a circumference of 40 mm." Another case (in St. Peter's Hospital) in the service of Mr. Coulson, was subsequently published in the London Lancet of August 28th, 1875, page 305, under the title of Perineal Section followed by the Operation of Dr. Otis for the cure of Fistula in the Perineum, by Walter Coulson, F. R. C. S., Surgeon to the Lock and St. Peter's Hospitals, is here quoted from the Lancet. " The following case considerably abridged, may serve as an introduction to some remarks on perineal fistulae and on ifche operation for Stricture, proposed by Dr. Otis of New York, and recently performed in this country. " Case is that of Robert D., aged forty-four,seaman. About MR. COULSON'S CASE. 125 five years previous to his admission, for the second time, into hospital, he had been treated as an in-patient by dilatation at Grey's Hospital. Two years ago (1873,) he was admitted with extravasation of urine, following retention. This condi- tion was relieved by free incision of the perinaeum. The patient made a good recovery, but a perineal fistula remained, which it was hoped might be closed by continuing the dilata- tion of the Stricture. At the time of his leaving the hospital a No. 5 English (12 French) catheter could be passed into the bladder; but the man neglected to attend as an out- patient, and when re-admitted, in May, 1875, he was unable to pass any urine naturally, the whole of it escaping in a small stream, through the perineal fistula. The passage of the urine now causes great pain and scalding, which continue for some time after micturition; he suffers from constant desire to micturate, the urethra is exceedingly sensitive, the urine loaded with mucus and pus, and no instrument can be passed into the bladder. Up to the 17th of May, several attempts had been made to pass elastic instruments into the bladder, by the penis, and through the perineal opening, but they failed. He has been taking fifteen minims of sandal oil three times daily, which has materially diminished the muco-puru- lent deposit in the urine, but has had no effect in diminishing the scalding. On two occasions he had retention of urine which was relieved, after some difficulty, by insinuating a small elastic instrument through the fistulous opening into the bladder, but all attempts to pass an instrument along the penis, from the meatus, were unavailing. However, an ex- tremely fine elastic bougie could be passed along the penis and out at the perineal opening. On May 17th, I performed the following operation. A No. 8 (E.) steel bougie was passed down along the urethra, as near to the fistula as the thick- ened structures surrounding it would permit. A free incision was then made through the fistulous opening, and the adja- cent strictured portion of the urethra was freely divided. A straight grooved director was then passed through the wound into the bladder, the edges of the fistula were pared 126 CURE OF PERINEAL FISTULA. and a No. 16 French elastic catheter was introduced into the bladder, the straight director acting as a guide. The cathe- ter was tied into the bladder and retained there until the fol- lowing evening. " No bad symptoms followed the operation, and the tem- perature of the patient remained unchanged. From this date until July 19th, both continuous and occasional dilatation was employed, and the edges of the wound were touched from time to time with caustic. The perineal wound became merely a fissured opening, but still it would not quite heal, and on every occasion that the patient passed water some portion of the urine escaped through the fistula. The ques- tion then presented itself, whether the fistula might not possibly be kept patent by some constrictio7i in the penile portion of the urethra. With the assistance of Dr. Otis an examination was made with the urethra-metre, and the existence of three distinct points of Stricture was demonstrated. It was there- fore resolved that resort should be had to his operation. The patient was placed under the influence of ether adminis- tered by Dr. Knott, and the urethrotome of Dr. Otis was passed down as far as the fistula. The instrument was then made to indicate a dilatation corresponding to 32 of the French scale, and the three points of contraction were freely divided. The last mentioned result was verified by the intro- duction of the bulbous sound (32) which was passed down as far as the fistulous opening, and withdrawn without a catch. A tube open at both ends and about five inches long, was tied into the urethra after the operation, and was allowed to remain for six hours. This was at the suggestion of Dr. Otis, but the tube was removed, at the patient's request, as there was no sign of bleeding ; the loss of blood after the operation was also slight. From the date of the opera- tion, July 19th to the 24th, no unfavorable symptom mani- fested itself. A 32 bougie was daily passed along the ure- thra to prevent adhesion of the cut surfaces, and the patient left the hospital cured. When he reported himself to me August, 16th, the fistula was completely healed." MR. TEEVAN'S CASE. 127 Mr. Coulson then follows with a description of my instru- ments and modes of operation, with an explanation of my views and the results claimed. In concluding he says: "Amongst the complications arising from Stricture, extra- vasation of urine, and injury to the urethra, there are few which occasion more inconvenience to the patient, and trou- ble to the surgeon than perineal fistula. In D.'s case, the complication resulted from an operation performed for the relief of extravasation, and, dilatation having been tried and failing to close the fistula, perineal section was for a second time resorted to; but in spite of this operation, and subse- quent dilatation, the fistula remained open. '• The result of Dr. Otis's operation certainly proved that slight contractions, which are not usually recognized as Strict- ures, may offer obstruction to the passage of the urine suffi- cient to prevent a urinary fistula from healing. The result of the internal division of the Strictures and the daily intro- duction of full-sized instruments left the mucous wall of the canal, after complete cicatrization had taken place, as supple and non- resisting to the passage of the full-sized sound, as a perfectly healthy urethra." In order to prove the results above shown by Mr. Coul- son, I will introduce in this connection a case published in the British Medical Journal of October 21st, 1876, as related by Mr. W. F. Teevan, Surgeon to the Lock and St. Peter's Hospitals, London, being an extract from the proceedings of the Clinical Society of London, as fol- lows: " Traumatic Stricture and numerous penile fistula cured by internal urethrotomy." Mr. Teevan related particulars of the case. The patient was a sailor who had injured his scrotum and penis by a fall twenty-one years previously. Numerous abscesses formed and sixteen fistulae resulted, through which all the urine was passed. In the course of a few years the fistulae in the scrotum (eleven in number) closed, but those in the penile urethra remained open. For a period of more 128 CURE OF PERINEAL FISTULA. than three months Mr. Teevan tried three separate plans of treatment, with but partial success. 1st. Retaining a catheter in the bladder. 2d. The patient drawing off all his own urine with a catheter for two months. 3d. The application of heated wires and probes tipped with the nitrate of silver. On January 6th Mr. Teevan performed Dr. Otis's opera- tion, and nine days afterward all the fistula were closed and remained so permanently. The points of interest in the case were, 1st. The Stricture being a traumatic one, of the worst description. 2d. The fistulae being in the penile urethra, always most difficult to cure. 3d. The fistulae having been open for the long period of twenty-one years. 4th. The failure of three different methods of treatment. 5th. The permanent closure of the fistulae after the Strict- ured portion of the canal had been enlarged by Dr. Otis's urethrotome to its natural calibre which was 31 m. in circum- ference. 6th. Subsequent to the operation no catheter was left in the bladder, nor was the urine drawn off." Through the courtesy of Mr. Joseph Lister, F. R. C. S., then Professor of Clinical Surgery of the University of Edin- burgh, and Mr. Annandale, F. R. C. S., Lecturer on Clinical Surgery, of the University of Edinburgh, I was enabled to present my views on urethral surgery before the British Med- ical Association at the meeting in Edinburgh, August 5th, 1875, in an address which was published in the British Med- ical Journal, February 26th, 1876. Two complete and beautifully finished sets of my urethral instruments, manufactured within a fortnight af- ter my arrival in London, by Messrs. Mayer & Meltzer, were placed on exhibition by them in the Surgical In- strument Hall of the Association, at the meeting of August, 1875. Later in the season, September, 1875, passing through MR. TEEVAN'S CASE. I29 Paris, I loaned my instruments to M. Collin, successor to M. Charriere, Surgical instrument-maker, who duplicated them for the benefit of the profession there. My time however was so limited that I could not then bring them the instru- ments, with my views and experience personally before the surgeons of that city, distinguished in the history of Genito- urinary surgery. On my return to the United States early in October, 1875, I found a greatly increased interest among surgeons in the views which for the previous five years I had persistently ad- vocated in societies, in the journals, in my hospital services, and in my Clinical Chair in the College of Physicians and Surgeons. All the various hospitals had been provided with my instruments, and dilating urethrotomy for the cure of gleet and Stricture was beginning to be generally practised. Gleet, in its relations to urethral Stricture, was becoming a matter of interest to the profession at large, and I was requested to write an article embodying my views as definitely as possible on the subject for the series of American Clinical Lectures, edited by Dr. E. Seguin, and published by Put- nam's Sons, of New York. This was written at once and published in October, 1874. Inasmuch as it became the subject of subsequent important public discussion, it is thought desirable in this place to reproduce it entire. Gleet, and its relations to urethral Stricture. The secretion of the urethral mucous membrane serves as a protector, and lubricant, for the preservation of this mem- brane from contact with the irritating urinary fluid. It is made up of germinal granules—particles of bioplasm (Beale), which rise up through the interstices of the sub-mucous cellu- lar tissue,* are transuded through the basement mucous membrane, and becomes organized as the protective and lubricative epithelial cells of the urethral mucuous mem- brane; and where the conditions of its evolution are in every respect perfect, in quantity just sufficient for the lubrication and protection of this structure. This is never sufficient to * Rindfleisch, Pathological Histology, Am. Ed. pp. 43, 99, et sea. 9 130 RELATIONS OF GLEET TO STRICTURE. be perceptible to the naked eye, except as a moist glazing of the surface. Any excess is always the result of an abnormal stimulation of the natural processes, except in a single in- stance, purely physiological, when it proceeds from an erotic excitement, and appears at the urethral orifice as a transpa- rent mucous exudation, which passes off with a cessation of the nervous impression which provoked it. The causes which unduly increase the secretion of this membrane (and in speaking of the urethral mucous membrane, I include the glands, crypts, and follicles, made up of its local redupli- cations), are to be divided into two classes :—first, active inflammation set up by contagion, or clap ; and second, mechanical injury or obstruction, such as urethritis, from lodgment of calculus, or injuries caused by irritant injections, or instrumental violence, or from urethral Stricture. The first effect of an approaching inflammation of mucous membrane is an increase in the natural secretion. The mucous cells are hurried along, through their different stages of development, and, as the amount of secretion increases, it is less and less perfectly elaborated ; the germinal material is drawn to the surface with increasing rapidity, until cells, which, in health, pass through a gradual development, from the germinal granule to the fully formed epithelial scale, now appear as a mass of emasculated corpuscles—pus cells, which constitute what we are accustomed to designate as a purulent discharge. The inflammation is thus characterized, during its contin- uance, whether arising from contagion or from mechanical or traumatic causes. The character of inflammation in the ure- thral mucous membrane varies in degree, rather than in kind. Its products are, to all appearance, similar, whether the result of gonorrhoeal contagion, or from injury caused through in- strumental or mechanical interference alone. The duration of the inflammation varies, as the cause is more or less vicious in its onset, or more or less persistent in its influence. An in- flammation set up by a gonorrhoeal contact will continue, in spite of the most efficient and judicious treatment, for sev- PATHOLOGY OF GLEET. 131 eral weeks, while the inflammation caused by the forcible in- troduction of a sound through a narrow meatus urinarius, may subside in a few days, and yet circumstances, wholly un- connected with contagion, may elevate this latter discharge, from a purely traumatic inflammatory product, so that it may communicate a disease to a perfectly healthy individual, in no way distinguishable from a gonorrhoeal inflammation. An inflammation, set up by contact with pus, from an ac- knowledged gonorrhoea, at once partakes of the vicious, con- tagious character of the inflammatory products from which it was derived. A simple urethritis may continue simple, and recovery take place within a short period, or it may be ag- gravated by various influences, such as vinous or sexual excess, contact with uterine or vaginal secretions, prolonged physical exercise, or from simple mechanical irritation, in a strumous or gouty diathesis, until it shall have acquired the property of contagiousness. Arrived at that point, urethritis of non-venereal origin, does not differ in any way from that which has been originally acquired by contagion. The con- tagium, or contagious element present in gonorrhoeal inflam- mation, would seem to be due to an acquired viciousness, from the fact, that this contagium may be developed, or in- duced, in simple urethritis, by the various causes above enu- merated, independently of contact with the gonorrhoeal se- cretion. This position, most important in practice, as well as in a medico-legal point of view, is capable of substantiation by eminent authority, and besides, I have personal knowledge of its truth, from a number of carefully observed and recorded cases. The active stage of an inflammation of the urethral mucous membrane is called an urethritis, when resulting from causes independent of venereal contact, and when refera- ble to a contagious origin, it is termed a gonorrhoea. Its du- ration in the great majority of cases, may be set down as four or five weeks. In the cases where complete recovery does not take place within this time, there is usually a sub- sidence of the more acute symptoms, and the case is then characterized by a painless or nearly painless discharge, more I32 RELATIONS OF GLEET TO STRICTURE. or less profuse, and more or less purulent, which persists, in spite of the most earnest and judicious treatment by internal and local remedies, for weeks, perhaps months—often years; at times reduced to a mere secretion, which sticks the lips of the meatus together, when, upon a slight indiscretion in diet, a little sexual or vinous indulgence, within a few hours it may return as a free, and possibly painful purulent discharge. This chronic form of urethritis, which has, from time imme- morial, afflicted humanity, and which has probably been the source of more trouble, to patients and surgeons, than any other known difficulty, is familiarly known as GLEET. It is usually considered either as a sort of chronic gonor- rhoea, and treated on the same general principles (by internal remedies, and local injections), or is looked upon as the result of a debilitation of the urethral mucous membrane but having no specific or contagious property associated with it, and is treated by specific and local means, with the addition of some constitutional remedies addressed to the condition or diathe- sis upon which the continuance of the difficulty is supposed to depend. Now, if it can be established that gleet is the result of a mechanical condition, that it may be produced, without the previous occurrence of a gonorrhoea, by a simple obstruction to the free discharge of urine'through the urethra, and that this obstruction may occur as a result of any inflam- mation or injury which shall implicate the sub-mucous urethral tissues, it will then be clear that no treatment which is not based upon the detection and removal of the mechanical difficulty can be more than palliative. And if it can be shown that the detection of contraction is possible in all cases of gleet, and that its removal is certain to result in the cure of the gleet, the proof of the non-specific character of gleet may be considered established.* Mr. Henry Dick of London, whose brochure on the " Pathology and Treatment of Gleet," f is in my opinion, the most valuable contribution to the literature of this subject in any language, says " Gleet is always the consequence of a * See page 139- + Published by Bailliere Bros., in 1858. STRICTURE THE CAUSE OF GLEET. 133 clap. I have never seen it idiopathically appear without clap, except in cases of disease of the prostate gland or the blad- der. I would not say that idiopathic gleet never exists, but I have never seen it." This statement conveys the impres- sion which is generally accepted by the profession in regard to the cause of gleet. Acute urethritis, from whatever cause, may be stated as a self-limited disease ;—a disease which, under various methods of treatment by internal remedies, such as copaiba, cubebs, sandal oil, etc., by alkalies and diuretics of various kinds, by local injections, such as sulphate of copper, sulphate of zinc, acetate of copper, acetate of zinc, acetate of lead, nitrate of silver, any and all of the mineral salts or vegetable astrin- gents, preparations of carbolic acid, liquid glass (silicate of soda), fuller's earth, or any one of the thousand injections which have been used and lauded for their curative influ- ence on acute urethritis—or by no treatment at all,—has a tendency to get well within a limited time, and that time may be stated to be about four weeks. Dr. Bumstead* for- mulates the experience of the profession, past and present, in the statement that the average duration of the disease is ' three or four weeks' " Greater success on the average," says Dr. Bumstead, " is probably not attainable by any means with which we are at present acquainted." I have met quite a number of well authenticated cases, where there was a his- tory of a severe gonorrhoea with inflammatory complications, which recovered within this time, under the use of baths alone ; —others, where homoeopathic treatment was resorted to ; and others again, where no treatment at all was had, and where recovery came within the four weeks. Now, while I am sure that a variety of remedies, local and general, may, when judi- ciously employed, enable the patient to pass through the disease with much more comfort, and less danger of subse- quent trouble, than without treatment, yet I am quite pre- pared to state as my opinion, based upon a large personal experience in the treatment of this disease by the most ap- * Bumstead on Venereal Diseases, Fhil., 1870, p. 92. 134 RELATIONS OF GLEET TO STRICTURE. proved methods, that it is a self-limited disease in its acute form, and, when it lasts longer than four weeks, or when apparent recovery takes place, and the discharge breaks out afresh without new exposure, that there is a complication present either the result of the current inflammatory trouble, or of some inflammation antecedent to the attack, which causes the continuance of the trouble, and which must be appreciated and removed before any permanent cure can be had. This complication is URETHRAL STRICTURE—Strict- ure in the sense of an abnormal contraction of the urethral calibre, at some point at or between the meatus urinarius and the bulbo-membranous junction ; and I will furthermore state it as my conviction, that the continuance of the inflammatory trouble (and whenever there is an urethral discharge there is incontestibly more or less inflammatory trouble) is due to the irritation kept up by the arrest, more or less complete, of the stream of urine at the point of Stricture, and by the imperfect emptying of the urethra after urination. Chronic gonorrhoea —Gleet—also variously designated as prostatic, gouty, scrofu- lous, is dependent, as a rule, on abnormal contractions of the urethral canal. The only exception that I recognize (aside from the presence of polypoid, or warty growths in the ure- thra) is the engagement of urethral sinuses (as the lacuna magna, or some one of those occasionally met near the mea- tus, possibly deeper down), and these I have never found en- gaged, unless more or less co-arctation at an anterior point was also present. Chronic urethral discharge means Stricture. I am quite aware, that well-defined Stricture may be present, without a palpable discharge, but there is always to be found evidence of a certain degree of irritation present in all such cases, although there may be no appreciable discharge. When, however, there is discharge, there will, in every case, be found, if the examination is efficiently made, a well-defined and un- mistakable point of Stricture. The dependence of continued inflammation in gonorrhoea, and of the continuance of chronic urethral discharge, upon the presence of Stricture, is no new discovery. All the recent GLEET MEANS STRICTURE. 135 approved authorities recognize it. Dick was the first, so far as I know, to insist upon a thorough examination of the ure- thra for obstruction in every case of gleet, and his instruc- tions for the examination of the urethra with the bulbous bougie of Le Roy d'Etiolles are minute and complete. Sir Henry Thompson says in his work on Stricture of the Ure- thra, page 90 : "I have known instances in which this symp- tom (gleet) has been so prominent that the patient has been treated for a gonorrhoea, during a period of many weeks, with- out suspicion arising that a Stricture existed, which was its sole cause ; the subsequent recognition of the contraction and its cure having been attended with the complete cessation of the discharge." Dr. Bumstead (Bumstead on Venereal Diseases, 1870, p. 93.) says: " It is not impossible that there* is Stricture of the urethra, which is the most frequent cause of the continuance of a gleety discharge following an attack of gonorrhoea." Van Buren and Keyes, p. 71, say, " The most common of all causes for continued gleet is Stricture, already present or forming" and yet in spite of the unmistakably pointed and positive statement of these, and other valued authorities, the usual treatment of chronic gonorrhoea and of gleet at the present day, is by nostrums, sandal oil, copaiba, urethral injections in multiplicity, and the use of medicated bougies and sounds. And why? It is not that urethral Stricture is doubted as a possible factor in the case; it is not that this is unrecognized as the most probable cause of the difficulty; but because the examination of the diseased urethra is con- ducted with imperfect instruments, and that as a consequence, no exhaustive examination of the canal is made. The least contraction at any point in the urethral canal has been demon- strated as capable of causing the indefinite continuance of an urethral discharge and even of establishing it, de novo, without venereal contact* If this is the fact, then some means for the detection of the least contraction of the urethral canal must be used in order to ascertain the presence or absence of Strict- * Page 20. I36 RELATIONS OF GLEET TO STRICTURE. ure. To this end, the first step must be to ascertain the nor- mal urethral calibre in the presenting case. It has been proved that every urethra is an individuality, and that no average standard is of use in examining a given urethra. The establishment of the normal calibre is the first step towards ascertaining whether or no there be any co-arctations in its BULBOUS SOUND. course. This can only be accomplished by actual measurement by means of an urethra-metre. The proposition is a purely mechanical one. Given a tube, urethral or otherwise, in which it is desirable to ascertain whether or not there exists a contraction of its calibre at any point, the first question to settle is the size of the tube; this effected, the determination of any variations becomes easy ; without it, impossible. The bulbous bougie was relied upon by Le Roy d'Etiolles, Dick, and others, many years since, and it has been growing in favor very slowly but surely, so that now it is an indispensable in- strument in urethral examination for Stricture. Explorations with an ordinary sound, catheter, or straight bougie, are practically valueless in determining the size, locality, and number of Strictures in a given case. The presence of a con- tracted meatus (a very common complication, as a result of infantile balanitis or gonorrhoeal inflammation) makes the de- tection of any deeper Stricture, if of greater calibre, quite impossible. The sudden release of a bulbous sound or bou- gie, of a size which, by firm but gentle pressure, may be made URETHRA-METRE. to pass through the meatus, indicates as it slips into the fossa navicularis, that contraction is present at that point; and the relief of the contraction becomes a necessity before KNOWLEDGE OF NORMAL CALIBRE IMPORTANT. 137 the deeper canal can be efficiently explored, or the nor- mal calibre of the urethra be estimated. It is here that the value of the urethra-metre in the diagnosis of Strictures becomes evident. This should be introduced through the contracted meatus (when this is not below 12 F.), and down to the bulbo-membranous junction. At this point the bul- bous portion of the instrument is to be expanded, by means of the screw at the handle, until a feeling of fulness is expe- rienced, when, if there is no Stricture at the point of trial, the pointer on the dial-plate will indicate, with sufficient certainty, the normal calibre of the urethra under examination. Now, drawing the instrument slowly out, if Stricture is present, the bulb will be arrested at that exact point. The screw is then turned, diminishing the size of the bulb, until it slips through the co-arctation, when a glance at the dial will show the calibre of the Stricture. This subtracted from the figures indicating the normal calibre, will give the precise value of the contraction. The remainder of the canal, examined in the same way, brings the bulb finally to the meatus, where, in the same manner, the greater or less degree of deviation from the normal size will be shown. Henle* has demonstrated the vertical section of anterior much fictitious importance portion of penis. as a ^gUlcje jn urethral ex- amination, viz., that the meatus urinarius is a measure of the size of the normal canal.f * Handbuch der systematischen Anatomie des Menschen, von Dr. J. Henle, p. 417. f A constant relation appears to exist between the urethral calibre and the size of the penis with which it is associated. This is a fact demonstrated by careful measurements with the urethra-metre in several hundred cases, without a I38 RELATIONS OF GLEET TO STRICTURE. What I desire now to make prominent is the fact that the best recognized authorities have long appreciated the value of Stricture as an agent in the prolongation of urethral in- flammation and irritation. Whenever it could be demon- strated by the imperfect means used, it was at once accepted as the probable cause of trouble ; it was only when no Strict- ure could be found that the surgeon was driven to the use of internal medication and topical applications. The urethra was vainly explored for Stricture, because the instruments in use were inefficient. The endoscope was the result of an in- telligent effort to clear up the diagnosis in cases of gleet, where no Stricture was found. Desormeaux, Cruise and others, discovered the granular spots studding the urethra in such cases, and the secret was apparently manifest. Topical applications through the endoscopic tubes apparently cured some, and gave temporary benefit to many; then an army of young endoscopists followed en train, believing, as taught, that the granular sensitive spots in such cases would, if not subjected to frequent ocular inspection and intelligent cauterization, result in true organic Stricture. And yet after months of faithful work in this direction, the return of gleet, without new contagion, made it evident that the true cause of gleet had not yet been reached in such cases. I have the record of at least a dozen instances* where the difficulty was single exception being met. The proportion runs as follows : When the flaccid penis measures 3 inches in circumference, the size of the urethra will be 30 milli- metres in circumference, or more. When it is 3J inches, it will be 32 or more ; 3^ inches, 34 ; 3f inches, 36 ; 4 inches, 38 ; 4^ to 4^ inches, 40 or more millime- tres. Where the urethra-metre is not available, this proportionate relation may be relied upon as not over-estimating the normal urethral calibre in any case. * The following is the record of a typical case of this sort: Mr. W., aged 25, came under my care December 1st, 1872. Contracted first gonorrhoea early in June 1872, was treated by injections locally, and alkalies internally, until August 1st, during which time he had no freedom from the dis- charge, nor from the acute suffering. At about this time, the vesical neck became involved, and he suffered most from frequent and painful micturition. Came under the care of Dr. ----, a skilled endoscopist, who discovered numerous granular patches in the course of the canal, extending quite into the prostatic por- tion, and applications of a strong solution of nitrate of silver were made through the endoscope, which afforded temporary relief ; urination still painful every hour. TOPICAL APPLICATIONS INEFFICIENT. 139 shown to be a Stricture near the meatus, which nevertheless admitted the usual-sized endoscopic tube (22 or thereabouts), and where the dependence of the granular spots upon this condition was proved by their complete disappearance upon the cure of the contraction without the aid of any other treatment whatever. This premises a conclusion arrived at by the experience gained in a very large number of cases, viz., that gleet is always dependent upon Stricture: that, while Stricture may be present when there is no gleet, whenever there is a gleet (in the sense of a chronic urethral oozing or discharge), an intelligent and thorough exploration, with suitable instruments, will invariably discover a distinct con- traction of the meatus urinarius, or a readily recognized coarctation of the urethra at some point; and further, that the complete restoration of the urethra to its normal calibre and suppleness at the contracted points will be re- quired to warrant the statement that a permanent cure has been effected. The complete division of Stricture has, in my experience, resulted uniformly in its complete disappearance within a period varying from three months to one year, and the cure of gleet has, as a rule, follozvcd the complete division of Strict- By September 1st, the discharge decreased to a slight mucus, following the use of pencils of tannin and glycerine. A spell of damp weather brought back the purulent discharge, with return of perineal pain and frequency of micturition. Tannin pencils again used, but after continuing for four weeks, and no improve- ment, patient was put to bed, and hot hip-baths were administered every two hours, etc., etc. After five weeks of various kinds of treatment, local and general, he came to me from his bed, December 1st, 1S72. On examination I found no difficulty in introducing No. 20 F. bulbous sound and discovered a firm cartilag- inous Stricture extending from just within the meatus to half an inch back. This I freely cut with Civiale's bistouri cache. Immediately following the operation, he expressed himself as feeling " like a new man." The discharge ceased within twenty-four hours, the perineal pain and frequency of micturition, and the ardor wince also ceased, and he returned to his duties, which were most active, on the following day, after having been laid up for over five months. The urethral granulations subsided and finally disappeared within a few zveeks without any local or general treatment. His recovery was absolute and complete, and the only solution afforded was the division of the Stricture at the meatus, to which the granular spots in the posterior part of the canal were undoubtedly due. 140 RELATIONS OF GLEET TO STRICTURE. ure within a period varying from twenty-four hours to four weeks after the final operation. Let us now consider the various degrees in which gleet is presented to the surgeon. First. When it is just sufficient to form shreds of inspis- sated mucus, which are observed on examination of the first washings of the urethra during the act of urination. Second. When it is in the form of a simple, transparent exudation, only sufficient to glue the lips of the meatus uri- narius together, and not even enough to stain the patient's linen. Third. When, on squeezing the penis and subjecting the meatus to pressure (as patients afflicted with gleet are very much in the habit of doing), a single drop of semi-opaque or creamy purulent fluid may be made to ooze out. Fourth. When it is met as a thin, profuse, nearly or quite painless discharge, easily reduced in amount by astringent injections, but as readily returning on their withdrawal, and, even if apparently cured, returning promptly on the least vinous or sexual indulgence. Fifth. When the discharge, thicker, decidedly yellow, and persistently profuse, exudes from an inflamed and pouting meatus, usually causing much redness and irritation upon contact with the preputial tissues. Each and all the grades or varieties of gleet above enu- merated and casually described may, it is believed, be proved to owe their persistence, if not their ^ristence, to simple, localized, mechanical obstruction to the passage of urine. The impetus which is given to this fluid during an ordi- nary micturition is of no insignificant character. The mus- cles of the diaphragm, abdomen and perinaeum combine to bear down, press against, support, and steady the bladder, while the active agents, the detrusor muscles, which interlace over the entire organ, exert an expulsive force sufficient to overcome the resistance of the sphincter vesicae, and to project the urine in a full, smooth stream through the urethra, to a distance of several feet. This, however, gives DEGREES OF GLEET. 141 but a faint idea of the effect which a prolonged resist- ance to the power of the muscular apparatus concerned in emptying the bladder may produce. In order to be fully appreciated, this should be observed in a person laboring under some obstruction to the passage of urine, such as occurs in urethral Stricture. If the Stricture is a slight one it may be apparent only in producing a want of rhythm in the muscular action of the urethra, which prevents a prompt and complete emptying of the canal. Thus it is that drib- bling, after the act, is occasioned. When the Stricture encroaches to a somewhat greater degree, the stream is no longer full and strong, but becomes twisted, and is projected with less force, and now that the patient often finds himself exerting a pressure of many extra pounds in bearing down upon the bladder, the beginning of the effect of Stricture be- gins to be realized. But let the case be one where the Strict- ure has closed the urethral lumen, so that a continuous stream is no longer possible : the pressure becomes so great, that, after a time, not only does the urethra become permanently enlarged behind the Stricture, but the urine is pressed back- ward from the bladder through the ureters, resulting in dila- tation of these delicate tubes to many times their normal size, the pelves of the kidney also participating in this forced dila- tation, until a positive sacculation may be produced. This power by which the urine is propelled, certainly furnishes the requisite conditions necessary to establish a point of irritation in a urethra when Stricture is present. It is only necessary to establish the fact that the normal resiliency of the urethra is diminished at a given point, to prove that, during micturi- tion, a perturbation in the stream must occur at such point, even if it is not sufficient to attract attention in any way. Hence the slightest contractions assume an importance which could not be inferred from the apparent freedom from trouble in passing the urine. They establish a localized point of friction, and, of necessity, an increased excitement in the ves- sels of the part, possibly only enough to disturb the complete elaboration of epithelial material, and to cause the shreddy 142 RELATIONS OF GLEET TO STRICTURE. deposit to take the place of the clear normal secretion; and this may occur with very slight, or not even the least abnor- mal sensation being present. The presence of the mucoid shreds in the urine may be the only evidence of commencing trouble. But a permanent point of friction once established, greater than the natural conservative power of the surround- ing parts is able to counterbalance, obstruction is increased by the natural aggregation of plastic material at the point of irritation. In this way the tendency to recovery is combated, and a permanent point of inflammatory action is established, Thus the difficulty, which commenced simply as an ob- struction to the resiliency of the urethral walls, progresses naturally and certainly, to the point of narrowing to a greater or less degree the calibre of the urethral canal. The second point of importance is the incomplete emptying of the urethra after micturition, which occurs as a necessary consequence of anterior contractions. If the muscular struc- ture is embarrassed, its function is imperfectly performed, and instead of completely emptying the canal of its irritating con- tents, a drop or more is retained, either to dribble away slowly within a few minutes after urination, or to be held behind the contraction by a spasmodic action (always readily set up in the vicinity of urethral irritations) until chemical changes heighten its irritative action, and it becomes capable of estab- lishing new points of irritation, such as are seen in granular urethritis, so-called. It is not impossible or improbable that, as Desormeaux and Cruise have taught, the granular spots found in the urethra in cases of gleet may be the beginning of Stricture ; but it is positively true that they may be, and most frequently are the legitimate progeny of an already- formed Stricture, anterior to the point of their location, and it is equally true that unless Stricture has already occurred as a result of the granular urethritis, the cure of the anterior co-arctation will result, without other treatment, in the dis- appearance of the granulations, and a complete restoration of the canal to its normal condition. The treatment of gleet by a systematic introduction of sounds and bougies, medica- GRANULAR URETHRITIS CAUSED BY STRICTURE. I43 ted or otherwise, is based upon the idea of a possible co-arc- tation of the urethra at some point. Ordinarily this plan is resorted to in the most empirical way, simply because the introduction of sounds and bougies is recommended by authorities for the cure of gleet. By our most intelligent surgeons, it is directed to the dilatation of Strictures, which have been suspected, or detected by the bulbous sound or bougie, and with a full appreciation of the probable depend- ence of the gleet upon the presenting Strictures. That this plan, intelligently pursued, has often cured gleet, no one will for a moment gainsay; but that it perma- nently removes the cause, no one at this day is likely to affirm. Nothing is more distinctly laid down in the writings of authorities in regard to the treatment of urethral Stricture, than that the results of dilatation are ahvays of a temporary character. So that it is well understood, in cases of the cure of gleet by dilatation of the Stricture or Strictures upon which it is dependent, subsequent dilatation must be kept up indefinitely, at varying intervals, in order that the gleet may not again be established. For a permanent cure a complete division of the contracting Stricture must be had, and any treatment which falls short of this will, of necessity, fail in doing more than to temporarily remove the obstruction which has been the cause of the gleet. The radical cure of Stricture was made the subject of a paper read by me before the New York State Medical Society in February, 1875, and may be found in the Transactions of that Society for that year. In that paper, the carefully tabulated results of two hundred and three operations will substantiate, in some degree, the claim I have made in regard to the constant asso- ciation of Stricture with gleet ; and the results of operations as there recorded will also make it manifest that my confi- dence in the radical cure of Stricture, as well as of the gleet which is so frequently associated with it, is not without rea- sonable foundation. CHAPTER VI. RETROSPECT. THE directness with which issue was taken, in the fore- going paper, with the time-honored views in regard to the normal urethral calibre, especially as those views were be- lieved to be still held tenaciously by the great representatives of the English and French schools,* and the positive assump- tion of a mechanical cause for the persistence and even of the existence of gleet, together with the importance claimed for the slightest urethral contractions, normal or pathological, es- pecially at the meatus urinarius, very naturally excited a wide- spread professional interest. A large and influential conserva- tive party was evidently disturbed by views so radically op- posed to the teachings of the fathers, from the earliest days, and an interest, that fell but little short of a general professional excitement, was felt when it was announced that my honored and accomplished colleague, Dr. Henry B. Sands, Professor of Anatomy in the College of Physicians and Surgeons, would * In a clinical lecture delivered by Sir Henry Thompson, November 18th, 1875, and published in the London Lancet of December nth, 1875, p. 827, is the following, " When therefore a young man consults you for certain troubles, relative to which you desire to learn whether urethral obstruction be a cause or not, do not be tempted for an instant to adopt so unnecessary a course (to say the least) as the introduction of very large instruments or of instruments with huge bulbs at the end of them. But take simply a flexible English gum-elastic bougie, well covered towards the point, with a blunt end, (since a tapering point, of course, will not mark distinctly the site of Stricture), not larger, as a rule, than No. 10 or n of our scale (19 to 20 millimetres circumference) and pass it very gently and slowly into the bladder. If it goes easily, above all, if it is with- drawn without being held, and slides out with perfect facility, take my word for it, he has no Stricture, and, quoad, obstruction, wants no use of instruments whatever " BY PROF. H. B. SANDS. i4S make this pamphlet the subject of criticism in a paper to be read on the 24th of January, 1876, before the New York County Medical Society of which he was then President. In accordance with this announcement, on the date then named, Dr. Thomas Addis Emmet, Vice-president of the Society, presiding, Professor Sands read the following paper " On Gleet, and especially its relations to Urethral Stricture." SURGEONS often pride themselves upon the certainty of their art when compared with that of medicine ; yet the hu- miliating confession must be made, that many important sur- gical problems still remain unsolved. To survey our present knowledge concerning a common but obscure disease, may not prove an unprofitable task, and may stimulate us to re- newed efforts in obtaining clearer and broader views respecting its pathology and treatment. I offer no apology, therefore, when I invite you to consider the nature of gleet—an affec- tion which is sure to command the attention of every surgeon, both on account of its frequency, and of the difficulties that are often encountered in effecting its removal. In recent times the term gleet has been employed in a very comprehensive sense, and has been made to refer to nearly every morbid urethral discharge, except that which is characteristic of acute urethritis. Thus we read of idiopathic gleet, due to the strumous or the gouty diathesis; of pros- tatic gleet, dependent on masturbation, vesical calculus, or piles ; and of gleet caused by the simple contact with the urethra of highly-acid urine. We shall avoid much confusion, I think, by giving to the word the restricted meaning which was ascribed to it by John Hunter, Sir Astley Cooper, and most of the earlier writers, who understood gleet to signify an imperfectly cured or chronic gonorrhoea. In this sense alone I shall employ the term ; and, although not prepared to deny the existence of the other varieties of gleet, I will say that I have very rarely met with any of them in practice. Understanding, then, that gleet is only a sequel of gonor 10 146 DISCUSSION OF DR. OTIS'S VIEWS rhcea, I remark that there is no very clear line of distinction between gleet and its parent disease. The term gleet has reference partly to the character and partly to the chronicity of the discharge. After a gonorrhoeal secretion has lasted for a period varying from one to four weeks, it almost always diminishes in quantity, while at the same time it becomes thinner and less opaque ; and a little later, in favorable cases, it disappears altogether, leaving the patient secure against a return of the disease, unless he is again exposed to contagion. Not unfrequently, however, the disease abates in intensity, but does not entirely disappear ; and the gleety discharge that remains may continue indefinitely, often for months, sometimes for years. The character and quantity of the dis- charge, too, vary as greatly as its duration. When most characteristic, it is thin, only slightly viscid, and nearly trans- parent ; at times, however, especially after excess in eating or drinking, it exhibits more distinctly the puriform character of the original gonorrhoeal secretion. The quantity voided daily may be just sufficient to stain the linen moderately, or it may be almost imperceptible. Often it is noticed only in the morning after rising, or when it is caused to escape by pres- sure exerted along the anterior part of the penis and urethra. Usually, the disease is unattended with pain, and does not affect the general health. Some patients, however, suffer greatly from anxiety and depression of spirits, and all of them are liable to an aggravation of the disorder after excess or fatigue. The brief outline of the symptoms of gleet which I have now given will serve to identify it as the affection with which all of us are so familiar. Omitting, for the present, the con- sideration of its pathology, I will say a few words respecting its management and cure. And, at the outset, it cannot be denied that in some cases —and these not always the least severe—recovery appears to take place spontaneously. I have known such recoveries to happen after'the disease had existed for many months, and after the usual remedies had been employed in vain. These BY PROF. H. B. SANDS. 147 cases are rare, yet they certainly do occur, and the truth of my statement will, as I think, be confirmed by the experience of every surgeon present. But such instances are doubtless exceptional, and usually treatment, either local or constitu- tional, is required to eradicate the disease. Sometimes its re- moval is favored by a spare, at other times by a generous diet, combined with change of air and scene. Sea-bathing, and tonic food and medicines, have cured many a gleet that has resisted the ordinary specific remedies for this disease. But other kinds of constitutional treatment may be indicated ; and the presence of a gouty, or strumous, or rheumatic dia- thesis, may call for its appropriate treatment, to aid in sub- duing the local disorder. Among internal remedies, copaiba and cubebs have always and deservedly been held in high esteem. Alkalies also, when largely diluted, are not without value in certain cases. In my own experience, however, local treatment has generally proved most efficient in the removal of gleet. Injections, either mild or-strong, superfi- cial or deep, according to circumstances, or the occasional in- troduction of a full-sized bougie into the bladder, have gen- erally yielded satisfactory results. When these and other similar methods of treatment fail, the disease will often be found to depend on a Stricture of the urethra, which, when discovered, should be got rid of by some one of the plans of treatment appropriate to that affection. I have enumerated these items of treatment, because they will aid us in attempting a solution of the question which it is my chief object to discuss this evening ; namely, the pa- thology of gleet, concerning which, as it appears to me, many surgeons at the present day hold views that are exclusive and erroneous. In the first place, then, let us bear in mind that the term gleet denotes merely a symptom, and does not indicate the essential nature of the disease. Like the analogous word leucorrhoea, it has a vague meaning, and serves often to hide a great deal of ignorance. The muco-purulent character of the discharge proves it to be inflammatory ; while we can be 148 DISCUSSION OF DR. OTIS'S VIEWS equally certain that it proceeds either from the urethra itself, or from some of the minute canals which open into this divis- ion of the genito-urinary tract. Pus secreted from any part of this extensive surface will probably issue from the external meatus in the form of gleet, but that which is the product of cystitis or pyelitis will escape only during micturition. Regarding gleet, then, as a symptom of chronic inflamma- tion, affecting some portion of the genito-urinary tract anterior to the bladder, what means have we at our command for determining more precisely the locality of the disease ? Here we begin to feel that our resources are limited, and our knowledge imperfect; yet much light may be thrown upon this point from three sources, namely : post-mortem examina- tion, the exploration of the urethra during life, and the effect of remedies upon the disease. The pathological changes which post-mortem investigations have revealed as connected with gleet, are thus described by authors. Sir Astley Cooper wrote in 1826: " If you examine the urethra after death, you will find the following appear- ances : inflammation extending for two or three inches down the urethra, and if the urethra be laid open within twenty- four hours, it will be quite florid as far as the seat of the gleet, but pale in the other part. The discharge does not proceed from the vesiculae seminales, or Cowper's gland, or the prostate, but from the lacunae. The discharge commonly called gleet proceeds from the lacunae of the urethra." * Roki- tanski has observed "Tumefaction of the mucous membrane, enlargement of the follicles, relaxation of the sinuses, and a white or colorless secretion." f Sir Henry Thompson says : " Observation demonstrates that the two spots which suffer most from gonorrhoeal inflammation are the fossa navicularis and the bulb ; I have had opportunities of observing this two or three times in the dead-house on the bodies of patients who had been suffering from gonorrhoea shortly before death. Unusual vascularity is found in the latter situation, particu- * London Lancet, vol. iii. p. 271. f " Pathological Anatomy," vol. ii., p. 179. BY PROF. H. B. SANDS. 149 larly if the affection have been chronic, while the intermediate part appears comparatively very little affected."* Foerster remarks that " Blenorrhcea sometimes lasts for a very long time without causing any material alteration in the texture of the mucous membrane." f Finally, stricture of the urethra has been frequently noticed at post-mortem examinations of persons who, during life, had suffered from obstinate gleet. To sum up, then, the lesions that morbid anatomy has demonstrated to be connected with gleet, we find swelling and increased vascularity of the urethral mucous membrane, enlargement of the lacunae, and sometimes organic Stricture. On the other hand, the disease occasionally leaves no traces that can be discovered after death. Now, these records show plainly enough, to my mind, that the essential cause of gleet is a catarrhal inflammation of the urethral mucous membrane, and of the numerous follicles or lacunae opening upon its sur- face. The textural changes—except when Stricture is pres- ent—are usually slight, and in some cases, even when gleet has existed for a long period, no material pathological altera- tions can be detected. We notice here an evident analogy between the urethral and other mucous membranes. Nearly all of them, when inflamed, furnish a muco-purulent secretion, which may continue for a long time without leading to any striking textural changes in the parts affected. It is inter- esting to note the morbid alterations which have been ob- served in the lacunae. Doubtless the implication of these slender and remote recesses will, in many cases, explain the obstinacy of the disease ; for we cannot apply our remedies directly to the inflamed surface. The rebellious character of that chronic inflammation of the eyelids called tinea ciliaris is, doubtless, due to a similar cause, namely, the extension of the disease to the Meibomian follicles. Finally it is also inter- esting to notice that there are two parts of the urethra which are especially prone to chronic inflammation, namely, the fossa navicularis and the bulb. We shall find that these facts * On " Stricture of the Urethra," p. 80. f " Pathological Anatomy," p. 553. 150 DISCUSSION OF DR. OTIS'S VIEWS in morbid anatomy corroborate the results obtained by clini- cal observation. In the second place, let us inquire how far the pathology of gleet can be deduced from an examination of the diseased parts during life. Sometimes the sensations of the patient afford a clew to the locality of the disorder. A feeling of itching, soreness, or smarting, in a certain part of the urethra, either during or after micturition, may coincide with the pres- ence of inflammation at that part. Frequent desire to mic- turate may indicate an extension of the morbid process into the prostatic segment of the urethra. A sensation of strain- ing and difficulty in voiding the urine may point to Strict- ure as a probable cause or complication. In many cases, however, the patient experiences no morbid sensation, and is aware of the existence of his disease only by the appearance of the gleety discharge. The length and narrowness of the urethra render the visual examination of its deeper parts difficult and uncertain, and the endoscope has failed to fulfill the predictions that were made respecting its usefulness. Yet the instrument, doubt- less has a certain value, and by means of it we can often de- tect circumscribed spots of inflammation of the urethra, the affected portions of mucous membrane exhibiting an uneven, granular, and highly vascular surface. These granulations are sometimes abnormally sensitive, and readily bleed when touched. They are often present in the fossa navicularis, where their detection is easy, but they occur with greatest frequency in the bulb. Much stress has been laid upon the presence of these granular patches, both as a cause of gleet, and as a forerunner of Stricture; yet it is an error to regard them as invariably present. They are absent in many, if not in most, of the milder cases, and cannot therefore be regarded as the sole cause of gleet. Many years ago Kleeburg* an- nounced that, in certain cases of this disease, the glandular follicles studding the mucous membrane adjacent to the ex- ternal meatus were swollen, red, and filled with muco-puru- * "Schmidt's Jahrbiicher," 1836, p. 35. BY PROF. H. B. SANDS. 151 lent secretion; and, having made the diagnosis, he readily effected a cure by probing the diseased ducts with the nitrate of silver. Robert* states that he has been able, in a number of instances, to cause an escape of pus from these follicles, by pressure made upon their walls. These observations I have confirmed by experience, and the facts are important, inas- much as they render it highly probable that the lacunae far- ther behind, which differ from these only in situation, are often affected in a similar manner. The deep-seated lacunae cannot be satisfactorily examined during life, but we have post-mortem evidence that they are implicated in gleet. The exploration of the urethra by means of sounds often affords much useful information, and, in obstinate cases, should never be neglected. When the point of the instru- ment passes over an inflamed patch of mucous membrane the patient will often complain of pain, yet not always, for some- times the diseased parts are not very tender. In examining the prostatic portion of the urethra, we shall be misled if we fail to bear in mind the natural sensitiveness of this region. The special'value of sounds, however, is that of enabling us to detect the presence of organic Stricture, which is so often associated with gleet. In certain cases bulbous sounds afford the easiest means of determining the presence and locality of a Stricture. In the third place, the pathology of gleet is, in some de- gree, elucidated by observing the action of remedies upon the disease. The frequent success which follows the employment of topical astringents points to the catarrhal character of the inflammation, while the successful application of such reme- dies to certain limited parts of the urethra indicates that these parts are especially involved in the morbid process. Many gleets are cured by the introduction of stimulating ointments or powders into the fossa navicularis, while others, which are not benefited by this mode of treatment, yield readily enough when the remedies are inserted as far back as the bulb. The disappearance of a gleet after the removal of a Stricture shows *' Maladies Veneriennes," p. 80. 152 DISCUSSION OF DR. OTIS'S VIEWS the dependence of the former on the latter ; while, in the absence of Stricture, the persistence of a gleet for years, in spite of treatment, probably often coincides with a thickened and congested state of the urethral mucous membrane along its entire length. I have seen cases which I have thought to be of this description, in persons of intemperate and other- wise irregular habits, and it seems reasonable to suppose that the urethral mucous membrane should be liable to the same kind of inflammation as that which we so often observe in the lining of the urinary bladder. We may now conveniently enumerate the following mor- bid conditions as causes of gleet: I. Chronic inflammation of the urethral mucous mem- brane, either diffused over the greater part of its surface, or limited to particular spots—those most liable to disease being the fossa navicularis and the bulb. 2. Inflammation of the lacunae which open into the urethra. 3. Stricture of the urethra. 4. Inflammation of Cowper's glands, the prostatic ducts, or the seminal vesicles. These, as well as chronic abscesses connected with the urethra, and warty vegetations studding its surface, are but very rarely causes of gleet. I now propose to examine certain views respecting the pathology of gleet, which I find to be widely prevalent at the present day, and which have for their most earnest and able advocate my distinguished colleague, Prof. Otis. They as- sume that gleet depends invariably on organic Stricture, especially upon what are denominated Strictures of wide cali- bre, and that the division of these by internal urethrotomy affords a method, and indeed the only method, of radical cure. To detect these Strictures, certain special means of exploration are said to be necessary, and perhaps I cannot better set forth the views to which I allude than by quoting the following sentences from some of the latest contributions to the literature of this subject : " Chronic gonorrhoea, gleet (also variously designated as prostatic, gouty, scrofulous), is dependent, as a rule, on ab- BY PROF. H. B. SANDS. 153 normal contractions of the urethral canal. The only excep- tion that I recognize (aside from the presence of polypoid or warty growths in the urethra) is the engagement of ure- thral sinuses, as the lacuna magna, or some one of those oc- casionally met with near the meatus, possibly deeper down, and these I have never found engaged unless more or less co-arctation at an anterior point was also present. Gleet is always dependent upon Stricture."* Again: "A constant relation appears to exist between the urethral calibre and the size of the penis with which it is associated. This is a fact de- monstrated by careful measurements made with the urethra- metre in several hundred cases, without exception being met. The proportion runs as follows: when the flaccid penis meas- ures 3 inches in circumference, the size of the urethra will be 30 millimetres in circumference, or more. When it is 3*- inches, it will be 32 or more; 3V inches, 34; 3f- inches, 36; 4 inches, 38; 4\ to 4* inches, 40 or more millimetres." f The urethra-metre is an ingenious instrument, the extremity of which is capable of being expanded into a sort of fenestrated sphere by the action of a screw at the handle, the circumfer- ence of the part expanded being indicated by a steel hand traversing a dial-plate. To ascertain the normal calibre of a given urethra we are instructed to introduce the urethra-metre closed, "down to the bulbo-membranous junction. At this point the bulbous part of the instrument is to be expanded, by means of the screw at the handle, until a feeling of full- ness is experienced, when, if there is no Stricture at the point of trial, the hand on the dial-plate will indicate, with suffi- cient certainty, the normal calibre of the urethra under ex- amination. Now, drawing the instrument slowly out, if Stricture is present, the bulb will be arrested at that exact point. The screw is then turned, diminishing the size of the bulb, until it slips through the co-arctation, when a glance at the dial will show the calibre of the Stricture. This, sub- tracted from the figures indicating the normal calibre, will * " Gleet, and its Relations to Urethral Stricture," by F. N. Otis, M. D., 1S75. f F. N. Otis, op cil., p. 254. 154 DISCUSSION OF DR. OTIS'S VIEWS give the precise value of the contraction. The remainder of the canal, examined in the same way, brings the bulb finally to the meatus, when, in the same manner, the greater or less deviation from the normal size will be shown." * " Vertical sections of the penis, from the junction of the glans with the body of the penis, show a uniform calibre throughout the fossa navicularis, to its external boundary at the meatus, the opening of which is of corresponding calibre. This may be accepted as the normal condition of these parts, and any vari- ations from such uniformity may be considered aberrations from the normal condition." f The Strictures which are sup- posed to cause gleet need not be close ; indeed, they are com- monly such as would escape detection by the ordinary meth- ods of examination. " If a urethra presents, the normal cali- bre of which is equal to a circumference of thirty millimetres of the French scale, and only twenty-nine of bulbous sound will pass without detecting obstruction, then the urethra is not ' about right.' It is strictured to the extent of one milli- metre in circumference, and can never be a healthy urethra while that Stricture remains." ^ Now let us inquire whether these statements can be veri- fied. If so, we shall find established an important principle in the treatment of gleet. I willingly admit that, if the healthy urethra has a uniform calibre, which can be ascertained and measured with precis- ion, it will be possible to detect the slightest abnormal devia- tions from its size. We must, however, obtain a clear idea of what is meant by the calibre of the urethra, as the use of the phrase has a conventional rather than a literal signification. The word calibre is ordinarily employed to indicate the size of a tube, such, for example, as the bore of a gun. If the urethra were such a tube, and if its walls were firm and inelastic, there would be no trouble in determining its calibre. But anato- mists have long recognized the fact that the urethra is not a * " Gleet, and its Relations to Urethral Stricture," by F. N. Otis, M. D., p. 253 t Dr. F. N. Otis, New York Medical Journal, April, 1874. % F. N. Otis on " Stricture of the Male Urethra," p. 9. BY PROF. H. B. SANDS. 155 tube, except when it is distended. Not only the mucous membrane which forms its immediate boundary, but the erectile and other tissues which surround it, are sufficiently elastic to close the channel completely, unless it is either naturally or artificially distended. This fact is readily de- monstrated by transverse sections of the penis, both of the dead and of the living body. On examining the surface of such a section, we notice that the situation of the urethra is denoted merely by a linear depression, caused by the com- plete contact of the opposed urethral walls. This contact ex- tends throughout the entire length of the urethra. By the expression calibre of the urethra, therefore, we are to under- stand the size of the canal when distended. Indeed, the phrase can have no other meaning. Now, as the urethral walls are elastic, it must be evident that the calibre of the urethra will vary within certain limits, depending upon the elasticity of these walls, and upon the amount of force used to separate them. Properly speaking, the normal calibre of the urethra would be its size when moderately distended by the urine during micturition ; and, although we cannot esti- mate this with accuracy, we have reason to believe that it is not very large. Anatomists have employed various methods for determin-' ing the calibre of the urethra, by experiments performed upon the dead subject. One of these methods consists in laying open the urethra by an incision along its entire length, and afterward stretching it out upon a flat board, and fastening it down with pins along the edges of the section. This has been done by Malgaigne, Jarjavay, Thompson, and others ; and the specimen which I now exhibit has been prepared in this man- ner. It affords the following measurements, and is well adapted to display the relative calibre of different portions of the canal: Meatus .....21 millimetres. Fossa navicularis ... 38 " Three inches behind meatus . 26 " Bulb.....30 " Membranous portion ... 20 " Prostatic portion ... 38 " 156 DISCUSSION OF DR. OTIS'S VIEWS The best method of ascertaining the greatest possible dis- tensibility of the urethra is undoubtedly that employed in 1852 by Reybard, who introduced into the canal an instru- ment having at one extremity a pair of steel blades, which could be separated by turning a screw at the handle, the dis- tance between the blades being indicated by a steel hand upon a dial, as in Dr. Otis's urethra-metre. Successive parts of the urethra were submitted to the action of these dilating blades, which were separated in every instance as far as possible, without causing a laceration of the urethral mucous mem- brane. The greatest separation of which the blades were capable was eighteen and a half millimetres. Upon examining, in the manner described, a subject sixty years of age, Reybard found: I. That the meatus could be dilated, without rupture, to double its natural size. 2. That, in that portion of the urethra corresponding with the middle of the penis, the blades could be separated fifteen millimetres, thus indicating a circumference of forty-six millimetres. 3. That in the bulbous, membranous, and prostatic divis- ions of the urethra, the instrument could be expanded to its greatest diameter, namely, eighteen and a half millimetres. This indicates, for all these parts, a calibre of at least fifty- eight millimetres. On repeating the experiment in a subject of twenty-five to thirty years of age, Reybard found the same relative diameters in the different regions of the urethra, but found the diameter, in each of them, seven to eight millimetres less than in the older subject. I am not aware that any attempt has been made to ascertain whether the urethra of the living subject is capable of bearing such a degree of distention as was effected in these cases, yet I think it quite possible that the experi- ment would succeed if the dilatation were cautiously and gradually applied. Another mode of estimating the calibre of the urethra is to obtain a cast of the canal, by injecting it with some kind of solidifiable material, such as fusible metal, plaster of Paris, BY PROF. H. B. SANDS. 157 or wax. I have tried all of these substances, and have found the latter to answer best. It is more manageable than either 2 4 CASTS OF URETHRA. 158 DISCUSSION OF DR. OTIS'S VIEWS of the others, as it melts at a low temperature, and can be made to solidify quickly by being subjected to the action of cold water. Plaster of Paris does not run very easily when the mixture is thick, and when it is thin it is slow to harden. Fusible metal makes a firm and durable cast, but it becomes solid at so high a temperature, and so quickly, that we can seldom be sure the canal has been fully distended. The casts which I exhibit have been made for me by Dr. Charles Mc- Burney, the able demonstrator of anatomy in the College of Physicians and Surgeons, who has bestowed mnch time and care in preparing them. The urethrae which they represent were free from any evidences of disease. In all cases the nozzle of the syringe was introduced into a pouch of vesical mucous membrane, obtained by making a circular incision through the membrane, about an inch behind the internal ori- fice of the urethra, and then dissecting it up from the sub- jacent parts. By this means the urethra is more certain to be thoroughly distended than when the injection is thrown into the bladder, while at the same time the canal itself is not interfered with. To secure a perfect cast of the external meatus, a similar plan was pursued in all cases but one. In- stead of closing the meatus by suture, a portion of the integu- ment of the glans penis was dissected up, thrown forward over the meatus, and then surrounded by a ligature. It thus formed a pouch which received and retained the injection after it had passed through the meatus. In making such an injection, the amount of force employed may be greater or less; and, accordingly, the distention of the urethra will be much or little ; but in all cases the entire surface will be subjected to equal pressure; and, conse- quently, although preparations obtained in this manner may not afford a certain test of the relative calibre of different urethrae, they offer a perfectly reliable indication of the relative calibre of the different portions of any given urethra. I ex- hibit to you four casts, each one representing the entire length of the urethra. Cast marked No. I was made by the employment of a moderately distending force. In obtaining BY PROF. H. B. SANDS. 159 the remaining three, as much force was used as it was thought the urethral wall would bear without rupture. The accom- panying table gives the dimensions of different parts of the urethra as indicated by the different casts. In all instances the figures represent the circumference in millimetres. No. 1. /Et. 40 to 50. No. 2. /Et. 27. No. 3. JEt. 40. No. 4. JEt. 29. 26 30 32 40 20 30 18 25 44 36 47 25 40 35 22 40 35 41 26 45 50 30 43 36 61 Three inches behind meatus.. Bulb..................... Prostatic portion at its widest 30 53 40 Now, the comparison of these figures shows some curious results. Cast No. I is considerably smaller than the rest, and this fact may perhaps be accounted for by the moderate force that was employed in introducing the injection. The remain- ing three were all the result of the greatest distention it was thought safe to employ, yet they differ considerably in size, No. 4, especially, being larger than No. 2 or No. 3. I think it fair to assume that the varying size of casts 2, 3, and 4, in- dicates a corresponding variation in size in the respective ure- thrae, although it cannot be proved that the distending force employed in every instance was the same in amount. But assuming that it was so, or nearly so, we ascertain that the dimensions of the adult male urethra vary in different indi- viduals. Whether these variations bear any definite ratio to the circumference of the penis, is a question that it will be convenient to postpone for the present. I will only add, in this connection, that the facts here demonstrated on the sub- ject confirm the observations that have long ago been made by surgeons and anatomists, who have generally admitted differences in the calibre of healthy urethrae. The table also shows that the calibre of the urethra, es- l6o DISCUSSION OF DR. OTIS'S VIEWS pecially of its bulbous portion, is, in some instances, much greater than it would appear to be from any examinations which have ever been made to ascertain its size during life. This statement agrees with the results already obtained by Reybard, in the experiments I have alluded to. But the special value of the figures is the unfailing indica- tion which they afford of the want of uniformity in calibre of different parts of the same urethra. This is no new fact, yet the recognition of it is so important in the present discussion, that I may be pardoned for setting it clearly before you. We notice, then, in examining any one of these casts, that it represents the urethra as displaying a series of alternating contractions and dilatations throughout its entire course. The meatus is generally contracted ; then follows a dilatation, somewhere in the glans penis, the fossa navicularis; behind the fossa navicularis the urethra is again narrowed for a dis- tance of several inches, when it expands more or less gradu- ally to form the bulb ; behind the bulb is a third contraction, corresponding with the membranous division of the urethra ; and finally we reach the last dilatation in the prostatic por- tion, and the last constriction at the internal meatus. We thus observe three dilatations, namely, in the fossa navicularis, the bulb, and the prostate; and four contractions, these being at the meatus, behind the navicular fossa, throughout the membranous portion, and at the internal orifice of the urethra. These dilatations, as is well known, are all found along the inferior wall or floor of the canal. I note the fact, in passing, that, with one exception, these casts demonstrate the bulb to be the widest or most dilatable portion of the canal. The prostatic portion is said to be the most dilatable, but, owing to the firmness of the tissues which surround it, great force is needed to expand it. In cast No. 3 the bulb is not so wide as the prostatic portion, yet it is wider than any part situated in front of it. These contractions and dilatations of the different parts of the urethra have long been familiar to anatomists, and have seldom been called in question. Their presence is tacitly BY PROF. H. B. SANDS. 161 denied, however, when it is affirmed that the calibre of the urethra is indicated by the dimensions of the bulb. The dila- tation called the fossa navicularis was known to the older anatomists ; it was described by Vesalius and Morgagni, and has been admitted by all authors with whom I am acquainted except Amussat and Dr. Otis. Amussat denied its exist- ence ; but the arguments which he employed are by no means convincing, and have been fairly refuted. Dr. Otis also de- nies the existence of the fossa navicularis, and regards the presence of a narrow meatus as abnormal. He says : " Ver- tical sections of the penis, from the junction of the glans with the body of the penis, show a uniform calibre throughout the fossa navicularis to its external boundary at the meatus, the opening of which is of corresponding calibre. This may be accepted as the normal condition of these parts, and any variations from such uniformity may be considered aberra- tions from the normal condition."* Dr. Otis does not state, however, that he has ever made these sections himself, and he is in error when he quotes the authority of Henle in support of his assertion. The accompanying plate, which is borrowed from that anatomist's work,f is designed by its author to illustrate the arrangement of the erectile and other tissues in the glans penis; and, moreover, Henle X states, distinctly in the text, that the meatus and the membranous portion are the narrowest parts of the urethra. He gives seven millime- tres as their average diam- eter. Now, the correctness of this statement is capable of the easiest demonstration. I am well aware that a very wide meatus is occasionally seen, but the opening is usually narrow when com- pared with the urethra be- vertical section of anterior hind it, and I cannot avoid portion of penis. * Dr. F. N. Otis, New York Medical Journal, April, 1S74. f J. Henle, " Anatomie des Menschen," vol. ii., p. 424. \ Op. Cit., vol. ii., p. 393. 162 DISCUSSION OF DR. OTIS'S VIEWS the conclusion that Prof. Otis has mistaken the exception for the rule. There is a peculiarity respecting the anatomy of the fossa navicularis, which I have not seen mentioned by anatomists, and which is illustrated by the casts now exhibited. I may remark that I have noticed the same peculiarity in the living body—I refer to the situation of this fossa. It is always found in the glans penis; but, while in some instances it is distant three-quarters of an inch or more from the meatus, in others it is placed almost immediately behind this opening. When it is situated at some distance from the meatus, that part of the urethra which lies in front of it is usually narrow, and of uniform diameter. When it is found directly behind the meatus, it appears as an abrupt dilatation, as in cast No. 3, when the meatus measures twenty-two millimetres, and the fossa navicularis forty millimetres, in circumference. In some cases, as in that represented by cast No. I, the fossa navicularis is only slightly marked, but I have rarely known it to be entirely absent. Now, it may be objected to the statements I have thus far made, that they relate merely to the dead subject, and that, the preparations which I have shown cannot indicate either the absolute or the relative calibre of the urethra in the living body. Accordingly, I have made some investiga- tions with the view of correcting any errors that might have arisen from the study of the cadaver alone. I have been in- duced to proceed with great caution, however, in this mat- ter, to avoid the injury to the urethra that might otherwise result. In practice, we find in the size of the meatus a rough test of the calibre of the urethra. As this is generally as narrow as any other part of the canal, we assume that the largest sound it will admit ought easily to traverse the entire urethra, un- less Stricture is present. And this rule I have usually found a good one, although, when the meatus is exceptionally small, it may be desirable to enlarge it, either for the intro- duction of a full-sized lithotrite, or for the examination of a BY PROF. H. B. SANDS. 163 Stricture which is not very tight. But, unless the meatus is unusually large, the greatest calibre or distensibility of the urethra cannot be tested by the largest sound that will pass through this opening, and I have found the ingenious instru- ment devised by Dr. Otis of great value in conducting this part of the investigation. I am unable, however, to obtain with the urethra-metre the same results as those recorded by Dr. Otis. In the first place, I can discover with it no exact ratio between the calibre of the bulb of the urethra and the cir- cumference of the penis. On the one hand, the circumfer- ence of this organ, even in its flaccid state, is liable to varia- tion ; and, on the other, the " feeling of fullness " that is said to indicate the distention of the urethra is, so far as I am able to appreciate, no reliable sign that the walls of the canal have been fairly stretched. I have carefully examined the urethrae of twenty healthy adults, and, with a single exception, I have succeeded in expanding the urethra-metre to its fullest ex- tent, namely, forty-five millimetres, without causing pain or inconvenience. In many of these instances I have been able to move the instrument, while thus expanded, forward a dis- tance of an inch or more, without encountering resistance. I infer, from these results, that the bulb of the urethra in the living subject is generally capable of greater dilatation than can be effected with the urethra-metre, and that this instru- ment has failed to prove the existence of a definite ratio be- tween the calibre of the urethra and the circumference of the penis. In the second place, I have always found, when the in- strument was expanded so as to distend only moderately the bulb of the urethra—and yet move freely within it—that, on attempting to withdraw the instrument, it would be arrested about one inch in front of the bulb, and that it became neces- sary to reduce its size before it could safely be drawn forward. It would then pass on easily until its expanded portion reached the meatus, when generally a further reduction be- came necessary before it could be finally withdrawn. In 164 DISCUSSION OF DR. OTIS'S VIEWS short, while the urethra-metre, in my hands, has failed to in- dicate the exact calibre of the urethra, as compared with the size of the penis, it has shown variations in the distensibility of its different parts, corresponding with those which have been demonstrated by the employment of injections in the dead subject. The application of these facts is at once easy and impor- tant. If they can be verified, they prove indubitably that the assumption of an unvarying calibre for any urethra is un- warrantable ; and it is plain that such an assumption must lead to the gravest errors in practice. If the calibre of the bulb of the urethra be taken as an indication of what the calibre of all parts of the canal in front of it ought to be, I cannot understand why Stricture will not frequently be diag- nosticated when none really exists. And, when it is remem- bered that not less than fourteen Strictures in the same urethra have been supposed to be revealed by this mode of examination, we may reasonably suspect, in the absence of post-mortem evidence, that there is something fallacious in the method employed. In fact, I am convinced that, when a healthy urethra, which has not been previously stretched, is explored, either with the urethra-metre, or with very large bulbous sounds, the instrument will often be tightly grasped at certain points, and communicate to the examiner a decep- tive sensation, as if a Stricture were present. This may pos- sibly arise from one of several causes, as, for example, a de- viation of the sound from the axis of the canal, a spasmodic contraction of the muscular fibres that surround the urethra, or a puckering of its mucous membrane before the instru- ment. Another explanation is suggested by certain interest- ing appearances in the urethral casts which I have just ex- hibited. Instead of presenting a smooth and even surface, they are often marked by slight transverse furrows and alter- nating ridges, indicating that the urethral mucous membrane, when greatly distended, yields more readily at some points than at others. I should be sorry to have it inferred, from anything I BY PROF. H. B. SANDS. i6S have said, that I am opposed to the operation of internal urethrotomy for the cure of Stricture. Some of the most gratifying results in modern surgical practice have been achieved by this method, but I believe it to be applicable chiefly to the treatment of close Strictures, and as an auxil- iary to dilatation. The dilating urethrotome, invented by Reybard many years ago, never met with general favor, on account of the accidents which attended its use, and the suc- cess of safer and milder methods of treatment. I am a firm believer in what. I fear, is becoming an old-fashioned doc- trine among us, namely, that gradual dilatation is far the best treatment yet discovered for the great majority of ure- thral Strictures. In regard to what are termed Strictures of large calibre, I believe that they rarely exist, and that, when they do, they seldom cause the symptoms which have been ascribed to them. I fully indorse the statement made by Sir James Paget, who 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 fixed condition of the urethra, but upon mere swelling of its mucous membrane, upon just such swelling as, with chronic catarrh, narrows or shuts up one or both nostrils. Manual surgery should find little or nothing to do in cases such as these."* I desire also to express my disapproval of the habitual use of very large sounds, as I believe that a sound exceeding twenty-five millimetres in circumference is rarely necessary, either for the diagnosis or treatment of a urethral Stricture, and that a canal, even smaller than this would indicate, may permit the ready evacuation of the bladder. The fact that the urethra can be distended considerably beyond this limit is no proof that it ought to be, and unquestionably much evil may result from over-distention. Finally, I cannot help thinking that the practice of slitting up the meatus, now so much in vogue among us, is injurious and irrational. The normal meatus is narrow, and its small * "Clinical Lectures and Essays," London : 1875. 166 CONCLUSION. size doubtless favors the projection of the stream of urine during micturition. When it is enlarged by a free incision along the floor of the urethra, the penis is thereby deformed, and a condition of artificial hypospadias is established. Ex- cept in special cases, therefore, it ought to be left as Nature has made it. If, upon all these matters, I have stated my convictions somewhat emphatically, it is because I am deeply impressed with their important bearing in practice. My sole object has been to elicit truth ; and, if I have ventured to criticise freely, I am willing that my own views shall be criticised in the same candid spirit. The paper read by Dr. Sands being before the Society for discussion, Dr. Otis was called upon by the acting President Dr. Emmet and spoke at some length in reply to the paper of Prof. Sands, occupying the time until the hour of adjourn- ment had arrived. When closing, he announced his inten- tion to discuss the matter more fully at the next regular meeting of the Society. CHAPTER VIII. ON THE RELATIONS OF GLEET TO STRICTURE. Discussion continued.—Dr. Otis's Reply. AT the next stated meeting of the Medical Society of the County of New York, held February 28th, 1876, Dr. Thos. Addis Emmet, Vice President, in the chair, the discussion of the paper by Prof. H. B. Sands, On Gleet and especially on its Relations to Stricture of the Urethra, was resumed by Dr. F. N. Otis in a paper. Prof. Henry B. Sands"opened his interesting and able paper " On Gleet, and especially in its Relations to Urethral Stricture," with these words : " The humiliating confession must be made, that many important surgical problems remain unsolved." This was the statement of a fact which, in his opinion, was especially applicable to the subject which he was about to discuss. In so many words, then, he confessed that gleet, and es- pecially in its relations with urethral Stricture, was a prob- lem for which he had, as yet, found no satisfactory solution. The object of the paper, as stated, was simply to excite dis- cussion; and particularly with reference to views which had been advanced by me, in which I claimed to designate the true nature and cause of gleet, and the only effectual and radical cure for this acknowledged opprobrium of surgery. Proceeding then to the definition of gleet, Prof. Sands referred to idiopathic gleet—gleet depending upon a strumous diathesis, prostatic gleet, masturbators gleet, etc., and re- marked, that " we shall avoid much confusion, by giving to the word the restricted meaning ascribed to it by John Hun- ter and Sir Astley Cooper, and regard it as an imperfect or i68 DISCUSSION CONTINUED. chronic gonorrhoea." Now, as this matter is presented avow- edly for the purpose of discussing my peculiar views in re- gard to gleet, and its relations to urethral Stricture, I shall most decidedly object to any such definition of gleet, as being, not simply imperfect, but as conveying impressions which, of necessity, will often lead to grave errors in the diagnosis and treatment of gleet. I have stated it to be the rule, that all gleet depends upon Stricture, not that all gleet depends upon gonorrhoea. It seems to me, then, from my point of view, that, in order to consider the question of gleet intelligently, we must first dis- cuss the nature and causes of Stricture ; having settled these points, the different varieties of gleet will be sufficiently indi- cated. In regard to the nature and causes of gleet, in the opinion of Prof. Sands, this disease is simply catarrhal. i. He says : " Gleet depends upon a chronic inflammation of the urethral mucous membrane, either diffused over a greater part, or limited to spots, chiefly to the fossae navicu- laris and bulb. " 2. Gleet depends upon inflammation of lacunae opening into the urethra. " 3. Gleet depends upon Stricture of the urethra." Supported by these three postulates, Prof. Sands takes ex- ception to my claim that " gleet always defends upon Stricture." A careful, not a hypercritical, examination of his position will, I believe, tend to simplify the assumed points of differ- ence between Prof. Sands and myself in regard to the causes of gleet, very materially. 1 do not deny that it is a chronic inflammation; nor that it is sometimes found to be diffused over a great part of the urethra; nor that it is sometimes confined to spots ; nor yet that it may occupy the continuous lining of the lacunae and mucous follicles. In the present discussion, however, the locality and pathological results of gleet are not so much at issue, as the cause of the continuance of those conditions upon which the muco-purulent discharge which we call gleet depends. DR. OTIS'S REPLY. 169 I have so often seen diffused and localized inflammatory conditions of the urethral mucous membrane associated with urethral Stricture, and have so constantly seen them disap- pear, upon the division of the Stricture, that I do not hesitate to affirm my conviction that all granular spots in the urethra are the result of retention of acrid urine, behind Strictures more or less salient; and that the most favorable condition to induce implication of the lacunae magna and the deeper sinuses and follicles is the presence of an anterior Stricture. The term gleet is used by Prof. Sands as indicating an im- perfect or chronic gonorrhoea. Now, gonorrhoea is a self- limited disease ; an active inflammation, produced by conta- gion, which continues, according to our best authorities, for three or four weeks, under the most judicious treatment; and I may here add, whether treatment is had or not, for it is the rule that, under favoring physical conditions, it gets well, in about that time, with no treatment whatever. Prof. Sands says: "A gonorrhoeal discharge, after it has continued from one to four weeks, almost always diminishes in quantity, becomes thinner and less opaque, and, in favorable cases, disappears altogether." Again he says, " Not unfrequently, the dis- charge does not disappear, and may continue indefinitely." The difference, then, between gonorrhoea and " chronic or im- perfect gonorrhoea " or gleet is, that the one gets well and the other continues indefinitely. In order to ascertain the reason of this continuance of a gonorrhoea—to find what constitutes the punctum malum—the essential difference between the fa- vorable and the unfavorable cases, Prof. Sands gives a re'sume' of the results of the pathological researches of Sir Astley Cooper, Rokitanski, and Sir Henry Thompson. In some cases, unusual vascularity was found at the fossae navicularis ; in others, general tumefaction of mucous membrane ; enlarge- ment of follicles, relaxation of sinuses, etc., and yet in other cases " no abnormal appearance could be detected." The sum- ming up, then, of these researches seems to shed no light upon the cause of gleet; it simply presents the results of long-continued inflammation, of a low grade, in certain cases; _70 DISCUSSION CONTINUED. while the fact that, in other cases nothing abnormal was found, is a sufficient commentary on the value of this method of ascertaining the cause of gleet. The pathological resume', then, simply shows, that the cause of gleet was not deter- mined by any post-mortem examination. Prof. Sands then cites the results of observations upon the living body. First, " sore- ness and smarting," he says, " may exist and mean nothing ;" " frequent desire to micturate may mean the presence of a morbid process in the urethra; sensation of straining may point to urethral trouble, but gleet may exist and persist, un- accompanied by any morbid sensation." Circumscribed granular spots may exist, and be revealed by the endoscope, but cannot be regarded as the sole cause of gleet. Observations during life, then, do not afford any definite information as to the cause of gleet. The results of the action of remedies are next invoked to discover the cause of gleet. " Sometimes," says Prof. Sands, " its removal is favored by a spare, and at others by a gen- erous, diet. Sea-bathing and tonic food and medicines have cured many a gleet that has resisted the ordinary specific remedies for the disease. In a strumous, gouty, or rheumatic diathesis, appropriate constitutional treatment may become necessary. " Copaiba and cubebs," he says, " have always and deservedly been held in high esteem. Alkalies also are not without value in certain cases. ... In my own expe- rience, however," says Prof. Sands, " local treatment has generally proved the most efficient in the removal of gleet. Injections, mild or strong, superficial or deep ; the occasional introduction of a full-sized bougie into the bladder. When these fail," he remarks, " the disease ivill often be found to depend upon Stricture of the urethra!'' I am quite willing to concede the influence of all the remedies and plans of treatment above enumerated. I re- cognize the fact that, whatever be the cause of a catarrh of the urethral mucous membrane, a condition of constitutional plethora, or, on the other hand, of extreme debility, would favor its continuance ; and that irritating urine, such as would DR. OTIS'S REPLY. 171 indicate the use of alkalies, copaiba, cubebs, etc., in any other trouble, would tend to palliate a gleet—nay, possibly, even cause the cessation of the discharge, where it was kept up by the irritating quality of the urine. But it is a very well- known fact (and I am quite sure that it will not be disputed by my friend Prof. Sands) that cessation of the discharge does not mean cure. The reason, the chief, I believe, that has induced the Professor to include the cure of gleet among the " unsolved problems of surgery" is, that, after cessation, under the varied treatment quoted, the discharge will, as a rule, return. A slight indiscretion in diet, a little vinous ex- cess, a little venereal indulgence, of the most unexceptional character, will bring back the gleet. The results of treatment, then, tif they do not indicate the cause of gleet, teach us, at least, that it is not in any condi- tion which such treatment can permanently control. Prof. Sands says, " When these and other similar methods of treat- ment fail, the disease will often be found to depend upon a Stricture of the urethra." Now, I would like to ask, in the most friendly and scien- tific spirit, why it is considered necessary to go through the above-mentioned category of constitutional remedies, and gleet specifics, and injections, and bougies, before this question is raised—nay, more, until it is settled? Again, I claim that, in order to discuss the subject of gleet intelligently, the sub- ject of urethral Stricture must first be considered. I have stated it as my opinion that " chronic urethral dis- charges are, as a rule, dependent upon urethral Strictures for their continuance," whether these Strictures be the product of a gonorrhoeal inflammation in the first instance, or the re- sult of inflammation of other origin. It is not likely that there will be any important disagree- ment as to the manner in which Strictures are formed, but I do not quite agree with Prof. Sands, nor with the authorities he quotes, in ascribing the first place in the causation of Stricture to gonorrhoea. I recognize the fact that it is most often brought to our notice through the occurrence and per- 172 DISCUSSION CONTINUED. sistence of this disease, and that all preexisting Strictures, or thickenings, or irritations, of the urethral mucous membrane, are increased and intensified by it. I would like, for a moment, to call your attention to some of the other—the non-specific—causes of urethral inflamma- tion and Stricture. Sir Henry Thompson (whose views on so many points are in complete accord with those of Prof. Sands), in his work on "Stricture of the Urethra" (second English edition, page 114), headed " Causes of Urethritis and thus of Permanent Stricture" says : " Urine may possess an irritating quality from the predominance of an acid or an alkali in it; a per- sistence of either of these conditions must be recognized as one of the undoubted causes of organic Stricture. Thus," he says, "Sir Benjamin Brodie states that alkaline urine is more likely to produce the disease (Stricture) than that which is acid, and that persons secreting the triple phosphate are almost sure to have Stricture sooner or later." Mr. Liston says, in reference to attacks of acidity of urine, that " their continuance, or frequent occurrence, may lay the foundation of disease of the urethra." And further, Sir Henry Thomp- son says (ibid., page 115), "Excess of venery, protracted erections, and prolonged intercourse, are recognized causes of Stricture." Lallemand, Ricord, Sir Everard Home, Acton, Gouley, Gross, and others, recognize masturbation as a cause of urethral Stricture, and certainly if we can accept, with Sir Henry Thompson, excess of venery, etc., we cannot deny this influence to masturbation. I have myself seen several ag- gravated and undoubted cases which fully support this view ; and, again, Sir Henry Thompson (ibid., page 117) says, "The influence of gout and rheumatism are undoubted causes of spasmodic Stricture ; these diatheses, therefore, predispose in this manner to the accession of organic Stricture." Not to pursue the causation of urethral Stricture further, for fear of wearying you, I desire now to ask your attention to a few observations upon, and natural deductions from, the foregoing citations from our most valued authorities. DR. OTIS'S REPLY. 173 In the first place, the influence of vitiated urinary secre- tions, excess of venery, prolonged erections, and protracted sexual intercourse, are distinctly recognized and insisted on, as a cause of organic urethral Stricture, and this, too, by au- thorities whose facilities for urethral examination were most imperfect, and hence could only detect, positively, the more advanced stages of Stricture. It is but just, it seems to me, to infer that, in very many cases examined by them when symptoms of Stricture were present, no Stricture was detected. The method now pursued by Prof. Sands, Sir Henry Thomp- son, and many other less enlightened surgeons, would signally fail in detecting the earlier invasions of Stricture in any ure- thra of a capacity above twenty-five millimetres in circumfer- ence. Now, when we come to consider the proportion of men who, at some time in their lives, have suffered from acrid uninary secretions (from a gouty or rheumatic diathesis, and various other causes) from excessive venery, masturbation, etc., does it seem to you necessary to insist upon it that every subject of a gonorrhoea had a previously normal condi- tion of his urethra ? Urethral Stricture is recognized by Prof. Sands as a cause of gleet. What amount of contraction is, then, necessary to constitute a Stricture capable of producing or prolonging a gleet ? By the admirable casts of the urethra, which he has presented in his paper, he has, in four specimens, demon- strated a difference in the urethra of different individuals. These casts (carefully enlarged drawings of which I now pre- sent to you) will form an interesting basis for study in refer- ence to what may be said to constitute a Stricture. In cast No. I, the walls of the canal are seen to be smooth and quite free from indentations. No. 4 is almost equally so, except within an inch or so from the meatus, where two or three slight indentations are seen. No. 3 shows four or five wrinkles occurring at a point coincident, or nearly so, with the locality of the peno-scrotal angle during life, and corre- spond with the thickened folds of mucous membrane which 174 DISCUSSION CONTINUED. are so commonly found at this point in examinations with 2 4 CASTS OF ALLEGED NORMAL URETHRA. (Electrotyped from Prof. Sands's'Wood-Cut.) 43 7843 74 DR. OTIS'S REPLY. 175 the urethra-metre. No. 2 presents not less than six distinct contractions between the meatus and the bulb. It must be borne in mind that a force, of no insignificant character, has been used in the distention of the urethrae from which these casts were taken ; and it may, I think, be reasonably pre- sumed that any accidental wrinkles would have been straight- ened out; in short, that nothing but permanent organic con- tractions would have left their imprint upon the plaster cast. Whether these can be called Strictures, or not, will depend very much upon what degree of contraction is considered worthy to be called Stricture. The practical point which this condition suggests, how- ever, is that, whether we call these points Strictures, or con- tractions, or wrinkles, they are certainly capable of interfer- ing with the smooth and easy passage of urine; that they would furnish admirable points of lodgment for the solid con- stituents of the urine during an acid or an alkaline dyscrasia —very slight, it may be acknowledged, but very marked when compared with the smooth and regular outline of No. 1. Now, if we can suppose two urethrae, which shall be the counterparts of those from which casts No. 1 and No. 2 were taken, to be invaded by a gonorrhoeal inflammation—which of them would, all other conditions being equal, escape with least damage—in which would a gonorrhoea be the least severe ; which would be least likely to suffer with subsequent gleet ? The urethrae which are represented by these casts were said to have been free from any evidences of disease : when, however, we recall the statement of Foerster, quoted by Prof. Sands, on page 7 of his paper, viz., that " blennorrhcea sometimes lasts a very long time without causing any mate- rial alteration of the urethral mucous membrane," we may reasonably question the inference that Nos. 2 and 3 were free from disease, while we have ocular proof of the presence of conditions which would favor a contrary conclusion. If No. 2 can be accepted as representing a perfectly normal condi- tion, the smooth and unwrinkled surface of No. I must then be acknowledged to vary from it in a very noticeable degree. 176 DISCUSSION CONTINUED. Should it be claimed that the smoothness of No. 1 is account- ed for by the less force used in making the injection, we will transfer the comparison to Nos. 3 and 4, which are sufficiently free from contractions to present a striking contrast with No. 2, although in case of these, as nearly as possible, the same force was applied. Convinced, as I am, that complete freedom from obstruction in the muscular structure of the urethra is essential to the perfect performance of the act of micturition ; that complete absence of points of friction is necessary to secure the greatest immunity from local and reflex disease, I should no more feel justified in presenting cast or cut of urethra No. 2 as typify- ing a normal urethra, than I would present a neighboring orifice to you, as normal, when surrounded by the shriveled remains of half a dozen haemorrhoids. These casts were claimed to show, among other things, the incorrectness of my views, in regard to the absence, in a per- fectly normal urethra, of that boat-shaped dilatation which is described by authors as occupying the first inch of the urethra, and termed the fossa navicularis. Four specimens are rather few to decide a disputed anatomical point, but, as far as they go, they prove the correctness of my position. It is entirely absent in No. 1. In No. 2, which is rich in dilatations and contractions, and with a meatus eleven millimetres smaller than any other part of the canal, it is present. In Nos. 3 and 4, if by courtesy it can be said to be present at all, it is with- in a quarter of an inch of a contracted meatus, and is merely a pouch-like dilatation, which I have always recognized as as- sociated with a contracted meatus, and have never seen in connection with a meatus of the normal size.* In his discussion of this point, Prof. Sands states that I misquoted Henle in reproducing his representation of a frozen section (" Anatomie des Menschen," vol. ii., p. 424). It was the illustration, showing that the normal meatus corresponded * Subsequent examinations of urethrae of the foetus and the newly-born have demonstrated it to be an acquired condition. See statement of Prof. Brown's Researches, page 243. DR. OTIS'S REPLY. 177 in size with the urethra behind it, which I quoted—the tran- script from a natural frozen section ; which proves my claim— and not his subsequent reiteration of a conventional idea. He has thrice presented this plate as a transcript from a normal condition of the penis at this point. The same drawing has been represented, by Drs. Van Buren and Keyes, as a normal condition under the title of " Vertical Section through Glans and Fossa Navicularis."* It corresponds completely with my own numerous observa- tions, on the living subject as well as on the cadaver. What Henle says is great- ly weakened, if not made wholly valueless, when his own transcripts from nature, vertical section of glans and fossa as well as the careful navicularis. observations of others, contradict his statements. In speaking of examinations in the living subject, Prof. Sands says (p. 162)," In practice, we find, in the size of the meatus, a rough test for the calibre of the urethra." This has long been taught by authorities, and has been adopted by many surgeons as a guide for estimating the calibre of the deeper urethra. The idea may almost be said to be pre- historic, and possibly occurred to Adam on his first urination. If our great progenitor could have been examined with a bul- bous sound, I doubt not that his meatus would have been found to correspond completely with the canal behind it, and hence, at that period (if man may then be believed to have been in physical perfection) the meatus would have proved an exact guide to the normal calibre of the urethra. When I now meet with such a case, I consider it the highest normal type of meatus. But, since then, indiscretions and other ir- regularities have crept into the world ; and now, after six or more thousand years, the result is, that the meatus, among other things, has varied from its original type, so that, at the * " Genito-Urinary Diseases, with Syphilis," page 30. 12 i;8 DISCUSSION CONTINUED. present day, if we accept the size of the meatus as a rough guide to the size of the urethra, we shall find it a very rough guide indeed. The fact is, that the meatus can be shown to be perfectly inconsistent in its relations to the urethral calibre, and that in not more than one case in ten does it occur that the size of the meatus is a reliable test of the size of the urethra. In the examination of one hundred living subjects with the urethra-metre— I was 13 mm. cir. 3 were 25i 3 were 15 4 " 26 i was 16 5 " 27 2 were 17 3 " 27i 3 " 18 2 " 23 3 " 19 " 1 was 23! i was J9i " 5 were 29 3 were 20 " 3 " 30 2 " 2o£ " 3 " 31 2 " 21 " 5 c< 32 5 " 22 " 4 " 33 3 " 22^ " 2 It 33i i was 23 3 " 34 i " 23? " 24 1 was 37. 7 were i was 24i " 100 24.72 17 were 25 Average size in one hundred cases, 24.72. In no case was the urethra, in the one hundred cases, be- low a calibre of 26 millimetres—ranging from this to 39— the average being 32.95. I think, then, that we are forced to conclude that the size of the meatus urinarius cxternus is not in any sense or degree a guide to the urethral calibre. It is worthy of remark that, in the one hundred examina- tions referred to, notwithstanding the very great dispropor- tion between the size of the meatus and the calibre of the spongy urethra, no marked trouble on that account was noted. These were, however, cases which claimed to be free from inflammatory antecedents. It is probably the fact that, as long as the meatus escapes inflammatory action, it does not become a source of trouble on account of its diminutive DR. OTIS'S REPLY. 179 proportions. We may have a meatus from the size of a mere pin-hole to the full size which corresponds with the calibre of the urethra behind it. None can, perhaps, be claimed to be abnormal, as long as the functions of the part are well performed; and hence, in the presence of so great variations, it might be difficult to fix upon the highest normal type of the meatus urinarius. We find, however, that various and grave difficulties and diseases are occasionally associated with a genito-urinary apparatus, where the meatus is not of the full size of the canal behind it, and that such difficulties are promptly relieved by a surgical procedure which permanently enlarges the meatus to that size. The fact that such difficul- ties do not occur, when the meatus is of the full size of the canal immediately behind it, gives additional weight to the assumption. That condition, then, of these parts which in- sures the most complete functional integrity, and is least liable to become a source or seat of disease, and which is also least liable to induce, aggravate, or prolong disease in the contiguous parts, may, I think, be safely and appropriately accepted as representing the highest normal type. Now, by observation of the one hundred cases reported, the meatus will be found to correspond with the canal behind it, in ten cases, while not one exceeds this limit. Besides this, it can be most positively proved that contracted meatus prolongs and intensifies gonorrhoea, produces gleet, and is the source of varied and grave reflex irritations. Profs. Van Buren and Keyes (p. 92) boldly state that " an individual with an average-sized penis, whose meatus will take only eight or nine (fourteen or fifteen F.), has Strict- ure (congenital) of the meatus, although he never may suffer any inconvenience therefrom." Prof. Gouley (p. 103, " Dis- eases of the Urinary Organs ") states that the proportion of Strictures in this region, as compared to the entire number he has seen, is at least 30 per cent. Thus it stands: individ- uals may have a meatus, strictured more or less, and never suffer any inconvenience therefrom ; again, this condition may give rise to grave trouble. Why this apparent difference ? i8o DISCUSSION CONTINUED. Simply, as I apprehend, that when the muscular structure of the meatus, and the urethra behind it, is in perfect condition, it is enabled to empty the urethra completely after urination. Let inflammatory action be set up in this locality, as may occur from extension of an infantile or an adult balanitis, or from gonorrhoea, or from any other cause, and a plastic exudation results, which, becoming organized, disables the urethral muscular structure at this point, and it is no longer able to act efficiently in expelling the last drops of urine ; they are retained, a dribbling results, and is the unvarying sign that such an accident has occurred. It is from this cause that the discharge from a gonorrhoea is retained, aggra- vating and prolonging the disease. Now, the only rational remedy, in this class of cases, is to relieve the obstruction ; we cannot restore the disabled muscular structure, but we can relieve the obstruction, mechanically, by making the orifice to correspond with the size of the canal behind it, and thus enable the urethra to clear itself of its irritating secre- tions. But Prof. Sands says : " The practice of slitting up the meatus is injurious and irrational," that " the normal meatus is narrow, and its size favors the projection of the stream of urine during micturition." It is not the normal meatus that requires any slitting, or any other operation ; it is the division of the abnormal meatus—disabled through antecedent inflam- matory action—which a rational treatment demands. I ven- ture the assertion that thousands of cases of gleet exist to- day, which have been treated by copaiba, and constitutional remedies, and injections varied and frequent, and even by full-sized bougies, for years, and vainly, which this compara- tively simple operation (of removing the obstacle to the com- plete emptying of the urethra) would promptly accomplish, besides affording immunity from recurrence, except through a fresh contagion. But gleet, troublesome as it is, is by no means the only untoward result possible from a contracted meatus. This point is admitted by physiologists to be a sort of telegraphic DR. OTIS'S REPLY. 181 depot for the whole genito-urinary system. Nor is it the genito-urinary system alone which may suffer from irritations of this locality. You have but to recall the fact, that a las- civious thought will cause a sensation at this point, and that slight irritation here will induce the sensuous thought. De- pression of spirits, especially in youth; incontinence of urine; pain on ejaculation ; neuralgias of the testicles, over the pubis, down the thighs, and even to the soles of the feet; spasmodic Stricture, with or without retention of urine ; pros- tatic irritation and enlargement; inflammation of the bladder and testicle—are each capable of being produced by this con- dition, in certain instances, as proved by the prompt disap- pearance of these troubles (often ineffectually treated by other and various means) through a free division of a con- tracted meatus. My paper on " Reflex Irritations through- out the Genito-Urinary Tract," read before the New York Academy of Medicine in February, 1874, adduces no less than nineteen representative cases of this sort, with all the particulars of antecedent and subsequent conditions. In the London Lancet of January 29, 1876, Mr. Furneaux Jordan, F. R. C. S., Professor of Surgery, etc., of Birmingham, Eng- land," in speaking of the possible influence of a contracted meatus, writes thus : " I not unfrequently meet with the cause and its results. In boys a common result is cystitis, simulating stone in the bladder. Boys, however, often escape notable trouble; as men they are not let off so easily. With the cares, indigestion, gout (disguised or open), and other ailments, which increase the acidity of the urine, there come one or several of the results of Stricture. One such effect is urethritis, which, by continuous extension, may lead to pros- tatitis, or cystitis, or epididymitis. There are some," he says,' " who under such circumstances would affirm that the ure- thral inflammation had been caused by contact with some noxious fluid. ... I will not," says Prof. Jordon, "here dis- cuss the merits or demerits of a policy of uniform incredulity. My answer is this : often in cases of diminutive meatus, the bladder is affected first, then the prostatic urethra; then per- 182 DISCUSSION CONTINUED. haps the inflammation may extend along the vas deferens, setting up consecutive orchitis, and from first to last there is no urethral discharge.* Frequency of micturition; supra- pubic pain; mucus or blood in the urine ; are, singly or com- bined, the subject of complaint. ... A diminutive orifice aggravates and prolongs a gonorrhoea or gleet or Stricture and their ordinary sequela. The treatment," he says, " which I adopt for a small meatus is an incision—the result in all cases —a large number—successful. The success is not always rapid, especially in old-standing cases of cystitis ; but, sooner or later, relief follows." Sir Henry Thompson says : f " I have given complete re- lief to distressing symptoms of very long continuance, the cause of which was not suspected, by dividing an external meatus which, nevertheless, admitted a No. 6 English cathe- ter ;" and he cites three cases when the very simple operation necessary had given complete relief to symptoms "which had long been regarded as of very obscure character." Now, if such troubles can be adduced as the possible effect of a con- tracted meatus, and such results can be shown by its division, can it be justly said that slitting a contracted meatus is irra- tional ? Prof. Sands (quoting from one of my papers on "Stricture of the Urethra ") says : " If a urethra present, the normal calibre of which is equal to a circumference of 30 millimetres, and only a 29 bulbous sound will pass, without detecting ob- struction, then the urethra is not ' about right.' It is strict- ured to the extent of one millimetre, and can never be a healthy urethra while that Stricture remains." Then he says, " Let us inquire if these statements can be verified; if so, we shall find established an important principle in the treatment of gleet." The question of the measurement of the urethral calibre, which is involved in the statement quoted, is one of so great importance, that I shall not apologize for entering upon it with some degree of minuteness. As a mechanical * " Stricture of Urethra," second London edition, p. 249. t Ibid. / DR. OTIS'S REPLY. 183 proposition, there is no room to doubt but that, if the canal, that is, the ante-bulbous urethra, is 30, and 29 only will pass without detecting obstruction, obstruction certainly exists. This, however, as I apprehend, is not the point in dispute, but it is as to whether this minute obstruction, in the first in- stance, if present, can be made out, and in the second, if made out, can it prove a cause of trouble. The first point, then, to consider, is, What do we understand by the normal calibre of the urethra ? In order to settle this, and to meet the objec- tions which have been urged against my own views on this subject, I will present briefly the method and results of ure- thral measurements by accepted authorities. From the year 1854 to 1875, Sir Henry Thompson taught that, " when 8 or 9 of the English scale could be passed easily through a given urethra, no Stricture could be said to exist." In one of his recent lectures delivered at the University College of London, November 18, 1875,* he says: " Simply take a flexible Eng- lish gum-elastic bougie, well curved toward the point, with a blunt end, not larger, as a rule, than 10 or 11 of our scale (that is, nineteen or twenty millimetres in circumference), and pass it very gently and slowly into the bladder. If it goes easily, above all, if it is drawn out without being held, and slides out with perfect facility, take my word for it he has no Stricture, and quoad obstruction, wants no use of instruments whatever." It will thus be seen that Sir Henry Thompson fails to recognize the varied capacity of the urethra in differ- ent individuals, and practically reduces all urethrae to a com- mon and fixed standard. It will also be observed that, with- in the last year, he has raised this standard from "8 or 9 Eng- lish " (17 and 18 F.), to " 10 or 11 " (19 and 20 F.), that is to say, about two millimetres. Why he has done so does not appear. Now, Sir Henry Thompson distinctly states that "in the living body the walls of the passage are closely applied to each other in a state of inaction, so that the diameter is only cal- culable when distention occurs from some cause .... In- * Reported in the London Lancet, December 11, 1875. 184 DISCUSSION CONTINUED. deed," he says, " the question of the diameter of the urethra must be considered as resolving itself, to a certain extent, into the measure of its capacity of bei?ig extended, and this is of greater practical importance than the mere width of the mu- cous membrane, when slit up after death;"* and yet Sir Henry fixes the urethral limit at 10 or II English, without the least reference to these facts. Prof. Sands says that " we have properly the.normal cali- bre of the urethra, when it is moderately distended by urine during normal micturition," and, although he remarks, " we cannot estimate this with accuracy, I believe that it is not very large." That is to say, it does not, in his estimation, make a calibre of more than twenty-five millimetres. He says, " Fi- nally, passing sounds exceeding twenty-five millimetres is very rarely necessary, either for the diagnosis or treatment of Strictures of the urethra." Prof. Sands thus virtually fixes the urethral calibre at twenty-five millimetres. Twenty-five millimetres are equal to 14 of the English scale. We are not informed why Sir Henry Thompson first fixed the urethral limit at " 8 or 9," nor why he subsequently granted an exten- sion to "10 or 11; " nor yet why Prof. Sands is willing to allow a calibre of 14. There is no evidence to show that these estimates are based upon any well-ascertained facts bearing upon this point. Profs. Van Buren and Keyes say (page 28 of their excellent work on venereal diseases,f and in italics), " A fair, average, well-formed urethra measures about three- eighths of an inch in diameter;" that is to say, thirty milli- metres in circumference. The French school (as represented by Dr. T. B. Curtis, of Boston, in his essay which won the Civiale prize in 1873, and has thus the stamp of approval by the French Academy) says, " The size of the human male adult urethra is seven millimetres in diameter," or 21 of the French scale. The late Mr. Guthrie, so much appreciated as a surgical authority, both in Great Britain and America, says, " The * *' Stricture of the Urethra," Thompson, second London edition, p. 6. f " Genito-Urinary Diseases," etc., p. 28. DR. OTIS'S REPLY. I85 urethra varies so much in different people, that it is scarcely worth inquiring into, particularly as the passage of instru- ments is always regulated by,the size of the orifice;" . . . . but, as to its positive size, he says : " I have a solid bougie which is rather more than half an inch (twelve and a half millimetres) in diameter. I had it made for one gentleman in particular, and it passed with perfect ease through the whole passage .... Very few urethras," he further remarks, " will admit a sound of more than 12 to 16." In view, then, of this apparent want of harmony (not to say definiteness), in arriving at a practical estimate of the normal urethral calibre, we must, I think, come to the con- clusion that the authorities quoted must have taken the size of the meatus, the volume of the stream, the results of post- mortem examinations, and the experiments on the extensibility of mucous membrane, as a basis, and have struck a general average as to what ought, in their opinion, to constitute a normal urethral calibre. In summing up these independent, individual estimates, we find them as follows : Sir Henry Thompson (10 to 11 E.) up to 19 or 20 millimetres. The French School......21 Prof. Sands up to .....25 Profs. Van Buren and Keyes .... 30 " Mr. Guthrie up to over \ inch diameter . about 40 Now, in a urethra of a calibre of 30, an instrument of 19 or 20 (" 10 or 11 " English) would pass a Stricture of ten millimetres' value without discovering it; one of twenty-five millimetres would fail to appreciate a Stricture of five milli- metres' value or one-sixth of the entire calibre of the urethra ; and should the normal calibre reach the size of 40, which it can be proved to do by Mr. Guthrie and myself, in rare cases, even an instrument of thirty millimetres in circumference would fail to detect a Stricture involving one-fourth of the passage. It would, then, appear to be a matter of some im- portance, for a person suffering from symptoms of Stricture, to ascertain the probable size of his own urethra before apply- i86 DISCUSSION CONTINUED. ing to a surgeon for aid ; otherwise, he might apply to a dis- ciple of the English school, who would not allow him a calibre of more than 19 or 20 (" 10 or 11 " English); or to a French surgeon, who would concede only 21 ; or to one who believes, with Prof. Sands, that " more than 25 is rarely necessary for the diagnosis or treatment of Stricture; " for all these would certainly fail to detect, much less be able to appreciate, the extent of a Stricture, above their estimates, in a urethra whictr should reach the fair average of the normal urethra of our more generous American authority, to say nothing of the possibilities of a urethra of the size of about forty millimetres in circumference, cited by that grand old English surgeon, the late Mr. Guthrie. The conclusion is, then, forced upon us, that some method of arriving at an estimate of the normal urethral calibre must be adopted, which shall eliminate, as completely as possible, the element of individual opinion based upon generalities. The clear and practical view of Sir Henry Thompson, that " the question of the diameter of the urethra must be considered as resolving itself into the measure of its capability of being distended," furnishes us with the only rational basis for a true appreciation of the urethral calibre in different individuals. Through a very great number of experiments, upon subjects living and dead, during a period of more than four years, the possibility of arriving at correct and uniform measurements of the urethral canal, by means of this instrument, the Urethra- metre (which has already been described to you by Prof. Sands), has finally been demonstrated. By means of this it has been found possible to determine (and with scarcely more discomfort than would result from the introduction of an ordinary sound or bougie) the limit of easy distention, and thus the normal calibre of urethrae, within one or two milli- metres in almost every case. In a great proportion of one hundred cases, recently examined, this limit was defined exactly; and this without regard to the contractions of the meatus, or the presence of Strictures above 13 F., which is the size of the closed instrument. My examinations with the DR. OTIS'S REPLY. 18/ urethra-metre have been, from the first, conducted with an entire knowledge and appreciation of the physiology and histology of the penis and urethra, as taught by authorities. It was fully recognized that the calibre of the urethra varied, anatomically, in different parts. The instrument was intro- duced, closed, to the bulbo-membranous junction, and then expanded slowly, until a feeling of slight fullness was experi- enced by the patient. If, then, it was easily and painlessly movable, it was drawn gently forward, and, if no positive obstruction was met, the urethra was considered free from Stricture. If, however, it was arrested at any point, the instrument was turned down until it could pass, and the amount of obstruction was noted from the dial. If the hold- ing was slight, and at a point of usual anatomical narrowing, it was not considered important, unless the instrument was distinctly resisted on being pushed back at such point. After making a great number of examinations, I was led to appreciate an important difference in the calibre of dif- ferent urethrae, and that an average standard was impossible. That while thirty millimetres was the full measure of one man's urethra, that of another would as freely admit a No. 40 solid sound through its entire length, and into the bladder. Another point, and one which has attracted some, but not sufficient, attention, was that of the proportionate relation, which I came to observe, between the size of the urethra and the penis with which it was associated. After an extended experience on this point, I am prepared to state that this re- lation is constant, and is about 1 to 3^; in a penis of three inches circumference the urethra would be 30, 3^ 32, 3^ 34, 3f 36, 4 38, 4\ to 4\ 40; and that an estimate of calibre made on this basis is a valuable guide when the urethra-metre is not available. It must, however, be borne in mind that the circumstances under which examinations are made occasion- ally (though seldom) vary, and that some experience is neces- • sary in order to recognize and appreciate the conditions which temporarily affect these relations. Even late authorities state that a large penis may be as- 188 DISCUSSION CONTINUED. sociated with a small urethra, and that a small penis may ac- commodate a large urethra. This important statement will be proved untrue by the results of my examinations. Out of the one hundred cases presented in the annexed tables, the size of the urethra corresponded with the size of the penis, exactly in accordance with my claim, in thirty-nine cases : 39 cases. Deviating from it i millimetre, 36 " " 2 millimetres, 17 " 3 2 " 4 1 " 5 3 " 6 " 1 " 7 1 " 100 " On page 21 of his paper, Prof. Sands relates his experi- ments with the urethra-metre. I am not surprised that, from his experience in twenty cases, he should arrive at conclusions on some points somewhat at variance with my own. The urethra-metre is an instrument which, like the stethoscope, requires a familiarity with its use, for which no anatomical knowledge, or dexterity in the use of other instruments, can fully compensate. The tactile skill which is required to ap- preciate the least amount of distention which urethral mu- cous membrane will bear, without damage, and yet shall give the assurance of its full expansion, will bear comparison with the appreciation of the true respiratory murmur in a chest- examination. Prof. Sands did find, however, that the instru- ment showed variations, in different localities of the urethra, corresponding with those which he had previously demon- strated on the dead subject. He says, " If the above facts can be verified, they prove indubitably that the assumption of an unvarying calibre for any urethra is unwarrantable ; and it is plain that such an assumption must lead to the gravest errors in practice." Now, I, for one, am sure that " the above facts" can be verified, and I most cordially agree with Prof. Sands in his DR. OTIS'S REPLY. 189 statement, as to the error of considering the urethra of un- varying calibre, as well as in regard to probable consequences of such an error. This is the error which is practically made by those who estimate the calibre of the urethra by the size of a bougie, and not by any one who makes an intelligent use of the urethra-metre. Prof. Sands has misapprehended me when he infers that I am accustomed to take the calibre of the bulbous portion of the urethra as a measure of what all parts of the urethra in front of this portion " ought to be." The passage quoted from my article on gleet, etc., from which this conclusion is drawn, is as follows: " At this point (the bulbo-membranous junction) the bulbous portion of the instrument (the urethra-metre) is to be expanded by means of a screw at the handle, until a feeling of fullness is ex- perienced, when, if there is no Stricture at the point of trial, the hand on the dial-plate will indicate, with sufficient cer- tainty, the normal calibre of the urethra under examination."* The feeling of fullness spoken of, referred, in my mind to the sensation oi the patient; and this I found was experienced, as a rule, before the true capacity of the canal, at that point, was reached; from the extreme sensitiveness which exists in some cases, the sensation of the patient affords no reliable guide in ascertaining the calibre of the ante-bulbous portion, with the urethra-metre. This abnormal sensitiveness is rarely present at the bulb, and thus the instrument, raised to a point occasioning a feeling of fullness to the patient (and not one of arrest to the operator) indicated, " with sufficient cer- tainty," the calibre of the ante-bulbous urethra, and not the size of the bulbous urethra, which authorities state, and I then fully believed was, as a rule, much larger. My meaning was perhaps not as clearly expressed as it should have been, but the errors which might arise from the impression that the bulbous and ante-bulbous portions are of the same size are perhaps not so great as Prof. Sands inti- mates, or as I myself would have premised, before making my * " On Gleet and its Relations to Urethral Stricture, American Clinical Lec- tures," p. 253, by F. N. Otis, M. D. 190 DISCUSSION CONTINUED. recent urethral measurements of one hundred cases of sup- posed normal urethrae. In these, the measured difference between the bulbous urethra and the part anterior to it was— In 35 cases 1 millimetre.* 21 2 millimetres. 18 " 3 6 " 4 2 " 5 " 2 " 6 2 " 7 " 1 " 11 " 13 no difference. The average difference in the one hundred cases was 2 tw millimetres, and the calibre of the ante-bulbous portion averaged 32.95. In my previous report of one hundred cases, in a paper read before the State Medical Society in February, 1875, and which were examined with the view to detecting Stricture, and not to ascertain the normal calibre, the average calibre was 3i£. The difference of about two millimetres in the av- erage of the first and second hundred cases may, I think, be accounted for by the more rigid, thorough, and methodical carrying out of the plan of measurement in the more recent examinations. In this connection, as opposed to the tradi- tional idea, it will be interesting to quote the opinion of that eminent English surgeon, the late Mr. Guthrie, who says : " This bulbous portion of the urethra is said to be larger than the anterior part, but I do not believe that it is, although it may appear so." Perfect security against mistaking a normal narrowing for Stricture may always be had, by examining from before back- ward. If the canal anterior to the contraction is of distinctly larger calibre, this localized contraction must be accepted as a Stricture. I recognize the elements of doubt, as to the cause and nature of localized urethral contractions, in some cases, especially as post-mortem examinations often do not * 1 millimetre equals -fa of an inch. DR. OTIS'S REPLY. I9I show any lesion of the mucous membrane over a point where Stricture has been recognized during life. Various conditions, resulting from persistent irritation of mucous membrane, may obtain, which are capable of causing changes—possibly atro- phy, with contraction of the trabecular structure of the corpus spongiosum, or obliteration of its meshes, and which might escape the observation of those who were looking only for cicatricial deposits. One thing is certain, that the subject has not yet received, from our microscopical experts, the attention its importance demands. The practical fact, however, re- mains, that whatever permanently constricts a localized por- tion of any urethra is practically a Stricture, and capable of causing the effects of Stricture, and is also amenable to the same method of treatment. The value of the examinations of one hundred cases,* re- peatedly referred to during the course of this paper, will be better appreciated by a knowledge of the circumstances under which they were made. The subjects of examination were, some in my own wards in Charity Hospital, others, through the courtesy of my colleagues, Drs. Keyes, Howe, Piffard, and Frankel, were selected from their wards. Quite a large proportion, fully one-half, were patients in Bellevue Hospital, kindly placed at my disposal by my friends Profs. Sands, Stephen Smith, and Dr. Erskine Mason. The examinations were conducted by me, in the presence and with the assistance, on different occasions, of Drs. Stephen Smith, George A. Peters, F. J. Bumstead, H. G. Piffard, L. Bolton Bangs, W. T. Bull, and various members of the house- staff of Charity and Bellevue Hospitals. In the accompany- ing tables the names of each of the gentlemen, as far as possi- ble, are associated with the cases examined or reviewed by them. In three of the cases, a reexamination was made after death ; two cases, in the presence and with the assistance of Dr. Stephen Smith, Dr. A. Jacobi, and Dr. L. Bolton Bangs ; and the third in the presence and with the assistance of Dr. Freeman J. Bumstead, Dr. George A. Peters, and Dr. Bolton * Tables at page 200. 192 DISCUSSION CONTINUED. Bangs. In the first two the reexamination was found to accord completely with that made during life ; in the third, the distensibility of the bulbous urethra was increased four milli- metres ; but the measurements in the anterior portion of the canal and size of the meatus remained the same. The meas- urement of the flaccid penis, in each case, was less by one- quarter of an inch than during life ; but as, in the former, the measurement was made after the removal of the integument, it so far shows that the measurement of the flaccid penis during life does not differ greatly from a post-mortem meas- urement. The results of examination were carefully noted by my friend and associate Dr. L. Bolton Bangs, whose sole office it was to record them. The tabulation, which is appended, was also made by him, solely, and has been subjected to no re- vision by any other person. In regard to the case of fourteen Strictures (reported by me to one of our medical societies, and subsequently pub- lished in the New York Medical Journal of April, 1874) referred to by Prof. Sands, I desire to protest against this grave accident to my patient being brought forward to dis- credit the results of my method of examining the urethra, especially so, as this warrants the inference that I am in the habit of discovering and operating upon Strictures that do not exist. I am aware of the claim of Sir Henry Thompson, that rarely more than three or four Strictures occur in a single urethra. Pursuing the same general mode of examina- tion, it is not difficult to appreciate the incredulity of Prof. Sands in regard to the existence of fourteen Strictures in a single urethra. If a man thrust his hand into a fire, there will be no dispute but that he may have, resulting, as many scars as he has received burns. In the same way there can be no limit to the number of urethral scars, which become Strictures, except by limiting the degree and continuance of the gonorrhoeal, or other fire, which has inflicted the primary injury. This drawing, which was presented, in, company with the DR. OTIS'S REPLY. 193 living subject, before the New York Medical Journal Asso- ciation early in 1874, is a fairly correct diagram of the num- ber, size, and locality of the fourteen Strictures. They were made out by me, on several occasions, before the operation, and at the time of the^operation these measurements were re- hearsed and confirmed, under aether, by Dr. George A. Peters and Dr. Deforest Woodruff, who assisted me during the operation. The Strictures were found, in a penis of three inches, to vary from twenty-two millimetres to one-third of a millimetre, and extended to 61 inches, beyond which the urethra was practically impermeable. The perineal section was performed for the posterior Strictures, and dilating urethrotomy for those anterior. The Strictures were, with the exception of three bands deep in the perineal urethra, made out with the bulbous sounds; the latter were recog- nized in the passage of the Maisonneuve blade, by me, and distinctly appreciated by Drs. Peters and Woodruff.* I was more than gratified to learn, from so able a surgeon as Prof. Sands ; from one who so thoroughly enjoys the con- fidence of the medical profession and of this community and country, that he thought so well of the operation of internal urethrotomy. " Some of the most gratifying results in modern surgical practice," says Prof. Sands, " have been achieved by this method. But," he continues, " I believe it applicable chiefly to the treatment of close Strictures, and as an auxil- iary to dilatation." I could have wished that he had accorded to this operation of internal urethrotomy, so highly com- mended, a broader scope. Prof. Sands announces himself as " a firm believer in gradual dilatation." For my own part, I can only consider gradual dilatation of Stricture, (except so far as it may be necessary to prepare the way for urethro- tomy,) in the light of a temporary expedient, and would use it, only as I would temporize with a vesical calculus, with demulcents and sedatives, when the condition of the patient was such as tp forbid the use of the scalpel or the lithotrite. See diagram showing locality of the fourteen Strictures in the case of W. C. H., page 63. 13 I 194 DISCUSSION CONTINUED. I fully recognize the responsibility of so pronounced an opinion on this important matter, and I trust that, during the discussion which is to follow, some sound reasons will be adduced to show why urethrotomy should be confined to grave and close Strictures ; why a resilient urethral obstruc- tion should be made the subject of oft-repeated stretchings— never without risk, and perhaps for a life time—instead of the prompt, rational, and what appears to me the more surgical, treatment by division. Is it his fault, or that of his surgeon, that the subject of a gleet is so often made to pay a weary- ing tribute to one member of our profession after another, until at last he drops into the clutches of that class which Sir Henry Thompson so graphically describes as hanging on the outskirts of our honorable profession : who will extort his last dollar in exchange for a placebo. I believe it can be proved, that every gleet is the result of Stricture, and that it is a true and safe economy to search it out in its inception— to divide it, and thus promptly restore the urethral calibre to its integrity, and before the damage it may occasion has im- plicated tissues and organs to an extent which may imperil life. Every Stricture is a mortgage bearing compound in- terest, and the wise man will promptly pay it off. Every gleet is a call for payment. You may for the time, with syringe and bougie, drive off this implacable, persistent dun, but he will return, in one guise or another, until the debt is paid, or the property is forfeit. Discussion following Dr. Otis's reply to Prof. Sands : * Dr. Weir proceeded to discuss the question under two heads: I. What is the size of the normal urethra? 2. What are its normal contractions ? His conclusions were: i. That the spongy portion of the urethra is the smaller and least distensible. * As reported in the N. Y. Medical Record of March 6th, 1876. DR. BUMSTEAD'S VIEWS. 195 2. That a healthy urethra can be distended in its spongy portion to admit 32 to 33 mm., French scale. 3. Normal contractions frequently exist as small as 29 mm. in the spongy portion. 4. The normal size of the meatus varies from 18 to 28 mm. 5. That the urethral canal is narrowed at the meatus, dilated in the glans, slightly narrowed at the termination of the fossa navicularis, and then is nearly uniform in size through the spongy portion, again enlarges at the bulb, etc. Dr. Weir, in the course of his remarks, referred to cases in which there were evidences of Stricture during life, but no evi- dences were found by microscopical examination after death. Dr. Bumstead remarked that there were many questions in connection with the subject under discussion upon which he wished to have further light and more experience before venturing an opinion upon particular points. The truth in the case has probably not yet been found. But with reference to gleet and organic Stricture the doctor expressed a doubt whether the former invariably depend upon the latter. He was not able to see any reason why we should not look for causes of a gleety discharge in a granular condition of the mucous membrane, hyperaemia at certain points, such as are seen in chronic conjunctivitis or inflammation of other mu- cous membranes. With reference to the use of the urethra-metre, Dr. Bum- stead regarded the feeling of fulness alluded to as a somewhat uncertain index, for it depends very much upon the sensibility of the patient and also very much upon the care exercised by the surgeon. Dr. Bumstead agreed with Dr. Otis, and ac- cepted the measurement of the central portion of the spongy portion, it being the least distensible, as the fairest index of the size of the urethra. How far that measurement corresponds to the size of the penis, he was not prepared to say, although from the limited number of examinations he had made, they had so far corresponded that he was willing to accept the statements made by Dr. Otis on this point. With regard to the size of the meatus, Dr. Bumstead dif- 196 DISCUSSION CONTINUED. fered with Dr. Sands, who regards it a rough test to the cali- bre of the urethra, and considers the freaks of nature in this direction, quite as constant as with regard to the length of the penis. We should never be tempted to take the size of the meatus as the index of the calibre of the urethral canal. He was of the opinion that, as a general rule, the meatus is smaller than the calibre of the urethral canal itself, and does not hesitate to divide it, either for purposes of dilatation or for the purpose of passing instruments other than dilators. With regard to internal urethrotomy for the cure of urethral Stricture, as compared with dilatation, his experience had differed from that of Dr. Sands, and he did not regard dilata- tion as the best means to be employed. It is well known how unsuccessful the treatment by dilatation has been, for Strictures subjected to dilatation have recurred time and time again, and that was the rule and not the exception. He had obtained much better results by internal urethrotomy, than by dilatation or by rupture. Some years ago Dr. Bumstead was in the habit of treating urethral Strictures by the use of Holt's divulsor, but latterly he has discarded this method of treatment almost entirely. For the treatment of Stricture in the anterior portion of the urethra, internal urethrotomy is rarely productive of harm, and has a great superiority over ordinary dilatation. He, had also found that internal ure- throtomy, when carried to a considerable extent has, in his hands, been productive of better results than when carried to a lower degree. Reference was made to several cases which had been cut so as to receive 26 French scale, and in the course of six months had so contracted as only to admit 14 or 15 of the same scale. These cases, cut a second time up to the same point, contracted a second time, and so on ; so that during the last two or three years it has been his custom to cut up to 35 and 40 French, and the tendency to contraction has been much less than before. The same may be said with regard to the habitual use of very large sounds. With reference to the statement made by Dr. Sands that instruments larger than 25 mm. were rarely necessary for pur- DR. GEO. A. PETERS' VIEWS. 197 poses of treatment or diagnosis, he did not believe it could be carried out in practice. He was of the opinion that sounds larger than 25 mm. were constantly required in practice, and he should not feel satisfied if he restricted himself to that size. With regard to slitting up the meatus, he was of the be- lief that it was done altogether too much, as well as cutting the urethra elsewhere, especially by the inexperienced. But he had seen no ill results from slitting the meatus, and did not hesitate to resort to the operation if necessary to effect the passage of an instrument. " I will say," adds Dr. Bum- stead, " as I commenced, that the truth with regard to this matter under discussion is yet to be arrived at. The subject requires further investigation before we express a full and decided opinion as to exactly how far dilatation of the ure- thral canal should be carried." Dr. George A. Peters, commenting upon the cases in which he had assisted Dr. Otis in making the measurements, remarked that he was surprised at the uniform correspondence between the actual measurement of the urethra and that called for by the circumferential measurement of the penis, the variation not being more than 1 or 2 mm. When using the urethra-metre he does not depend upon the sensations of the patient with reference to the distance to which the blades can be separated, but trusts to his own sense, and gives them sufficient separation, so that the instrument is barely grasped by the urethra without distending it unduly. At the meatus the instrument must be reduced in size two or more millime- tres before it can make its exit, if it has moderately distended the canal before reaching that point. With reference to slitting the meatus urinarius, he has had no trouble or fear in resorting to the operation, and has found it very essential for the purpose of perfecting the treat- ment of Stricture, and sometimes for the absolute diagnosis. He has failed sometimes in affording any relief when the meatus has been slit for the cure of what was supposed to be reflex trouble, but has never seen any actual harm arise from the procedure. 198 DISCUSSION CONTINUED. With reference to the use of instruments, the doctor re- marked that he had carried them up to 35, sometimes 40, and was confident that he had obtained more permanent benefit than when they were carried only to 25 or lower. With reference to the question of internal urethrotomy he agreed with Dr. Bumstead in the statement that it was to be relied upon for the treatment of Stricture of the urethra rather than dilatation or rupture. Dr. Keyes remarked that the fact that the urethra can be distended to very great dimensions has been known for a long time, but that this fact has any practical importance has not been shown. So also the urethra will permit of extensive cuttings ; but these, together with excessive dilatations, have fallen into disuse, thus showing that the profession has declared itself against extreme measures in these directions. That the rectum can be dilated sufficiently to admit a man's hand, and the female urethra so dilated as to readily admit the index finger, does not necessarily make it the most judicious method of obtaining admission through these open- ings. Why any difference should be made respecting the male urethra he was not able to understand. That the measurements vary very greatly has been shown by the figures of every observer, and these variations which have been found in the calibre of the urethra, are enough to disprove the value of any instrument for its measurement beyond certain rea- sonably high limits. If anybody could establish the absolute calibre of this canal it would be valuable, but it seems difficult to obtain such a standard. In the treatment of gleet by dilatation the doctor recom- mended that instruments below rather than above 30 mm. in circumference should be used, and stopped when the symp- toms disappear. Dr. Keyes remarked that he had not used a sound for this purpose above the size of 36, and that size was used only once, and in a patient who had an exceptionally large urethra and penis. The symptoms of gleet cease almost always after the use of instruments below 30. In the DR. KEYES' VIEWS. I99 anterior portion of the urethra internal urethrotomy is better than dilatation in the treatment of Stricture. In the deeper portions of the urethra Stricture does not yield to internal urethrotomy so readily. Traumatic linear Strictures are best treated by external section. And so it is ; no fixed rules can be given with refer- ence to the treatment of Stricture, but every case must be studied by itself. To establish measurements, therefore, upon fixed standards which shall decide delicate questions with reference to operative interference or general treatment are apt to do more harm than good. The discussion closed with the remarks of Dr. Keyes.* Following are the tabulated measurements of 100 sup- posed normal urethrae referred to during the previous dis- cussion. * Dr. Keyes was associated with Prof. Wm. H. Van Buren in the preparation of their valuable work on Genito-Urinary Diseases with Syphilis, published by Appleton & Co., 1874, but little more than a year previous to this discussion. By reference to page 28 of that work (and to page 83, of this) it will be seen that Messrs. Van Buren and Keyes state emphatically that " a fair average well formed urethra measures about three-eighths of an inch in diameter (i. e. 30mm. circum- ference). This estimate, (much greater than any before published, except by myself) was based either upon the published results of my observations or upon measure- ments with the imperfect means in use before my invention of the Urethra-metre. It varied only Ij$q mm. in circumference (less than ^fa diameter) from the results of my actual measurements made with the most perfect mechanical accu- racy, as published in March ] 875, and quoted on page 178 and on page 72,1874. Why the use of instruments, in the treatment of gleet by dilatation, Mow, 30 mm. (previously claimed by him to be the average size of the well formed urethra) should be recommended was not explained. The suggested reductio ad absurdum (in Dr. K.'s opening remarks), by com- parison of simple measurements of the male urethra with introduction of the hand into the rectum, or the finger into the female bladder, lost its point when it was considered that mechanical measurements, without force, and with mathematical accuracy of results, alone had been claimed—with which procedure the forcible rupture of the sphincter ani or sphincter vesicae, referred to, had nothing in com- mon. A painstaking experience with a good urethra-metre, say in 40 or 50 cases, will not fail to convince any surgeon of the absolute accuracy of the results claimed for this instrument. In comparison with these results it will also be seen that all deductions from previous estimates and measurements, by other methods, are wholly unreliable. 200 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. m v 1 I-O Measurements with ~ c .2 6 "1". 0 a O.o el SO3 •0 c at 3 0 °~ S 0 rt 0 C 0 2 0^ JO. Measurements with Urethrametre. E.S .£« c S 10 29 40 13 14 15 16 17 74 39 40 4i 50 56 No Gon. No mastur- bation. * No Gon. No mastur- bation. No Gon. No Gon. No Gon. No mastur- bation. * No Gon. No mastur- bation. No Gon. No mastur- bation. No Gon. Masturba- tion. Urinates every 2 hrs. and twice at night. Very long prepuce. Cystitis. Occasional semi, emis- sions. Urinates at night and often dur- ing day. Urethra very sen- sitive. Urinates once at nisht. Not ex- amined. do. e ula reed Not ex- amined. not en- larged. small and soft. Not ex- amined. 2 inches lat. mea- sure- ment. not en- larged. 5i 5* 4i 3! 3f= 3i = .,8- 3f- 3:0 3i= 3i= 36 36 34 36 34 32 30 At Bulb = At3£= From 3^ to Meatus Meatus = 22i 36 + 35 [=34l At Bulb= 36! At 3i= 35 From 3 J to 2=35 at 2 in. 34 det. band From 2 ) __ to Meatus ) ~ 35 Meatus=25 At Bubb^ 36 At 3^=34 for 1 inch From 2\ \ _ to Meatus j ~ 33 Meatus=i5 ATB^lb^ 38^ At 3i= 35i From 3J 1 _ , to Meatus J — ■"* Meatus= 25A S-.S "0 500: ^3 At Bulb=36 From 3 in. ) _ to Meatus ) — \reatus=33 34 At Bulb= 35 At 3i= 34 From 3|- to 2 = 34 at 2= 30 Stricture From 2 to |= 34 At £= 28 Meatus = 30 At Bulb= 34 to 2 incbes= 34 From 2 | _ to Meatus [ — 33 Meatus= 15 At Bulb= 31 to 2|= 31 F'rom i\ to 1 = 28 at 1= 27 Stricture From I I g to Meatus ) us=i5 1 to 9 °-p M re -• 202 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. a rt u rt (X, w. o o z bf < S3 . O CS g Si! Is £ o5 O o • B £« Ecu ■s'i Sen 2'Fi hi>.<2« B C O i) OJ — UCL, Measurements with Urethrametre. E.S 3S Sid 1836 19 49 60 No Gon. No mastur bation. No Gon. 67 23 59 30 No Gon. Urinates 1 at night. Urinates at night No Gon. 24 25 37 25 No Gon. Urinates I to 4 times at night. Congenl. Phymosis Not ex- mained. Small. Not over one inch lateral. 5f No Gen. No Gon. No mastur- bation. No Gon. Masturba- tion. Urinates Lateral 2 to 3 times meas. i\ at night. inches. Large. Lateral measure- ment 2\ inches. 3i= 34 3f= 4f 5 3*= 5i Urinates once at night. do. Urinates 4 to 5 times at night. Lateral meas. i\ inches. Lateral meas. ri inch 3i- 36 29 37 At Bulb to 2^=36 From 2\ to £=35 From \ ) _ to Meatus ) — 2? Meatus =27 At Bulb to 3^=37 From 2i I _ fi to Meatus) — 3 Meatus =33 At Bulb to 21=31 From 2J ) _ to Meatus [ — 3° Meatus =24 At Bulb } to 3 inches f J From 3 to 1^=36 From i£ to £=34 Meatus =29 31= 3i= 3i= 37 37 32 At Bulb to 3 =39 From 3 / _ 1 to Meatus ) —37^ Meatus =-5 74 3 to At Bulb to 3^=41 From 3| J _ to Meatus j ~39 Meatus =33^ At Bulb to 3 =33 From 3 ) _ 1 to Meatus j — 3I^ Meatus = 2oA 32 At Bulb to 2^=32 From i\ ) _ to Meatus J —3I Meatus =21 ri 3 to 5 13 NORMAL URETHRAL CALIBRE. 203 MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. 20 4C 27 28 2g 3<- 3i 3- 33 24 28 39 50 34 16 27 34 4 L .5" S-B ^ o S.S . X I o S i * P- O I- I<0 No Gon. No mastur- bation. No Gon. No Gon. No mastur bat ion. No Gon. No mastur bation. No Gon No mastur- bation. No Gon No mastur- bation No Gon. Masturba- tion from 10 years old. No Gon. Masturba- tion from 9 to 14. No Gon. Masturba- tion from 8 to 21. Urinates 3 to 4 times at night and 4 times daily. Urinates 4 times daily, not at nighi Emissions 2 or 3 even 2 weeks. Trouble- ome erect- tions night' Some drib- bling. Urinates 1 to 3 times at night. Urinates I to 2 times at night ; 6 times daily. Urinates twice at night. Some drib blinsj. Urinates twice at night. not en- larged. not en- larged. Enlarge (double). Lateral meas. 2 inches. Lateral meas. 2 inches. 5i 4* 5* 3i= 3i= 3 = 3i= 3i= 3|= 3i= 3i= 32 34 30 32 34 34 35 32 At 2j = 3i$ From "2.\ to Meatus Meatus At Bulb to 3^ = 354 At 3^ =34" Meatus =22 At Bulb to 2^=33 Strict | =33 = 13 At Bulb to 1^=32 From \\ to ,^=30 Meatus =22 -31 At Bulb to 3^=32 From 3i [ _. to Meatus) Meatus =25^- \7BuIbto2f = 35 From l\ { _ to Meatus ) j4 Meatus =25 At Bulb to 3^ = 38 From 3i ) _,« to Meatus j J*t Meatus =25 :30 At Bulb = 34s Stricture at 4^ From 3 in. j__ to 1 , _° Meatus =26 AtOBulb to 3 =33i From 3 to Meat Meatus 3 [ = itus ) 33 At Bulb to At3i From 3J to Meatus Meatus 3i = 32 = 28 I =32 = 19 14 15 16 17 18 19 3 to 5 204 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. CD c Oh O Z bf < < F, 2 " 3 life Ph B a B - 35 36 37 39 40 4* 42 46 31 45 33 55 39 30 No Gon. No mastur- bation. No Gon. Masturba- tion every day, 11 to 14 No Gon. No mastur- bation. No Gon. No mastur- bation. No Gon. No mastur- bation. No Gon. No Gon. No Gon. Urinates once at night. No drib- bling. Frequent nocturnal emissions. No drib- bling. Urinates once at night. Urinates 3 times at night. Urinates at night; 4 times daily Not ex amined. Not en- larged. 51 3i= 5f- 41+ 3i= 3i= 3|= 3i= 3i= 29 3i 34 At Bulb to2f=32 At 2f =26 From 2§ 32 32 36 34 34 At Bulb to 3^=37 From 2,\ \ fil to Meatus j * Meatus =16 to Meatus f Meatus =29 ■}=' At Bulb to 3 =33 At 2\ =30 From 2\ to 1 = 32 Meatus =20 At Bulb to 2 J From 2 to Meatus Meatus =32 > 2$=34i j =34| \t Bulb to 3^=32- From 3i f _ to Meatus ) ^ Meatus =30 At Bulb to 2^=38 From 2" to Meatus Meatus -4 — } = 34f 4 At Bulb to 2^=35- Froin 2| to 1 = 33 lo Meatus =31 Meatus =22 4-At Bulb tO 2f For I to Meatus Meatus |=3, = 36 = 34 = 24 + 23 24 1 to 3 26 27 NORMAL URETHRAL CALIBRE. 205 MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. a a. >*. 0 n bi < E £ Is 0 en •< a •2d '■5* B m 0 a oj eg »3 oh PL, •a c d 3 v 0 u ft. ?3 . 0 « c 0 ^ El •c'a '<- <" tu "° ~Z E u3 Measurements with Urethrametre. V rt u - 43 21 No Gon. 5i 3i+ 34 36 33 32 36 36 32 32 At Bulb to 3^=371 From 3^- > __ to Meatus ) ~33 Meatus =24 28 44 41 3? 46 si- 3f-3f= At Bulb to 3 =38 From 3 t -,6i co Meatus) ~->u? Meatus =26 2C? era. .0 1 S» O CL 45 No Gon. si At Bulb to 3^ = 34 From 3^ ) _ to Meatus j ~~ ^3 Meatus =21 30 46 No Gon. 5 3i= 3|= At Bulb to 3 =36 From 3 / _ 1 to Meatus, — 34a Meatus =24 31 47 46 No Gon. 5i At Bulb to 3 =38 F'rom 3 ) to Meatus ) — ^7 Meatus =33^ 32 3 to 5 48 29 No Gon. 5i 3|= At Bulb to 3 =36^ From 3 ) _ to Meatus j — ^5 Meatus =27 49 34 42 No Gon. 5i 3i= At Bulb to 3^=37 From 3 J to 3 =34 At 3 = 30 Stricture. From 3 to 2=34 At 2 = 30 Stricture. Meatus =18 34 50 No Gon. 4f 3i= At Bulb to 3-| = 33 From 3\ i to Meatus ) J Meatus =27 J.R. VV. 35 3 to 5 206 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. _ 1 a' .So |* 0 a SO3 OhL, 13 B O 0 d ~3 . L il ■o'e £0 o3 Measurements with Urethrametre. o en ca u o 6 •> Meatus =31 38 3 to 5 54 No Gon. 5i 3i= At Bulb to 3 =37 From 3 > _ to Meatus ) ~3I Meatus =27 3 to 5 55 No Gon. 5i 3i= At Bulb to 3 =33 From 3 > __ to Meatus) — 31 Meatus =18 39 56 No Gon. No mastur-bation. Urinates twice at night. Ure-thra very sensitive. 5i 3f= At Bulb to 3^=34 From 3^ ) _ to Meatus j J*f Meatus =26 jn en ™3 <* =2,0 03" •""-d 0'? 57 30 69 No Gon. Urinates every 2 hrs. and once or twice at night 5i 3i= At Bulb to 2f=34 From 2f ) _ to Meatus) ~^2 Meatus =32 41 5« No Gon. Lateral measure-ment l| inches. 4f 3i= At Bulb to 3^=34 From 3J ) _ to Meatus j JJ Meatus =32 42 1 to 3 59 40 No Gon. Frequent seminal emissions. 5i 3i= At Bulb = From bulb ) _ to Meatus ) Meatus = 36 36 30 + re a P T3 O — a. p 0 re p NORMAL URETHRAL CALTBRE. 207 MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. 1 a .• •0 t 0 2 O SI < a B of 0 a Oo V, 3 opt, >-. Ph •a e « 3 O Length of Flaccid Penis from Meatus to B. M. Junction. In inches. 0 ^ d 0 o-c a 0 ,o a s'Z S B u O U £ 0 ■o'e -_ 0 -'i 0 3 Measurements with Urethrametre. 1 V en B U O 6 Z 0 0 be < 0 en E.S ai 3 0 a _-a d U . OS 11 O w. 60 41 38 41 * Urinates 2 to 3 times at night. 5i 3t= 33 33 At Bulb to 3i=34 From 3£ ) _ to Meatus\ JJ Meatus =20 3 O. o-3 -U O n s ° 61 No Gon. Masturba-tion daily from 15 yrs. old for 6 years. Urinates 2 to 3 times at night. Si 3f = At Bulbto2i = At 2i From i\ ) _ to Meatus ) — ■ Meatus =: 33 30 33 25 S3 -8 0 8 Si 4 5 5 45 62 No Gon. Masturba-tion from 18 to pres-ent time. Urethra very sensi-tive. 4i 3 = 3f= 30 36 40 At Bulb to 3 =: At 3 =1 From 3 )___ to Meatus f Meatus =2 46 i to 3 63 65 40 No Gon. 4f At Bulb to 3^=' At 3J =; From 3i ) _ to Meatus ) — -Meatus = 2 n 3 0 ps "a 3 p-5' re ->o o o . a j a S£ a a o Efc Measurements with Urethrametre. i^J3 a E.S loE L-a ed P cd cdj3 So 69 70 71 72 73 74 75 53 49 36 48 41 4s r9 No Gon. Masturba- tion every day for 5 or 6 years. No Gon. Urinates 2 to 3 times at night. No Gon. No Gon. No Gon. No Gon. Urinates once at night. No Gon. Penis firm No Gon. Penis firm 4i 3i 5i 5- 41 5i 3f= .1__ r4 — 2? 3i = 2?- 3 = 3i = 3 + a in 3_ 5- 32 36 30 30 32 34 30 34 At Bulb to 3 =33^ From 3 to 2^=32 At 2i=disti'ct band Meatus =25 At Bulb to 1^=40 At ij =35i to Meatus =38 Meatus =29 At Bulb to 3 =34 From 3 ) __ to Meatus \ ~ 9 Meatus =25 At Bulb to 2^=32: Point of arrest. From 2\ \ to Meatus) J Meatus =3! At Bulb to 2^=36= Point of arrest. From 2\ ) _ to Meatus j ~~ 34 Meatus =34 5i 52 53 3 to 5 3 5 a* re ^ 2.M-. • 2. T3ai re 3' re re > -1 - JiS * a-re At Bulb to 2|=35| =Point of arrest. From 2| ) _ to Meatus ) — ^4 Meatus =29 At Bulb to 2^=36= Point of arrest. From 2\ | to Meatus J. JJ Meatus =24 At Bulb to 3 =36 = Point of arrest. From 3 | _ to Meatus) ~34+ Meatus =284 55 3 to 5 56 57 NORMAL URETHRAL CALIBRE. 20Q MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. o en a o <4 o Uh Ph O <— Z br < < ■c « £ ?lacc Meat ction. o m-1) o E^' ength of enis from to B. M. Jun In inche c a 'J Measurements with Urethrametre. rt . oE a.s _-a E.S ed Q 5f = 36 5. ft« 3 --re w re % 3 0 re At Bulb to 3 =35 = Point of arrest. At 3 =30 From 3 }_ to Meatus j Meatus =25i :32 * r =35i tus ) JDa At Bulb to 3f=42 = Point of arrest. From 3| to Meat Meatus 4-At Bulb [°3i From 3i to 2 =3S \t 2 =36 At 1 =33 Meatus =22 62 3 to 5 f = 39 210 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. o B o a l*H Ph o ** z bo < a = < ^a 21 a a _ 3-a * E ° -J re 3. 3^ = 31 95 24 No Gon. Frequent 5 At Bulb to 3 =33 seminal For i inch =29 74 emissions. To Meatus =32 27 Meatus =23i 75 96 Gon. 5 yrs. 5 3i= 31 At Bulb to 3i=33 ago. From 3i ) _ to Meatus) J Meatus =22i s 0 3 » Relative proportion corresponds a re within two Milimetres in 76 cases. CLvO 53 r1 »-■ hS ID 97 No Gon. 5 3f = 31 At Bulb =32 from bulb ) _ to Meatus ) J ?S Meatus =26 re 98 53 Gon. 3 yrs. ago. 5 3i= 32 At Bulb 1 to 3 inches) At 3 inches =30 For i inch =30 At 2i =34 From 2i ) 2 0 Meatus ) Meatus =32 Measuren lents in this case confi rmed on the' dead subject by Frof. Stephe a Smith a nd Prof A. J aco bi. 212 NORMAL URETHRAL CALIBRE. MEASUREMENTS OF THE NORMAL MALE URETHRA IN 100 CASES. a .2 cd Ph <*-o a be < Antecedent History. Present Condition. Functions, etc. Prostate Gland. Length of Flaccid Penis from Meatus to B. M. Junction. In inches. L ° en 1 0 0 O-B a 0 a a E en Is 0* ■o'a V 0 731 Measurements with Urethrametre. o cd a o 6 Z Dis. from Mea-tus in inches. 0 a ~-a cd ed 73 .a 2o 99 32 No Gon. 3i= 34 At Uulb ) to Meatus ) -'■^ Meatus =33 1 to 3 o o 38 No Gon. 5 3i= 34 At Bulb t _ to 3J in. ) ~37 From 3\ to 1=34 At 1 =30 Meatus =34 3' re — 3 0 =."" a ? BX3, -; re JJi ■3a Patient then admitted " kick " on penis 3 or 4 years previous. In making these examinations it was found that in almost every instance, there were 2, 3 and 4 distinct ridges at or near the peno-scrotal angle, i. e., from one to two inches anterior to the junction of the bulbous with the membranous urethra. These were at a point where the mucous membrane would naturally fall into transverse folds, in the pendent position of the penis. The occurrence of an erection during examination, in one instance, confirmed this idea, inasmuch as the absence of the ridges was demonstrated with the urethra-metre at 36. But the subsequent examination of the same organ in flaccid condition with the ure- thra-metre again at 36, three bands were distinctly recognized. These folds then, would form inviting recesses for the lodgment of the solid constituents of the urine during an acid or an alkaline dyscrasia. Prolonged or repeated irritations from such cause, would naturally produce thickenings in these folds, soon inter- fering with their resiliency, so that they could no longer be obliterated on the natural distensions of the canal; more or less obstruction to urination necessarily results ; in other words, a point of irritation has been established, a urethral con- traction commenced, which, although not perhaps sufficient to attract attention, per se, yet on the establishment of a gonorrhcea, would be quite sufficient to in- crease the virulence of the disease, and finally to keep up the urethral discharge indefinitely. In confirmation of this view of the formation of non-specific Stricture at the peno-scrotal angle, I exhibited to the Society, upon the occasion of the reading of my reply to Dr. Sands's paper, a lad of nineteen years, who gave posi- tive assurance of never having had gonorrhcea. He was first conscious of urinary difficulty at the age of seven ; but beyond frequency of micturition, did not re- member any trouble until about three years since, when he began to suffer more or less pain during and after micturition, and which was referred solely to the body of the penis. He presented at my college clinic about a month previous. Examination resulted in the discovery of a vesical calculus measuring i£ inches in NORMAL URETHRAL CALIBRE. 213 its long, and £ of an inch in its short diameter. The lithotrite (No. 22 F.), in passing through the urethra was slightly held at about three inches, and then slid easily into the bladder ; the stone was readily seized and crushed. On withdrawing the instrument, a small quantity of the debris held between its jaws, resulted in a little greater distension of the urethra than in its entrance, and arriving at the point before mentioned, and which had been the seat of the pain on urination, it was sharply and firmly arrested, and quite a little force was required for the ex- traction of the instrument. This Stricture (which I demonstrated with the bulbous sound No. 26) must be admitted, as confirmatory of the occurrence of Stricture with- out precedent gonorrhcea, and from the fact that he had stone in the bladder, the antecedent lithiasis, in connection with the folds of urethral mucous membrane just alluded to, affords an apparently satisfactory explanation of the method by which the Stricture was formed in this case, which may be accepted as typical of a large class. CHAPTER IX. RETROSPECT. SOON after the foregoing discussion in New York, viz. on March 16th, 1876, Mr. Berkeley Hill, Professor of Clinical Surgery in University College of London (as well as a repre- sentative writer on Diseases of the Genito-urinary organs), de- voted a lecture to the consideration of my views and operations as they had come to be understood after the lapse of nearly a year from my personal enunciation and demonstration of them in that college. This lecture was subsequently pub- lished in the London Lancet, in the issue of April 8th, 1876. In order to show the status of urethral science in Great Britain at the time of my visit (as is done on page 215) and to illustrate misunderstandings of my views which may have obtained elsewhere I reproduce this Lecture in full, as well as my " Explanatory Remarks," in reply, which, with a good sense of " English fair play," were promptly published by the editor of the Lancet, in the issues of June 3d and June 10th, 1876. A Clinical Lecture on the Treatment of Incipient Stricture, by Otis's operation, delivered at University College Hospital, London, Eng., March 16th, 1876, by Berkeley Hill, Pro- fessor of Clinical Surgery in University College. Gentlemen:—In a lecture which I had the honor of de- livering before you more than a year ago,* I endeavored to describe and classify the various causes of the scanty urethral discharge known by the term " gleet." I pointed out that, * Reported in The London Lancet, of Feb. 13, 1875. DISCUSSION OF DR. OTIS'S VIEWS. 215 produced by affections of very different nature and in differ- ent parts of the urethra, these discharges required very dis- tinct kinds of treatment for their cure. I still adhere to that opinion—one common to most who study urinary disorders. Last July, you recollect, Dr. Fessenden N. Otis, a distin- guished surgeon of New York, demonstrated in our operating theatre his mode of curing gleets and Stricture of the urethra, in a lecture remarkable for its clearness and for the skill with which his manipulations were performed. In that exposition Dr. Otis enunciated views which vary considerably from, and indeed are opposite to, the doctrines usually taught in this country. I propose to-day to examine what we were told on that occasion with the light that some experience we have been able to gain in our own hospital has thrown upon it. In doing this I would not have you suppose that there was little to be learned from our American confrere; on the contrary, I am satisfied that much of what he told us is per- fectly true, and a real contribution to our knowledge of ure- thral affections. The chief points of Dr. Otis's demonstrations were : 1. The human urethra varies much in its calibre in differ- ent persons. Hence an instrument that is a full size for one man may be either much too great or too small for another. 2. The urethra is really much wider than is generally taught. 3. The meatus urinarius is normally as wide as the rest of the canal. 4. The gleet is always due to Stricture. It is " the signal that nature hangs out to call attention to the fact that Strict- ure exists somewhere." 5. In the term Stricture Dr. Otis includes those early in- durations which have not sufficiently advanced to interfere with the passage of urine or to produce any symptom beyond a discharge. But he maintains them to be really bands of contractile tissue fibre produced by inflammatory action. 6. Stricture is most frequent in the first inch from the 2l6 MR. HILL'S DISCUSSION meatus, and is less frequent as the distance from the entry increases. 7. Complete division of a Stricture and maintenance of the incised part at its natural width until the incision is thor- oughly healed prevents return of the contraction, and, more- over, causes absorption of the indurated tissue from the affected part. I propose to examine the novelties, one by one. That the urethra should vary in calibre in different persons, considering that the penis also varies greatly, might well be presumed a priori; and Dr. Otis has most satisfacto- rily demonstrated that it does so. But I trust you have not forgotten the description of the urethra given by Sir Henry Thompson in his lectures to you before Christmas. He there showed how the urethra is not a tube at all except while some body is passing along it, and defined it to be a closed valvular chink, capable of distension to a different amount in different parts of its length. It will be well to bear this in mind, and also that for our purpose to-day we are concerned only with the spongy portion of the urethra. Books on anatomy tell us that the bulbous portion is somewhat wider than the rest, having a circumference of seven-tenths of an inch, and that the remaining part is one or two-tenths less in circumference; further, that the meatus does not exceed one-quarter of an inch in width. These measurements are doubtless taken from the dead body, and if we conclude that they represent the dimensions of the living urethra, we shall be in error. The practical importance of ascertaining what is the usual extent to which the " valvu- lar chink " is dilated during micturition is this ; diminution of capacity in the urethra means impediment to the flow of the urine from the bladder. If the balance between the natural expulsive force of the bladder and the friction of the stream along the urethra is disturbed, the bladder is irritated, the kidneys are affected, and the beginning of the long chain of events, which terminate not infrequently in death, is made. To know if a man has Stricture, we must first know what the OF DR. OTIS'S VIEWS. 217 natural distensile power of his urethra is, and to ascertain this, Dr. Otis discards any arbitrary standard, which, you know, is set at about No. 12 of the English scale, but meas- ures each urethra before he proceeds to operate upon it. For this purpose he has invented a most ingenious instrument which he calls the " urethra-metre." It consists of a slender cannula marked in inches, at the end of which a set of steel springs can be expanded into a bulb by advancing a stem with- in the cannula. This movement is obtained by turning a screw at the handle, and the amount of expansion is recorded by an index on a dial-plate. When screwed close the instrument is not larger than a No. 6 English sound—that is a circum- ference of less than half an inch. It can be expanded to a maximum circumference of an inch and three-quarters—two and a half times the seven-tenths of an inch which your anato- mical guides tell you is the circumference of the widest part of the spongy portion. To measure the urethra the expanding sound, covered by a thin india-rubber sheath (c, Fig. 1), is introduced in its contracted form as far as the bulb, between five and six inches. It is then screwed up until the patient announces he has a sense of fulness, but not so tightly that the instrument cannot be moved without being grasped by the passage. This gives the size of the canal at the bulbous part. The urethra-metre is gently withdrawn, the expanding part being enlarged or diminished as tight places or slack ones are passed, and the several dimensions are noted by ob- serving the index, and the distance of the expanding part from the meatus. Any diminution from the widest measure- ment Dr. Otis holds to be a Stricture, and abnormal. For the further examination of these contracted areas, Dr. Otis employs a series of bulbous sounds ranging from about No. 4 English catheter to one much greater than any size in our scale. But before describing them I must remind you that Dr. Otis, like nearly all who work at urethral affections, has discarded the English scale, one entirely arbitrary, ascending from the smaller to the higher numbers by wide grades of unequal length. He chooses the French scale, which is per- 218 MR. HILL'S DISCUSSION fectly scientific. It takes the millimetre for its unit, and the number of the instrument denotes its circumference in milli- metres. Thus No. I French is one millimetre in circumfer- ence ; No 20, twenty millimetres ; and so on. Compared with these, No. 1 English is equal to No. 3 French, and No, 11 English to No. 20 French. Here is a gauge Mayer and Meltzer have made for me, with forty sizes cut in the plate. The plate is marked on one side with the French numerals, and also graduated with a decimetre divided into centimetres and millimetres. On the other side the English numerals are marked opposite their respective sizes, and there is also a scale of six inches, divided into sixteenths of an inch. Thus the catheter-gauge forms a ready means of comparing French with English measures. Dr. Otis's series of bulbous sounds are spread out before you. They have a slender stem of about four millimetres screwed into the wider end of a bulb or bullet. The best shape for the bulb is that of a turkey's egg, which you know is a little more pointed at the small end than the egg of a common hen. The bulbs range in size from No. 8 to No. 40. Their number corresponds to the big end. With these instruments Dr. Otis has measured over 500 urethrae, from which he tells us that the expanding capacity of the urethra bears a constant ratio to the circumference of the penis below the glans. Hence if you measure the outside of the penis you can foretell the size of the urethra. Further, that the average size is between thirty-one and thirty-two millimetres, or an inch and a quarter—that is more than half as large again as the measurement hitherto accepted. From these observations also, Dr. Otis finds that the meatus, when not congenitally narrowed or contracted by balanitis in boy- hood, a frequent occurrence, is as wide as the rest of the ure- thra. I have not measured a number of urethrae approaching to 500, but I will give you the results of my measurements so far as they go. Since last spring I have measured ninety-five urethrae (all of them in subjects of urinary disease, by the OF DR. OTIS'S VIEWS. 2ig way), and in only three did I find the meatus as wide as the rest of the canal. One of the three exceptions was that of a man who never had gonorrhcea, but an exceedingly narrow traumatic Stricture of the bulbo-membranous part. In him No. 32 sound slid easily down to the Stricture by its own weight. This would show that the meatus may be either normally narrower than the rest of the canal, or that morbid contraction is exceedingly common. Be that as it may, practically we have generally to deal with a narrow meatus, the average size being twenty-two millimetres. The meas- urement of these ninety-five urethrae, has satisfied me that we have under-estimated the size of the urethra, and that Dr. Otis is correct in claiming larger calibres for that canal. But I have not found the bore, so to speak—the capacity for distension, in more accurate diction—to be uniform from the bulb to the meatus. At the bulbous part the urethra is wid- est, and remains of even width for about two inches. It then narrows gradually, and for the rest of the passage is about three millimetres less, being most narrow at the outlet. This is, as you well know, in agreement with the description of anatomists, only that the distensile capacity of the urethra measured in the living body was greater than the limits they set down. Thus the spongy urethra is conical in shape, resembling the tapering nozzle of a syringe. Whether this be a provision of nature to make the escaping stream more forcible I know not, but you will recollect that the special raison dttre of this part of the urethra is to conduct, not the urine, but the semen. Of this I am persuaded, that the less calibre of the urethra at this point is natural, and not the result of inflammation, so long as it is gradual and not abrupt. Morbid narrowings are easily perceived by the sudden way in which they obstruct the bullet, and by the suddenness with which it is released when they are passed. Next, with regard to the invariable presence of a non- dilatable area of the urethra, a band of contracting fibres, that is, a Stricture of more or less development, in every case of gleet. I repeat that I still think that Stricture in any 220 MR. HILL'S DISCUSSION shape is not the sole cause of gleet, though doubtless this is the most frequent condition in such cases. With respect to Stricture being most frequent in the first inch and a quarter of the urethra, out of 258 Strictures, Dr. Otis found 115 within that distance of the meatus, and the remainder in decreasing frequency in each succeeding inch. This you know is contrary to the received doctrine, which places Stricture most frequently at the bulbo-membranous part. My experience does not support Dr. Otis's statement. In 1870 I recorded 63 Strictures, examined with bulbous sounds, at the Male Lock Hospital in 1869, when I found them 43 times between four and a half and six inches—a po- sition, allowing for variation in inches length of the passages in different persons, almost the same in all. Next, having ascertained the presence of some unnatural narrowing of the spongy urethra, does internal division cure it, and prevent its return or further development, and conse- quently cure the gleet ? If we adopt Dr. Otis's teaching, our course is simple. A patient applies for cure of a gleet. His gleet must be the consequence of Stricture ; cut com- pletely through it to the erectile tissue, so as to make the urethra a little wider than before, and take care to maintain this artificial patency while the incision is healing : the cure is then complete and permanent. This is the result of ope- rating in a large number of cases, a report of which has been published in several forms. In 100 published cases, 31 patients were found without recontraction when examined at a considerable period after operation ; 52 others were not examined, but reported themselves well; the remaining 17 were not quite cured, though relieved. Such evidence in- duced me to give a trial to this method. I may state that all the cases operated on here were those of long standing gleets with contraction in one or more parts of the spongy urethra, and had undergone multifarious treatment. The number of patients is sixteen ; fifteen of my own and one of Dr. Otis's—the case in which he operated in our theatre on the 6th of July last. In five cases the gleet stopped after the OF DR. OTIS'S VIEWS. 221 operation, and the patient was at the last report—taken in none less than three weeks, in most some months, after the operation—able to pass a bougie of the estimated size of the urethra. In short, they may be claimed as cures. But of these five the operation was serious to two; one had free bleeding for three days, the other three attacks of rigors. Of the remaining eleven, among whom Dr. Otis's own opera- tion must be included, the gleet persisted in all ; in several the urethra shrank again to its size before the operation, and in some very serious complications ensued. In four bleeding lasted several days, and in one was even alarming. Three patients had rigors ; in two the shivering was unimportant, being that which follows the first transit of urine along the incised urethra in certain individuals, but is not repeated or attended by further consequences. In the third patient the rigors preceded abscess in the buttock. One patient had orchitis. Thus in seven the operation might be termed a trifle, causing no pain nor any after-fever; but in five only was the operation successful. It maybe contended that want of practice on my part, or imperfect performance of the op- eration, were the causes of this small success. But I am pro- tected against this danger by having had the benefit of Dr. Otis's personal instructions, and by the fact that one of the least successful cases was that in which Dr. Otis operated himself. The man was in sound health with the exception of his gleet and contraction of the urethra at two and a half inches from the orifice. He made light of the operation, sub- mitting most patiently to the somewhat prolonged manipula- tions ; being animated by the patriotic resolve, as he after- wards told us, that " No Yankee should make him flinch." The patient bled copiously after the operation ; the haemor- rhage not stopping altogether for six days. No other compli- cation ensued, the man was able to get up as soon as the bleeding had stopped, and would have left the hospital at once if permitted. However, though he remained some weeks longer with us, and afterwards attended assiduously for the regular passage of the sound, his gleet persisted till 222 MR. HILL'S DISCUSSION Christmas, and was at last cured by other means. There still remains a scar or induration in the erectile tissue, which gives a crook to the organ during erection. Whether the division of the contracting band caused permanent absorption thereof in any of these patients I do not know, but have very little expectation that it did so. Certainly it failed of this effect in almost all. When telling you, as those who frequent my wards already know, that I have abandoned this operation for curing gleets accompanying slight contraction of the urethra, I should not omit to tell you that in one point I have varied from Dr. Otis's operation. His urethrotome, which I hold in my hand, is used as follows :—The instrument is passed along the ure- thra until the end is well beyond the Stricture. The instru- ment is then dilated until it stretches the urethra to its full capacity, or, to make sure, to one or two millimetres beyond that capacity. Next a small cutting edge, previously con- cealed, at the end of the dilating part, is drawn along the tightly-stretched tissue to the meatus. This long furrow is made in the mesial line in the roof of the urethra. Disliking o this long cut, which divides uncontracted parts, as well as the strictured parts, I have employed, except in one case, a Strict- ure incisor, which, while it stretches the urethra to the size previously determined, cuts only where it is strictured. Its mode of action I shall explain when speaking of the division of narrow Strictures. As the contracted areas are as freely divided by this plan of cutting, I cannot fairly charge it with the numerous failures that have attended Otis's plan of treat- ing wide Strictures. The plan of treating these affections to which I have re- turned is that which I adopted before—namely, the repeated passage of bougies, large enough to distend the Stricture, but not large enough to be tightly grasped. The size of the bou- gie is increased at each visit—that is, about twice a week—to keep pace with the increasing expansion of the urethra until the capacity of the uncontracted parts is reached, when the same size is continued by the patient himself for several weeks OF DR. OTIS'S VIEWS. 223 longer. When the meatus is greatly smaller than the rest of the passage, I cut it either by Otis's meatome, this straight probe-pointed bistoury, or by a bistouri cache, to which Coxeter has added a second shield, which can be separated from the first by a screw-pin, and so make the fibres tight be- fore they are divided. The incision is made in the floor, and must be pretty complete, as the little ring of fibres is very tough, and often needs two or three applications of the knife to divide it fairly. But do not misunderstand me. I do not mean that every gleet requires instrumentation forthwith as a matter of course ; on the contrary avoid the use of instruments whenever you have satisfactory evidence that the discharge is not of long standing. The exact length of time that indicates Stricture is uncertain, for the inflammatory induration constituting Stricture is formed very slowly in some persons, but com- paratively fast in others. As a general rule don't search the canal when the discharge has lasted only six months or less. Be sure, however, that the whole duration of the discharge is really contained in six months, and that there have not been previously periods of clap or gleet to which the present dis- charge is only a successor. Several relapses of gleet are very strong evidence of Stricture. Bear constantly in mind that the introduction of an instrument of any kind into the ure- thra is an evil, and though in time the canal gets accustomed to the foreign body, this, like many other faculties, is not acquired without discomfort or pain. Resort to instrumen- tation only when you are satisfied there is legitimate cause for it. Nevertheless when you do employ instruments to search for Stricture, use such as are adapted to the end in view ; and at our next meeting I will explain to you why I prefer bulbous sounds and bougies to those of equal thickness throughout. CHAPTER X. DISCUSSION CONTINUED. Explanatory Remarks by Dr. Otis, in Reply to Mr. Hill* AMONG the many valued professional courtesies extended to me during a brief stay in Great Britain last summer, none was more esteemed than that which proffered me the opportunity of fairly presenting to the medical profession in England my somewhat peculiar views in relation to some points in urethral surgery. Through the invitation of Mr. Berkeley Hill, Professor in the University College of London, and by the aid of the clinical material kindly placed at my disposal by him, I was enabled to do this, in a lecture at the University College, under circumstances every way favorable and agreeable to me. The recent vigorous yet friendly analysis of this lecture by Mr. Hill, together with a summary of fifteen cases of urethral Stricture, operated on by him according to my method, and reported in The Lancet of April 8th, is just re- ceived. I desire the privilege of correcting, through the same influential medium, some important misapprehensions of my views and methods of procedure, and also to answer some objections made on points of special interest to all concerned in the progress of urethral surgery. Mr. Hill has formulated my innovations upon the usually accepted views, as follows : " i. The human urethra varies much in its calibre in dif- ferent persons. " 2. The urethra is much wider than is usually taught. " 3. The meatus urinarius is normally as wide as the rest of the canal. * Originally published in the London Lancet of June 3d, and 10th, 1876. MR. HILL'S OBJECTIONS. 225 " 4. Gleet is always due to Stricture. " 5. In the term Stricture Dr. Otis includes those early indurations which have not sufficiently advanced to interfere with the passage of urine, or to produce any symptom be- yond a discharge. But he maintains them to be really bands of contractile tissue fibres, produced by inflammatory action. " 6. Stricture is most frequent in the first inch from the meatus, and is less frequent as the distance from the entry increases. " 7. Complete division of Stricture and maintenance of the incised part at its natural width until the incision is thor- oughly healed and prevents return of the contraction, and, moreover, causes absorption of the indurated tissue from the affected part." In the first place, let me pay a merited tribute to the ability, fairness, and kindliness with which Mr. Hill has con- sidered questions involving so radical a departure from the time-honored teachings of authorities. In regard to the first proposition, Mr. Hill frankly admits that " the urethra varies in calibre in different individuals. Considering," he fitly remarks, " that the penis also varies, this might be well presumed a priori." He thus rejects the assumption of a fixed standard, which he states is usually set at 12 of the English scale. This conclusion is arrived at after the careful measure- ment of ninety-five urethrae, and fully confirms my claim that no intelligent diagnosis of the number, calibre, or extent of Stricture, in any individual, can be made while the assump- tion of a fixed standard is admitted. In this connection Sir Henry Thompson is quoted as say- iiio- that " the urethra is not a tube at all except when some body is passing along it," and defines it to be a " closed valvular chink." I am unable to attach any importance to the objection that the urethra is not a tube because it is a closed tube when not distended. It might with more reason be objected that the chink, being an aperture or a crevice, when closed, ceases 15 226 THE AUTHOR'S REPLY TO to exist, and hence, notwithstanding its valvular attachment, would fail to convey any correct idea of the urethra. Mr. Hill, however, in a very masterly paragraph, has presented the practical aspect of the urethra, independently of appellatives, by showing the necessity of ascertaining to what extent a given urethra should be capable of being normally distended. He says : "If the balance between the natural expulsive force of the bladder and the friction along the urethra is disturbed, the bladder is irritated, the kidtieys are affected, and the begin- ning of the long chain of events, which terminate not unfre- quently in death, is made." (Page 216.) How, then, is this most important balance usually dis- turbed ? Not by that most patient of all asses, the bladder, habitually doing its work more quietly and with less consid- eration than any other organ of the body, but by the urethra— sensitive, easily and frequently irritated, inflamed from various causes, and finally strictured to a greater or less degree. This it is that " increases the friction and disturbs the balance." Hence it becomes a matter of first importance to ascertain, at as early a period as is possible, the normal calibre of every urethra in which symptoms of undue friction are present, in order to ascertain the amount of constriction which has oc- curred. Thus, the least appreciable encroachments become worthy of attention, and hence we have reason for including, under the term Stricture, " those early indurations which have not sufficiently advanced to interfere (markedly) with the passage of urine, or to produce any symptom beyond a discharge" (point 5th), and these are readily and with precis- ion made out by means of the urethra-metre and the bulbous sounds which Mr. Hill has illustrated and described. The assertion that " gleet is always due to Stricture " (point 4th) finds corroboration in the known facts, that con- striction always increases friction; that increased friction causes irritation ; and that continued irritation of mucous membrane, anywhere, often produces and always prolongs a mucous or muco-purulent discharge. This then is my defence for considering the slightest encroachments upon the normal MR. HILL'S OBJECTIONS. 227 urethral calibre worthy of consideration and treatment. I have stated it as my opinion that " gleet is always due to Stricture," yet I do not mean to be understood as claiming that division of Stricture always cures gleet. Inflammation of the eye, as a rule, always results upon the presence of a foreign body in it, and yet it is quite conceivable that the diseased action, originally set up by the presence of the for- eign body, may not be entirely removed by the removal of the first cause ; yet no one will deny that it is wise surgery, in every case (when it is possible), to remove the foreign body. Gleet may continue after the removal of its cause ; the in- flammatory action long continued, may have spread to the continuous mucous membrane of the urethral lacunae and sinuses, and persist in spite of the removal of Stricture (or of the use of other means) indefinitely: those are exceptional and sad cases, but do not seem to me to invalidate the claim that " as a rule gleet depends upon Stricture," or that Strict- ure when present, should be removed as the first and most rational mode of remedying the evil. Point 3d is an anatomical one. "The meatus urinarius is normally as wide as the rest of the canal." I would not be understood to mean by this that it is usually so, but that this is the highest normal type of meatus. In a paper published in the New York Medical Journal, April, 1874, on " Urethrotomy, External and Internal," I remarked of this correspondence that it " may be considered as the normal condition of these parts, and any variations from such uniformity may be considered aberrations from the normal condition. These (aberrations), however, are, as a rule, of no practical importance unless the tissue composing them has been previously invaded by inflammatory action." " As long as the meatus escapes inflammatory action it does not become a source of trouble on account of its diminutive proportions. Let inflammation be set up in this locality, as may occur from extension of an infantile or an adult balani- tis, or from gonorrhoea, or from any other cause, and a plas- tic exudation results, which, becoming organized, disables 228 THE AUTHOR'S REPLY TO the urethral muscular structure at this point, and it is no longer able to act efficiently in expelling the last drops of, urine ; they are retained, a dribbling results, and it is the un- varying sign that such an accident has occurred. We may have a meatus from the size of a mere pin-hole to the full size of the urethra behind it, and yet find no difficulty in any case. In a recent public examination of a hundred patients in Charity and Bellevue Hospitals, claimed to be free from inflammatory antecedents, the meatus In I was 13 mm. cir. In 17 were 25 n 3 were 15 11 3 " 25i i was 16 " 4 " 26 2 were 17 " 5 " 27 3 " 18 " 3 " 27i 3 " 19 " 2 " 28 i was J9i " 1 was 28i 3 were 20 " 5 were 29 2 " 20i u 3 " 30 2 " 21 " 3 " 31 5 " 22 tt 5 " 32 3 " 22i " 4 " 33 I was 23 " 2 " 33i I " 23i " 3 " 34 7 were 24 '' 1 was 37i i was 24i a Average size in one hundred cases, 24.72. In no case was the urethra, in the one hundred cases, be- low a calibre of 26 millimetres—ranging from this to 39—the average being 32-95. In none was any trouble complained of. None, then, can be strictly claimed to be abnormal as long as the functions of the part are well performed, and hence, in the presence of such great variations, it might be difficult to fix upon the highest normal type of the meatus urinarius. We do find, however, that various and grave dif- ficulties and diseases are occasionally associated with a geni- to-urinary apparatus where the meatus is not of the full'size of the urethra behind it, and that such difficulties are often promptly relieved by a surgical procedure which permanently enlarges the meatus to that size. The fact that such difficul- ties do not occur when the meatus is of the full size of the MR. HILL'S OBJECTIONS. 229 canal behind it, gives additional weight to the assumption that " the condition of these parts which ensures the most complete functional integrity and is least liable to become the source or seat of disease, and which is also least liable to in- duce, aggravate, or prolong disease in the contiguous parts, may be safely and appropriately accepted as representing the highest normal type. Of the hundred cases above reported, the meatus was found to correspond to the size of the ure- thra behind it in ten cases, while none exceeded that limit. In his ninety-five cases Mr. Hill found the above-named cor- respondence in only three cases ; his examinations, however, were made in subjects who confessed to previous or present inflammatory urethral trouble. The correspondence in my own hundred cases was more than I had previously claimed, which was about one in twenty. One hundred cases is prob- ably too few to decide, and further observations are needed to settle this point with exactness. In regard to the calibre of the spongy portion of the ure- thra (point 2) Mr. Hill frankly states that his measurements of ninety-five urethrae confirm the truth of the statement that " the urethra is wider than is usually taught." He has, how- ever, misapprehended in inferring that I consider the ante- bulbous urethra of uniform size. My observations completely coincide with Mr. Hill's that at the bulbous part the urethra is the widest (i. e., most distensible). From this I have found a gradual narrowing for from one to two inches, and then a calibre almost uniform to the meatus, except where this is several degrees less in size, when there would be an expan- sion of from a quarter of an inch to an inch behind it, at the point usually referred to as the fossa navicularis. Measured with the urethra-metre, this difference between the bulbous and spongy urethra was In 35 cases 1 mm. In 2 cases 6 mm. 21 " 2 " 2 " 7 " 18 " 3 " 1 " 11 " 6 " 4 " 13 " no difference. 2 " 5 " 230 THE AUTHOR'S REPLY TO The average difference in the 100 cases was 2T£¥ millimeters, and the calibre of the ante-bulbous portion averaged 32-95 mm. Point 6th.—" Stricture is most frequent in the first inch from the meatus, and is less frequent as the distance from the entry increases." Mr. Hill dissents from this proposi- tion, and says: " In 258 Strictures, Dr. Otis found 115 in the first inch and a quarter, and the remainder in decreasing frequency in each succeeding inch. This, you know," says Mr. Hill, " is contrary to the received doctrine, which places Strictures most frequently at the bulbo-membranous part. My own view does not support Dr. Otis's statement. In 1870," he says, " I recorded 63 Strictures examined with bulbous sounds at the Male Lock Hospital in 1869, when I found them 43 times between four inches and a half and six inches." I would simply recall the fact, that, at the date of these ex- aminations, the urethra-metre had not been devised, and con- sequently in all cases where the meatus was of less size than the deeper urethra no efficient examination was possible ; and all Strictures of larger calibre than the external orifice of necessity escaped detection. Had Mr. Hill's explorations been conducted from behind forwards, as with the urethra- metre, I feel quite confident that a difference of opinion on this point would not have been recorded. In all cases of Stricture of gonorrhoeal origin, we might infer, a priori, that the Stricture would occur most frequently where the inflam- mation had been most intense and prolonged—i. e., at the anterior portion of the canal. Strictures from lithiasis, mas- turbation, excessive venery, traumatism, &c.,* would natu- rally be expected in the deeper portions of the canal. The fact that no thorough examination of the urethra, with refer- ence to Stricture, can be made without the urethra-metre must, I think, make it necessary to throw out all recorded re- sults as to the exact number, size, and locality of Strictures when the explorations have been conducted by means of in- struments of uniform size, or even with the bulbous sound or bougie alone. "Thompson on Causes of Organic Stricture. Eng. Ed. p. 115. MR. HILL'S OBJECTIONS. 231 In regard to the seventh point— viz., that " complete di- vision of Stricture and maintenance of the normal urethral cal- ibre, until the incision is thoroughly healed, prevents return of the contraction, and, moreover, causes absorption of the indurated tissue from the affected part," I am able to add five additional cases to the thirty-one referred to by Mr. Hill, where, out of 100 cases reported, this number was demon- strated to be absolutely free from Stricture upon a thorough re-examination, at periods varying from a few months to three years and a half from the dates of operation. Mr. Hill's ob- servation of sixteen cases has left him in doubt as to whether or not " permanent absorption " follows complete division of Stricture. Previously to citing the results of operation in these sixteen cases (fifteen operated on by himself and one by me), Mr. Hill alludes to my method of operating on Stricture for the cure of gleet. He says : " A patient applies for the cure of gleet. His gleet must be the consequence of Strict- ure. Find that Stricture ; cut it completely through to the erectile tissue, so as to make the urethra a little wider than before, and take care to maintain this artificial patency while the incision is healing. The cure is then permanent and com- plete." Now if Mr. Hill were speaking of the cure of Strict- ure instead of gleet, the description of the method could hardly be improved ; but to say that the cure of a gleet is immediate, complete, and permanent, after the operation on the Stricture, is what I do not desire to claim. I would be understood as holding that Stricture is the cause of gleet, and that its removal is necessary to the permanent cure of gleet. I have already alluded to conditions, implications of deep follicles and sinuses, etc., which may prolong the gleet indefi- nitely after the cure of the Stricture. The removal of the Stricture or Strictures is the first condition of permanent cure of gleet, and in the majority of cases, after this is accom- plished, the gleet will cease, without other treatment, in from one to four weeks after the healing of the wounds. But in exceptional cases the condition before alluded to—the legiti- mate results of Stricture in certain individuals—will keep up 232 THE AUTHOR'S REPLY TO the gleet for an indefinite period, and must be treated on general principles, final success depending upon the character of the especial complications, the knowledge, skill, and in- genuity of the surgeon in charge of the case. Finally, Mr. Hill proceeds to consider the results of ope- ration on his sixteen cases, all of which he fairly states were in individuals " who had long-standing gleets, with contrac- tion in one or more parts of the spongy urethra, and had undergone multifarious treatment." Strictures were exam- ined for, and found. They were operated on in supposed accordance with the method previously described, and five out of the sixteen cases operated on by Mr. Hill were promptly cured of both Stricture and gleet. A sixth opera- ted on by me was reported cured, after five months, " by other means." In the remaining ten, recontraction of the Strictures took place, and the gleet persisted. Why? Evi- dently because of the recontraction of the Strictures. And why did the recontraction take place? Why did the Strict- ures disappear completely in five cases and reappear in ten ? Simply, as I apprehend, because in case of the latter the Strictures ivere not completely divided. This is not remarka- ble, it seems to me, under the circumstances, although Mr. Hill used his own ingenious modification of my dilating ure- throtome, and observed all the principles necessary for the suc- cessful performance of the operation in these ten unsuccessful cases. Complete division of Stricture, in my experience, can- not be demonstrated at the time of the operation. A certain amount of distension is necessary to fix the Stricture before it can be completely divided; hence a sufficient time must elapse after the operation to test the question as to whether the Strictures are, or not, completely divided, and this is never less than ten days or two weeks. If after this time an examination with the full-sized bulbous sound shows complete freedom from Stricture, there need be (judging from my own experience), no fear of any return of Stricture. If, on the contrary, remains of Stricture are detected, it is the evidence of incomplete division, and the operation must be repeated, MR. HILL'S OBJECTIONS. 233 and the remaining fibres severed. Without complete and ab- solute sundering of the Stricture to its ultimate fibre, recon- traction sooner or later is certain. It is not a question of using my urethrotome or Mr. Hill's, or any other special in- strument, but one of principle. It is not a question of whether division of Strictures may be effected' by one opera- tion or ten ; neither the permanent cure of Stricture nor of gleet can be reasonably expected, while a fibre of the Strict- ure remains undivided. Let the sundering be complete, and proved by a re-examination at a period sufficiently long after the operation to give security against mistaking over-disten- sion for complete division, and I will not hesitate to take the responsibility of claiming ultimate absolute permanent removal of urethral Strictures. In describing my urethrotome, Mr. Hill is somewhat in error. He says: " A small cutting edge, previously concealed at the end of the dilating part, is drawn along the tightly stretched tissue to the meatus, . . . making a long furrow in the mesial line in the root of the urethra." He further says: " Disliking this long cut, which divides uncontracted parts, I have employed, except in one case, a Stricture incisor which, while it stretches the urethra to the size previously determined, cuts only where it is strictured." My object has ahvays been to divide only contracted tissue. Strictures have been carefully located and measured before operation. The knife which is concealed at the end of my instrument is drawn through the Stricture and at once returned to its con- cealment. If other Strictures are present, the instrument is especially readjusted for them. Mr. Hill records against my mode of procedure "persis- tent bleeding " in four cases ; " rigors " in three ; " abscess in the buttock " in one ; " crook of the penis " in one ; " orchi- tis " in one. This certainly looks like a formidable array of accidents to occur in sixteen cases. 1st. In regard to " per- sistent bleeding." This accident, (if accident it can be termed in cases where vascular tissues are freely and inten- tionally incised,) may always be readily and easily controlled. 234 THE AUTHOR'S REPLY TO Simple compression by an ordinary bandage will always stop it in the spongy portion of the urethra. The introduction of a flexible tube after the operation will always prevent it. The magnitude of the object to be attained will warrant the employment of either or both of these simple measures in every case, and will give security, perfect and complete, against any injury from haemorrhage. 2d. " Rigors" occurred in three cases. The simple passage of any instru- ment through the curved or fixed portion of the urethra may alone suffice to produce this accident, and would be still more liable to result upon dilatation of this part. My plan is never to pass beyond the bulbous urethra if it is possible to avoid it, and my own urethrotome has been contrived expressly with the view of dividing Strictures, as far as the bulb, without entering the fixed portion of the urethra. Acting on this principle, rigors have not occurred in more than one out of a hundred cases, in my experience. From this I am able to state that all operations confined strictly to the penile ure- thra are virtually free from danger of this accident, or from any marked constitutional disturbance, except in cases habit- ually subject to this trouble. 3d. " Abscess of the buttock" is recorded against one operation. This might be accepted as accounting for the rigor which it may be presumed occurred in this case, but cannot be entertained as the result of any operation upon the penile urethra. 4th. " Orchitis " followed the operation in one case. Orchitis is recognized as occur- ring not unfrequently from the simple passage of any instru- ment through the curved portion of the urethra. I have never met with it as the result of any interference with the spongy portion of the canal. In one of Mr. Hill's cases—that operated on by myself— persistent bleeding is noted, and notwithstanding the assidu- ous passage of sounds, his gleet persisted for five months ("until Christmas "), and was then cured by other means; and, besides, a scar or induration remained in the erectile tis- sue which gave a crook to the organ on erection. It seems to me not irrelevant to state that this case was operated on MR. HILL'S OBJECTIONS. 235 by me in the theatre of the University College Hospital un- der the impression that he was to receive care immediately after the operation. It turned out, however, that he was an out-patient. He subsequently drove his van for several miles, then walked a couple of miles, and returned at about 10 P. M. to the hospital, was subjected to treatment for his haemorrhage, and had some constitutional disturbance for several days. I think that the inflammatory complication, which undoubtedly caused the induration in the erectile tissue, would rarely occur in cases where the necessary care and rest are insisted on. Out of between five and six hundred operations I have seen six cases followed by the crook or curvature to which Mr. Hill alludes, in the worst case persisting about a year; but in all of these inflammatory trouble succeeded the opera- tion. In two a urethritis was present, which had persisted acutely for several months, and in the others, extensive, very dense, and deep Strictures were divided. It is a question whether this rare accident would ever occur if the Strictures were uniformly divided on the floor of the urethra, as Mr. Hill is in the habit of doing. My cases were all cut superiorly and in the median line, as I believed I could more certainly sunder the Strictures in this way, and with less liability to troublesome haemorrhage. I am at present making observa- tions with the view of ascertaining the best point for division, and I may ultimately coincide with Mr. Hill in incising Strictures on the inferior floor of the canal.* The final cure of gleet in the last mentioned case is stated to have taken place five months after my operation, "by other means." At the date of operation it was one of the " cases of long standing, with contraction in several portions of the canal, and had resisted multifarious treatment." Is it quite tertain that this case was finally cured by other means, and that the cure was not chiefly due to removal of the * A large subsequent experience has satisfied me that not only in regard to trouble from haemorrhage, but in regard to completeness of results, the superior incision is greatly preferable, June, 1878. 236 AUTHOR'S REPLY CONCLUDED. Strictures ? I rather incline to the opinion that the continua- tion of the gleet was due to the " cicatricial knot " which fol- lowed the operation and complicated the case ; and its grad- ual absorption (usual in such cases) removed the remaining source of irritation, and the gleet ceased. In Mr. Hill's own fifteen cases one-third were promptly cured. In the remain- ing ten recontraction took place: this, it appears to me, is a good and sufficient reason why the gleet should persist; and I feel confident that the results of thorough re-division of these Strictures would go far to establish the truth of my views. In closing his lecture, Mr. Hill objects to any examination of the urethra for Stricture until the gonorrhcea and gleet shall have lasted for six months. It is a well-known fact (see Thompson "On Stricture," English edition, p. 115) that Strictures are often present from other causes than a gonor- rhcea ; that a gouty or rheumatic diathesis, etc., may cause them, and that even a first gonorrhcea is often aggravated and prolonged by them. Is it then wise to ignore for a long period a well-recognized cause of trouble when the alternative is a prolonged and possibly a useless, if not harmful, course of urethral injections and nauseous medicines? However much we may deprecate unnecessary instrumentation, we cannot lose sight of the fact that unnecessary injections and unnecessary medication are quite as much to be deprecated. A careful, judicious, and thorough urethral examination im- mediately after the acute stage of a gonorrhoea has passed, I have never found to result in more than a temporary discom- fort, and less than often follows the use of a single injection. I do not claim perfection for any method or means of mine, but I offer my instruments and my experience to the profes- sion, abroad and at home, with the sincere hope that they may be tested in the fair and generous spirit shown by my friend Mr. Hill, and that ultimately we may arrive at the so- lution of the most vexed of all surgical problems—viz., the best way of curing Strictures and gleet. CHAPTER XL DISCUSSION CONTINUED. pHE next public discussion of my position on urethral i- questions appeared in May, 1877, in the Maryland Medical Journal, by Dr. Thomas R. Brown, Professor of Clinical and Operative Surgery, and of Diseases of the Genito-Urinary Organs, in the College of Physicians and Surgeons, Baltimore. This critique is considered worthy of citation because of the practical efforts which Professor Brown has made to solve the questions most in dispute, and especially on account of origi- nal observations of the foetal urethra, and that of the newly born (page 243,); important as bearing upon the significance of the dilatation usually found in the anterior part of the adult urethra heretofore described by anatomists as a normal condition, and called the fossa navicularis, but which I have claimed to be the result of mechanical dilatation behind a contracted meatus urinarius. Again at page 242, he raises a point or two in regard to estimates of size of urethra from circumference of penis, which may have a general interest, while on the same page he confirms them in citing a case with a penis 4f inches in circum- ference, associated with a urethra 47 mm. circumference, per- haps the largest on record. Again, ibid., his experience as to most frequent locality of Strictures ; in 100, 75 per cent. anterior to 41. inches, confirms the claim made page 97, as against previous authority. Again the emphatic endorse- ment of my claim as to the importance which may attach to Strictures but slightly invading the urethral lumen, page 192. Professor Brown's opinions have an especial value from the fact that his position heretofore, has been in a measure antag- onistic to my own. 238 DISCUSSION OF DR. OTIS'S VIEWS Citation. DURING the past three years the attention of Genito- Urinary surgeons has been especially invited to the study of urethral Strictures, their pathology and treatment. The fresh interest in this subject is, in great part, due to the new de- parture of Professor Otis, as to what constitutes a Stricture. Heretofore, the French surgeons have taught that an urethra through which a twenty-one of their scale could be passed, is free from Stricture. According to the English school, if an eight or nine of their scale can be passed into the bladder, no Stricture can be said to exist, while the American standard of 31^ millimetres was quite universally accepted as correct. In opposition to these current views, it is claimed, as the outcome of many experiments, that there is no such thing as a " standard urethra" which applies to every man any more than a standard hand or foot, but that they vary in size in different individuals, according to the physique. So the ure- thra varies with the size of the flaccid penis. It is moreover claimed that this variation is definite and according to a rule: beginning with a penis three inches in circumference, its ure- thra would measure 30 millimetres, and for every ^ inch in- crease in the circumference of the penis, there would be an urethral increase of two millimetres. These results have been verified by Otis in nearly all of 500 examinations. The establishment of this proportionate relationship, if sustained, would be a valuable addition to both anatomy and surgery, and for the purpose of testing its correctness many investiga- tions have been made—notably, by Drs. Henry B. Sands, Weir, Mastin and myself in this country, Teevan, Watson, Berkeley Hill, Cooper and Coulson in Great Britain—with a result that is anything but satisfactory. The second proposition and perhaps most important in a practical point of view, is that which relates to results of treatment. It is insisted upon, and if true the argument is a sound one, that operations performed in accordance with the rules laid down, followed by the proper after-treatment, BY PROF. BROWN. 239 yield perfect results and complete cures, cures so complete that the previous seat of Stricture cannot be detected by a properly sized olive sound, and so complete that the danger of re-contractions no longer applies,* enabling the patient to dispense with the dependence upon the introduction of the sound for the purpose of keeping his urethra open. The fourth point is, that by far the most Strictures, in fact nearly all, are found in the spongy urethra. This con- trasts with Sir Henry Thompson's position, who locates sixty- one per cent, in the membranous, or bulbo-membranous part, and is doubtless to be explained by the fact that the anato- mical basis of the former's collection of cases and that for the latter, are distinct and dissimilar. The coarser procedure of the one ignored, as having no existence, what the more re- fined method of the other esteems important and demands treatment. Hence it is that we hear so much of late about Strictures of large calibre ; not only because they are morbid conditions of themselves, but chiefly because they are apt, if let alone, to go from bad to worse, and sooner or later impair seriously the efficiency of the organ. It will be observed that this advance seems to take no account of the by no means dis-established assumption, that slight constrictions not only may be present, but may become harmless in the course of time, undergo absorption, or by a process of infection, (strictly rendered) take on the structure and function of the tissues in which they are seated. These are the salient points of this new method, and the importance of keeping our premises constantly in view must explain this reference to what, after a fashion, is already before the profession. And whilst we must admit .that the author has conducted his investigations with commendable fairness and zeal, we must also regret that his challenge of criticism has not been accepted. We have had any amount of h priori reasoning presented against his formidable * See reference to report of Prof. Alfred Post, Drs. Miner, Woodruff, upon an examination of patient operated upon for five (5) Strictures " with complete ab- sence of a trace of Stricture." N. Y. Med. Journal, April, 1878. 24O DISCUSSION OF DR. OTIS'S VIEWS array * or on the other hand such complacent acceptance of the claims, both alike damaging to the cause of truth, that we would pronounce not so much " not proven " but " not tried." The trial has made little progress, the case is still open with all the presumptions necessarily favorable to Dr. Otis's side. Let us briefly consider some of the results of the trial as far as it has progressed. As to the question of the normal urethral calibre, Sir Henry Thompson, who has all along been the great cham- pion for small sounds, has recently admitted that f " he had long seen the practical necessity of a higher estimate of the normal urethral calibre than that generally assumed." With this sentiment Mr. Berkeley Hill, of the University College Hospital, London, agrees, and for the sake of illustration I quote the following of his : " I did Syme's perineal section in a case of traumatic Stricture lying in my wards, and who had been several weeks in Guy's and St. Bartholomew's Hospitals, and under private treatment before he came to me, without any instruments having reached his bladder, I measured the circumference of his flaccid penis, and found it 3]- inches. I turned to my audience and said : ' now according to Dr. Otis's observations, this urethra should easily admit 32 F.' I took up 32 F. sound, (at the size a general murmur ran round); I placed it in the meatus and it slid down to the bulb quite by its own weight. Then it was stopped of course by the Stricture. 1 then proceeded to divide the Stricture upon a Syme's grooved and shouldered staff in the perineum ; the thick part of the staff was No. 26. I held it up to the audience along with the usual one of No. 16, to show the difference. After division I took the 32 F. sound again and slipped it readily into the bladder." In connection with another case he states, " I divided a contracted meatus this afternoon in a private * See Sands " On the Causes of Gleet and Calibre of the Male Urethra," New York Medical Journal, March, 1876. R. F. Weir, New York Medical Journal, April, 1876. Boston Medical Journal, November, 1876. f British Medical Journal, Feb. 26, 1876. BY PROF. BROWN. 241 patient, (his own doctor being in attendance) ; after which No. 39 F. passed readily down into the bladder, as I had an- nounced that it would when I measured the canal with the urethra-metre. I then made the practitioner pass the 39 himself, in order that he might be sure that there was no hocus-pocus in the matter." Testimony of this character must carry weight, especially when it is considered that the cases cited evidently constitute parts of a series. It is scarcely necessary to argue farther, this need for a higher estimate of the normal urethral calibre. So far as my own examination of nearly one hundred cases extends, while not prepared to affirm that the exact proportionate relationship between penis and urethra exists, I am convinced that the capacity of the urethra is much greater than has been supposed and that the size of the urethra bears some ratio to the penis. It is im- portant to state here that all of my measurements were made with the urethra-metre, a most invaluable instrument. The amount of benefit, however, derived from its use depends upon the skill and delicacy acquired by long education in its manipulation. And under no circumstances must the " limit of easy distension " apply to the patient, except to a minor degree. That " feeling of fulness " referred to the patient, " sense of distension " must be regarded as too varying to make it the " sine qua non " of a grave surgical operation. As stated above, my examinations do not justify me in con- ceding the relative size of penis and urethra, so far as the measurements of the latter were made with the urethra- metre. This may spring from a want of proper tact in handling it. In certain examinations it was quite evident that the same penis in a state of flaccidity may vary in its dimensions, when exposed under different temperatures, also that there were variations in different parts of the same organ—the point near the peno-scrotal angle measuring less than immediately behind or at the corona glandis ; in fact does not the nature of the tissue of which the penis is made up suggest such con- clusions ? Under such circumstances as 'these what part must 16 242 DISCUSSION OF DR. OTIS'S VIEWS be selected as standard?* With the statements of Prof. Sands, and Dr. R. F. Weir, that contractions occur in differ- ent parts of the normal urethra and are not prima facie evi- dence of disease, as indicated by a series of eight carefully prepared wax casts, my investigations do not agree. In all instances where obstructions to the easy movement of the urethra-metre were met with, there was abundant reason for suspecting disease. The converse is equally true that where the urethra was found to be normal, the withdrawal of the instrument was accomplished without resistance. These and the post-mortem experiments serve to convince me that con- strictions do not belong to normal urethrae, and where they do exist they must constitute the rare exceptions. It is a curious fact, which seems to have gone unnoticed, that in both of the collections of casts referred to the principal nar- rowings were in the anterior half of the urethra, a possible effect of the injection not continuing in the same state of liquefaction throughout, or again, if this supposition be not correct, might not these few cases when placed beside Prof. Otis's 500 cases, be classed with urethrae in a state of disease. This is especially probable when we recall the fourth proposi- tion as to the most frequent site of Stricture, a position which I fully indorse. Out of nearly 100 Strictures divided by my- self, including many that are usually designated as impermea- * The estimate of the size of the urethra from its proportionate relation to the size of the penis, is but approximate and intended only to serve as a guide where the urethra-metre is not available. Examined by the rule laid down p. 89, experience has shown that the estimate will never exceed the normal calibre, though it often falls short of it several millimetres circumference. The flaccid penis is subject to variation from heat, cold, etc., but practically it will be found that the relative conditions will always be the same when the patient presents to the surgeon. Measurements should always be made at about midway of the body of the penis. In a recent edition of the standard work of Prof. S. W. Gross of Philadelphia, on the genito-urinary organs, edited by his son Prof. L. D. Gross, he says (in a note following his illustration and description of my urethra-metre, page 472) in regard " to the proportionate relation between the penis and the urethra," " From a number of measurements made upon private and hospital cases, the Editor is enabled to add confirmatory evidence of the correctness of Dr. Otis's estimates." —F. N. O. BY PROF. BROWN. 243 ble, at least 75 per cent, were found within the anterior 4\ inches. I am therefore led to infer that those deeper con- strictions are nearly always the consequence of extension of disease from in front. With reference to the controversy as to the existence of the boat-shaped dilatation—the fossa nav- icularis—I have been forced by my post-mortem, rather than by the urethra-metric inquiries, to consider it to be the rule for this, or at least some form of dilatation to be found. In my examinations, not exceeding a dozen, to be sure, made according to the directions of Malgaigne and Thompson, it was always present. I feel however almost convinced that it is acquired and not congenital, and dependent upon the constant and increased tension to which this part is subjected in the resistance to the exit of urine offered by a contracted meatus. For the purpose of determining this point, I have examined a number of fcetal and infants' urethrae, some of them in the presence of my colleague Prof. Bevan, and up to this time I have met not a single one in which this dilatation occurred. In all of these examinations the meatus was inva- riably found to be narrower than the rest of the canal. As an evidence of how utterly unreliable our hitherto arbitrary mode of excluding Strictures really is, I would cite from among a number, the case of Wm.----, in attendance upon my clinic, as an out-patient, at the College of Physicians and Surgeons. The size of his penis was 4f inches, and upon in- troducing the urethra-metre, and expanding it to what I be- lieved the proper size, the indicator marked 47 millimetres. Without any more than the usual discomfort, and but very inconsiderable pain, it was withdrawn easily along the entire urethra, it only becoming necessary to diminish the bulb at the meatus, and at that point to 35 millimetres. Now in this case, how very unreasonable it would have been to have allowed the introduction of a No. 8 or 9 of the English, 21 of the French and 31^ of the, American scale to effectually dis- pose of the question as to whether there was Stricture in that man's penis or not, when not one-half of its normal calibre had been ascertained. And even taking his meatus as the 244 DISCUSSION OF DR. OTIS'S VIEWS guide, its indication would have fallen short to the extent of 12 millimetres. I am therefore compelled to agree with Prof. Sands, that " in practice we find in the size of the mea- tus a rough test for the calibre of the urethra," a test indeed so very rough and unreliable as to preclude our making any use of it in an operation which has for its object a complete division of the Stricture. From what has been said, I am forced, with the qualifica- tions stated, to agree with the principles contained in this postulate, and to decide that the old methods of examina- tions abound in faults. Under its teachings very decided disease must have been overlooked, and an easy explanation of the intractability of that bugbear gleet, now recognized as the offspring of Stricture, obtained. In passing I may state here that this dependence of gleet upon Stricture has been greatly misunderstood, because when the Stricture has been effectually divided, the urethral discharge did not cease. Many have considered this to disprove the connection, but this is obviously unjust, for the reason that the Stricture was not the gleet per se, but the cause of it, and in a way easily to be explained. The obstruction favors the accumulation within the urethra of residual urine bound to undergo decom- position. This urine, acting as an irritant, constantly ap- plied, especially to the sinuses of Morgagni, induces a chronic catarrh, which requires after the division of the Stricture, treatment of the most persistent, discouraging character. As it is true that all acute diseases tend towards recovery, it is equally true that all chronic diseases tend, with as much em- phasis, in an opposite direction. This, we all must admit, holds true of gleet. I am not prepared here to explain those cases of gleet, wherein the discharge had continued over such a period that analogy would warrant an assumption of Strict- ure, and which are said to have disappeared entirely upon expectant treatment. I can only say that I have met with no such cases during these investigations, and feel inclined to question the completeness of the alleged recoveries. On the other hand, I have met with a number while presenting a. BY PROF. BROWN. 245 somewhat similar history, they have, in addition, complained of a peculiar susceptibility to contract " fresh cases " of what they called gonorrhcea or simple urethritis, contracted whether after legitimate or illegitimate sexual indulgence; after " taking cold," or after slight excesses in eating or drinking. By way of illustration, I extract from my " Case Record " a brief synopsis of two cases : Case 1. Mr.----Jr., contracted four years ago a case of gonorrhoea, which after the usual treatment and a long time "got well." Has noticed since that time that scalding with urination and a discharge would follow sexual inter- course. This discharge, which the patient states, is like that in his previous attacks, when seen by me, was not the frank, purulent discharge of gonorrhoea, but was decidedly more serious, though the usual symptoms of irritation were present. I observed that during urination the stream was too small, somewhat twisted and followed by dribbling. An attempt to pass 32 F. was made but failed, this being the size indica- ted. Before the canal could be traversed, it became neces- sary to use the smallest olive in my possession, which is marked 13 F ; the contractions being so considerable as to pre- vent the use of the urethra-metre, until after a Thompson's divulsor had been introduced and dilated. Three distinct Strictures were made out—one 3 inches, the second 2\ inches, and the third \\ inch from the meatus, all of which were com- pletely divided. Now this man considered his penis well, except as to these recurring attacks of gonorrhcea. Case 2 presents almost identically the same history, except as to the number of Strictures, there being but one, and as to the suspected cause of his urethral attacks—" cold." The Stricture, located in this instance 2\ inches from the meatus, was alike perceptible to myself and to his physician, Dr. Saltzer, of Baltimore. In both cases, the usual after-treat- ment of the tri-weekly introduction of the proper sized sound was followed out strictly and with good results. Another point, in this connection, is the alleged insignifi- cance or harmlessness of Strictures of large calibre. Before 246 DISCUSSION OF DR. OTIS'S VIEWS accepting this there is need for more extended observation. I fully endorse the claim of the pathologist that this simple cicatricial tissue is liable to increased hyperplasia and liable to become not only a more and more serious condition in itself, but also liable, even in its early stages, to produce consequences that may prove dangerous and even disastrous. If space permitted, I should like to give the details of two cases in point; the first that of a man dying in the Hospital of the College of Physicians and Surgeons from toxaemia consequent upon extravasation of urine through a hole in the urethra ii inch long, beginning just behind a Stricture through which a No. 12 Van Buren's conical sound could easily be passed. The second case occurred in the practice of Mr. Walter Coulson, of the Lock Hospital, London, and is reported in the Lancet of August 28, 1875, pages 332,333 ; in which perineal fistules refused to heal after the usual sec- tion, until some Strictures of large calibre, anterior to the fistulous openings, were freely divided. After this the patient entirely recovered. The anterior Strictures were large enough to admit a No. 10 E., and still they offered suffi- cient resistance to the flow of urine to keep the false passages from healing. I do not mean in either of these cases to dissent from the now generally accepted opinion, that perfectly normal urine is innocuous even when injected under the tissues, but, more than probable, in both of these the urine was not normal. These are some of the notes which I have wished to make about that which I hope and believe will become a valuable addition to our fund of surgical knowledge. At some future time I propose to extend these comments, especially with reference to the results of the operation, not sufficient time having as yet elapsed to make me willing to venture an opin- ion. I feel justified in stating, even now, that I have made re-examinations where the Strictures have been completely divided, nine months after the operations, without finding re- contractions. In reply to a letter asking for information, Prof. Brown writes, under date of April 5th, 1878, as follows: Upon the BY PROF. BROWN. 247 whole a careful study has made me a convert, in the main, to the principles of your procedure, and I never think of consid- ering any of my operations complete, until the indicated sound as well as bougie-a-boule has passed 'sans resistance.' I have, moreover, very certainly, by inviting sceptics to many of my operations, served to dismantle the old doxies, and, by doing the Otis operation, have been instrumental, in a measure, in dis-establishing the false views which have so long obtained. / have divided over 300 Strictures without a single death. * * * Every day convinces me more and more of the great importance of free division of the Stricture, with a view of preserving the normal calibre of the urethra. With regard to your claim of the relative size of the urethra and penis, on the careful observation of an immense number of cases it has never happened to me to find, for example, a penis of three inches with a urethra measuring less than 30 mm., but I have found a large number where the urethra measured more." CHAPTER XII, Report of thirty Operations for Urethral Stricture, Otis's method, by Claudius H. Mastin, M.D., LL.D.r of Mobile, Ala. DR. MASTIN writes, May 16th, 1877, "It affords me pleasure to testify to the value of your method of op- erating for urethral Stricture. Before I had resort to dilating urethrotomy, I thought it impossible to make a radical cure in these cases; but since I have given it a fair trial, I have changed my opinion, and I now unhesitatingly say, I believe that certain selected cases can and will be cured by your method, provided the operation is judiciously done, and the after treatment properly conducted. To this date, my cases of Internal Urethrotomy number 280. They have been per- formed with a variety of instruments, Maisonneuve's, Civiale's, Ricord's, Otis's and my own. I have as yet, never met with an accident, nor have I lost a single case. I have used your dilating urethrotome in some 30 cases, and I feel justified in saying, that it is especially adapted to all cases of hard, firm, organic Stricture in the penile urethra; especially is it valuable in those cases of chronic urethral discharge dependent upon what you term, " Strictures of large calibre," and I believe that when the profession comes to know and understand the operation, no surgeon will consider him- self prepared to treat urethral affections, unless he has " an Otis urethrotome." If the cases are properly prepared for the operation, I do not see that there is any more danger in your operation than in any other. Haemorrhage in my opinion, is not more liable to occur after BY DR. MASTIN. 249 your operation, than after any other, and even should it take place, it can be speedily and easily controlled. I believe that the success of every operation for urethral Stricture, by the knife, depends upon the amount of cicatri- tial splice which we gain after an operation, and as the operation which you have devised insures a wider splice than any other that I as yet know of, I say, unhesitatingly, your operation is, in my opinion, the operation best calculated to produce a perfect and radical cure. In Strictures of long standing, with great density of tis- sue deposited, I do not believe that any other urethrotome, save Otis's or one constructed upon its principle, will or can give the same satisfactory results. The following cases are taken without selection from the list of operations which I have done with the " Otis urethrotome," and will go to show the results of his method in my hands. I give them just as they have been taken from notes, without, however, going into detail as to the preparatory or after treatment, which is usually resorted to. Case 1. Geo. S., an engineer, aged about thirty,'had suf- fered from Stricture in the penile urethra for about three years. He had been operated upon with a Maisonneuve urethrotome two or three times ; but with no other benefit than to give passage to his urine. Constant dilatation had been resorted to without benefit ; he suffered from a painful irritation of the entire urethra, and was annoyed with a per- petual discharge. I found him at the time he presented him- self to me on the 25th of December, 1874, using a No. 28 F. sound, which he informed me, had been given him by his for- mer surgeon " to keep the urethra open." Upon examination (by Dr. Otis's rules, and by the use of his urethra-metre) I found the normal size of his urethra 36 F. After due prepa- ration, I operated upon him on the 28th day of December, 1874. Carried out the after treatment with large sounds, until the last of January, 1875, when I discharged him, appa- rently entirely relieved. Since then, now over two years, I have had him constantly under observation, and have fre- 250 SUPPORT OF THE AUTHOR'S VIEWS quently examined him, both with the ball probe and the urethra-metre, and, to this date, I have been unable to find any recontraction. Case 2. Mr. O. C, master mechanic, aged forty-two to forty-three, presented himself for treatment of urethral Strict- ure, which had existed for some four or five years. An ex- amination revealed two Strictures of large calibre located in penile urethra—one about 2\ inches down the urethra, the other just in front of the bulb. He informed me that he had been operated upon by divulsion, by internal urethrotomy, with a Maisonneuve's urethrotome, and been treated by caus- tics and continuous dilatation. He came to me on the 14th of February, 1875. I found that his Strictures would admit a No. 28 F., and that there was a good deal of irritation and a very free discharge. His normal urethra according to rule, furnished a calibre of 38 F. To this point I cut him with an Otis urethrotome, and treated him with large sized sounds until all discharge had ceased, and his urethra offered no re- sistance whatever to the ball probe or the urethra-metre. I have been particular in keeping this case under close observation and frequent examination, and I defy any sur- geon to find a trace of contraction present. He has had, and there now remains some prostatic trouble, unconnected how- ever with the former Strictures. Case 3. D. S., a barber, aged fifty-two, presented for treatment on 5th September, 1875. I found a tight, firm Stricture, 2\ inches down urethra ; opened it with small blade of Maisonneuve's urethrotome, 8 mm. in diameter, through which I passed Otis's instrument, and cut the same to the normal urethral calibre which was 35 F., I treated him with large sounds, and discharged him on the 1st of October, 1875, as cured. Careful examinations reveal no contraction up to this date (May 16, 1877). Case 4. A. B., drug clerk, twenty-five years, presented for treatment November 7th, 1875. Examination revealed close Stricture in penile urethra, 2\ to 3 inches down, normal urethra 33 F. I cut him with the Otis urethrotome, and BY DR. MASTIN. 251 treated him as usual after these operations. To date no com- plaint, and no evidence of any recontraction. Case 5. J. C, lawyer, twenty-two years ; recent Stricture in penile urethra; normal calibre 32 F. I cut this Stricture only to 31 F., and tried to dilate with large sounds up to 32 F. He objected to the continued use of the sound, and said he thought he would be cured without their use. The end of this has been, the Stricture has in a measure recontracted, the discharge returned and he has placed himself under care, for treatment. I consider the failure, for a failure it has been, is entirely due to my negligence in not cutting the Stricture up to 32 F., and then keeping up the use of the sounds until all irritation and discharge had ceased. Case 6. J. S., broker, aged thirty-one ; Stricture of large calibre in penile urethra, three inches from meatus. Con- stant discharge. Has been treated in Galveston, Texas, by sounds, injections, etc. Came to Mobile in April, 1875. I found normal urethra 32 F. Operated upon him May 1st, 1876 ; treated him by usual method. He had a severe attack of urethral fever, after the operation ; had been subject to rigors after every urethral interference; yet he has promptly recovered, and in February, 1877, I examined him and found no evidence of any return of Stricture. His health has improved vastly, and he expresses himself as perfectly well. Case 7. S. F., merchant, aged twenty-eight years. Strict- ure of large calibre ; a very troublesome discharge, and gen- eral health disturbed. Stricture located in the penile ure- thra, just in front of bulb. Normal urethra 35 F. Operated upon him July 6th, 1876; cut with Otis's urethrotome. Results perfect. No contraction as late as April, 1877. General health greatly improved, discharge entirely relieved, and says he is as well as he ever was in his life. Case 8. J. P., bookkeeper, aged about twenty-six years. Stricture of large calibre in penile urethra three inches from meatus, general health failing ; great anxiety of mind ; has been under care of a physician for some months who told him he had prostatic disease, etc. Used small bougies, injec- 252 SUPPORT OF THE AUTHOR'S VIEWS tions and porte caustics, until he presented himself to me for treatment Dec, 1876. I found no prostatic trouble, but a very irritable urethra, of normal calibre 35 F. and a Stricture contracted to 28 F. I cut him with Otis's instrument, on December 8th, 1877. He improved rapidly, and to-day is in better health than he has been for two years past. All dis- charge has vanished ; there remains no irritability of the ure- thra, and I am unable after the most careful examination to find a trace of strictured tissue. I believe that time will prove that his cure has been perfect. Case 9. R. M. Q., bookkeeper, aged forty years. Stricture at bulb; says he has had Stricture from early boyhood, result of an injury received by riding on the pommel of a saddle. There is a great deal of urethral deviation, the penis being twisted full one-third around on its axis. I saw this case first in Sept., 1869^ just after an attack of retention. I then cut him with a Maisonneuve urethrotome, followed by that of Civiale, and furnished him with sounds up to thirteen and fifteen English measure, with instructions to keep his urethra open. This he neglected to do, and per- mitted his Stricture to contract so much that it seriously in- terfered with the passage of his urine. He said he disliked to come back to me, after neglecting instructions, so he put himself in the hands of a physician, who divulsed his Stricture with a Holt divulsor, and told him he was cured. This divulsion was in 1870, sometime in the fall of the year ; but instead of curing his Stricture, he was made worse, for on March 19th, 1871, he placed himself again in my hands with a Stricture contracted to No. 1 French. He now objected to any opera- tion, and requested that I would dilate his Stricture "just enough to permit him to urinate and he would be satisfied." In the course of a few days I had opened his canal so that it would admit a No. 10 English catheter. He now thought he could keep it open, and declined any further treatment. I heard no more from him until the 25th of May, 1872, when he sent for me to relieve him of retention. I found his Stricture impassable, and after a fruitless trial of over two hours, to BY DR. MASTIN. 253 get through the Stricture, even with the smallest whale- bone probe, I frankly informed him that the only alterna- tive was either to tap the bladder, or open the urethra in front of the Stricture, and then work through the co-arctation. He preferred the latter, and I at once performed my modifi- cation of la Boutonnier. His recovery was rapid, and every thing gave promise of a successful termination of his troubles, but during the summer of 1875, he contracted a blennorrhagia, which proved rebellious to treatment and caused his Strict- ure to recontract enough to give him considerable trouble and anxiety about his urination. Fearing retention, he came to me for another operation, and I proposed and performed the operation with the Otis urethrotome on the 29th day of Nov., 1875. I opened his Stricture to 32 F., that being the normal size of his urethra. To this date, 16th May, 1877, I can find no evidence of any Stricture remaining. In fact he is much better than after any previous operation which had been done. Case 10. R. B. M., gentleman aged 29 years, May 19, 1875, presented himself, with a firm Stricture in penile ure- thra, great irritability of urethra and considerable discharge. Had been operated upon by some physician, as the patient informed me, with a " sort of spring instrument," cutting from the point. I suppose it was an old Stafford's instru- ment. There had been no results beyond increasing the dis- charge and inflammation. I found his Stricture would admit a 23 F. sound, and his urethra a 32 F. in its normal portion. I cut him to this point; treated him about thirty days with large sounds, and he has remained perfectly well ever since. Recent examina- tions reveal no evidence of any recontraction. Case 11. J. L., wine merchant, from Ohio, aged 32 or about that number of years, presented himself on 10th Feb- ruary, 1877, with Stricture in penile urethra, just in front of bulb. Has had retention on two occasions. Stricture hard, discharge purulent and in large quantities. His Stricture would admit 25 F., and his normal urethra was 32 F. I cut 254 SUPPORT OF THE AUTHOR'S VIEWS. him up to 32 F., treated him with large sounds, and at the expiration of fourteen days, as he was so much relieved, I concluded to venture upon letting him return home. To- day, May 16, 1877, ^e called at my office, as he was passing through Mobile, and I found his urethra perfectly smooth, with no discharge and no Stricture. Very sincerely, C. H. Mastin, M. D. Out of thirty operations reported by Dr. Mastin, twelve cases are quoted in full, and of these complete radical cure of the Strictures is claimed in nine cases, as proved by re-ex- aminations as follows : One 2 years One 2 years One 2 years Two 1 " Two 1 " One o " One o " and 6 months after operation. 4 0 " " " 9 " "•-' " 6 10 " " " A " «« " CHAPTER XIII. Report of seventy-one operations for Stricture—by Otiss method (45 Tabulated Cases.) By R. W. Pease, M. D., Prof, of Surgery in the Syracuse University, N. F. * T N 1874, a gentleman whom I had treated for Stricture of i- the urethra at the membranous portion, for several months, and who, prior to coming under my care, had been treated by most capable physicians, one a world-known surgeon, drifted away from me, because I, like those who preceded me, had failed to give him any relief by the stereotyped method of treatment—the use of bougies. His symptoms, in brief, were a desire to frequently mic- turate flocculent urine, and a constantly recurring gleet. The protracted malady had sadly undermined his health, as evidenced by great nervous irritability, induced by his dis- turbed rest. Fortunately, he came under the care of Professor Otis, of New York. The diagnosis made by Professor Otis was a Stricture one- half inch from the meatus, and none at the membranous por- tion. The meatus was cut to 40, French scale, that being the capacity of his urethra, and in a few days he returned to Syracuse, every symptom mitigated, and in a few weeks all evidence of contraction of the urethra was removed, the urine cleared up, the nervous symptoms dissipated, and, in short, the patient cured. My patient was a gentleman of great intelligence, and his representation of the methods used to diagnose the difficulty, together with what I had incidentally seen, in the journals, of Professor Otis's views and practice in urethral surgery, * Read before the Medical Society of the State of New York, June, 1877. 256 THE AUTHOR'S CLAIMS CONFIRMED added to my own growing dissatisfaction with the results of treatment as universally employed by the profession, led me to a careful investigation of his methods of diagnosis, and treatment of Stricture. This review has brought me to the following conclusions: 1st. That the means of diagnosis usually employed in de- tecting Strictures, is exceedingly faulty, as the bougie fre- quently fails to locate, or even to give the least indication of contractions that are causing serious disturbances. 2d. That there is a definite relation between the circum- ference of the flaccid penis and the circumference of the urethral canal. 3d. That this law established, the treatment of urethral Stricture is immensely simplified, and the chances of its per- fect cure greatly augmented, as by this law we know defi- nitely what must be accomplished to secure a cure, i. e., re- store the canal in its entirety to its normal calibre. 4th. The metallic bulbs given the profession by Dr. Otis, furnish us with an unerring guide, accurately defining the faintest contraction, and enabling the surgeon to record faith- fully and treat intelligently every case that presents itself. This instrument is very completely supplemented by the urethra-metre, which enables the surgeon to define with one instrument every Stricture, and, by its dial, measure each contraction without changing instruments. 5th. Having defined the contractions and ascertained the calibre to which the canal must be restored, what are the best means of securing the result ? It will be admitted that a Stricture consists of a fibro-plastic band surrounding the entire canal, resilient in character, with a tendency to recon- tract after dilatation. The end of all treatment has been to promote the absorption of the exudates forming these bands, which have interrupted the canal. It is not for me to specify the various methods which have been resorted to, to accom- plish this object, but it will not be disputed, that the profes- sion are nearly a unit in employing the system of gradual dilatation as giving the best results. Indeed, they speak of BY PROF. PEASE. 257 curing Stricture by this method. But as to the best that can be done by this treatment, it is sufficient to quote from two authorities, which express the sentiment of all the author- ities on the subject. Wade, of London, says : " After the patient is pronounced cured by his surgeon, he is obliged to continue the system- atic use (always repulsive and often hazardous) of a sound or flexible bougie for the rest of his life." Hamilton, in his last edition of " Principles and Practice of Surgery," says, " that in whatever manner the relief of the Stricture has been effected, whether by dilatation or rupture, by caustic or incision, the result is the same, the Stricture will inevitably return, unless the use of the instruments is continued. Once a week, during the remainder of his life, the patient must introduce a sound or catheter of the size of No. 12, or he may confidently anticipate, sooner or later, a re- newal of his troubles." With this opinion Dr. Otis takes issue, and asserts that in no sense is a Stricture cured while such means must be con- tinuously resorted to, to keep patent the passage to the bladder. Having given us an accurate method of diagnosing Strictures, he follows it with the general law of a definite relation of the circumference of the flaccid penis to the cir- cumference of the urethral canal, and to effect a cure, this re- lation must be reestablished. My own experience, which now covers more than 100 cases, corroborates the last statement in every instance. Indeed, there is scarcely an exception to the rule, and in every case where the relation has not been observed between these measurements, the operations I have made have required rep- etition. Finally, he has given us the best instrument yet devised to overcome the mechanical difficulties to be en- countered. His urethrotome combines all the good qualities of a divulsor, and supplements it with a blade capable of most ac- curate adjustment; in this respect superior to the urethro- tomes of Maisonneuve and Civiale, as it may be expanded 17 258 THE AUTHOR'S CLAIMS CONFIRMED to a degree sufficient to divide any Stricture fibres that may be traversed by its blade. Dr. Otis asserts that Strictures divided by this instrument, or by any other, in accordance with the irrevocable law, of complete division of every fibre, followed by the daily use of sounds of the full capacity of the canal, until all bleeding ceases, will accomplish a speedy cure. We have, by the propositions submitted, an accurate and scientific method of treating a dangerous and repulsive disease, instead of an arbitrary, unscientific and universally-conceded unsuccessful means of removing a common and distressing surgical malady. Professor Otis invites the profession to a trial of his methods, to an examination of his statements, and asks, that having examined and tested, we give the re- sults of our investigations and experience, that an intelligent opinion may be formed of what is conceded to be a new de- parture in urethral surgery, so that it may stand or fall by such honest and searching investigation. In accordance with this request I herewith submit a report of forty-five cases, nearly all of which have been recently examined, and the results of which are presented w7ith an earnest desire that they may incite the examination the importance of the subject demands. The tabulated statement accompanying this paper con- tains a number of cases of special interest. No. 12 was a case of long standing, and had been treated with sounds for a considerable time, but when their use was relinquished, the contraction immediately reappeared, bring- ing with it a train of disagreeable and painful symptoms. The operations made have effected a perfect cure, as an ex- amination on the 19th ult. reveals not a trace of Stricture. The operation in this case was followed by a downward curv- ature, which persisted for more than a year. It has now ceased. No. 16 had been under my care for two years, constantly treated with bougies, and the Stricture persistently re-con- tracting. The patient is cured, as a recent examination BY PROF. PEASE. 259 indicates a canal restored to its normal calibre at every point. No. 13 is a case full of interest, as showing the reflex effect of these difficulties, as the pain in his testicles and legs has been entirely removed for several months, but reappearing upon recontraction, to disappear again upon severing the strictured bands. When the first two operations were made, I was a novice in this method of treatment, and worked tim- idly. The last operation shows a satisfactory result, and, I believe, there will be no further return of his difficulty. No. 21 is a crucial test of the efficacy of thorough division of Strictures by incision, as this patient has been under my personal care for the last ten years, all of which time his Strictures were dilated from 12 to 15 English scale, and the sound constantly indicated contraction at the mem- branous portion. The bulbous sounds and the urethra-metre defined Strictures at the meatus, a second, at one inch, and a third, at one and three-quarter inches. These were cut by the meatome and dilating urethrotome to 35 ; when a 34 sound passed by its own weight into the bladder, without obstruction or resistance at the membranous portion—the ap- parent Stricture proving to have been wholly spasmodic. The result is entire recovery, with his urethra restored to its full capacity. It is more than a year since the operation, and on the 20th ult. there were no signs of recontraction. Nos. 3, 6 and 11 were cases presenting many points of great interest, but neither space nor time will permit me to comment upon them as they deserve. If in No. 3 a perfect result has not been secured, the im- provement is so satisfactory as to at least fill the patient with gratitude. No Strictures remain, the prostatic enlargement is very considerably diminished, the involuntary micturition ended, and manly vigor taking the place of feebleness of body and mind. No. 31 was followed by urethral fever of a severe char- acter, confining him to his bed for two weeks. All special treatment being suspended during the attack, it was followed 260 THE AUTHOR'S CLAIMS CONFIRMED by considerable recontraction. The second operation was followed by no bad symptom. Recovery complete, as reex- amination one year after evinces. In two cases, 14 and 26, there was severe haemorrhage, but there was no difficulty in checking it. In 26, it is singular that so soon after the operation, the diabetes should have disappeared. I do not know that it had any influence over the diabetic disease—it certainly did not if the difficulty grew out of cirrhosis of the liver, for this pro gressed to his death ; but if the disease depended upon cere- bral irritation, then it is altogether probable that it very greatly influenced it, if it did not entirely remove it. No. 42 is of special interest. At my first visit, July, 1876, I found this patient suffering from acute cystitis, nephritis and urethritis. His age was sixty. Twenty years prior he had had gonorrhoea. Had been treated within a few years for enlarged prostate. At this time he micturated every half hour ; bladder, however, could only be emptied by catheter. Otis's urethra-metre passed back to the bulbo-membranous portion, and turned up to 33—not quite the capacity of the urethra—detected, on withdrawal, Strictures at 4! inches and others not well defined, because of the severe urethritis ante- rior to this. A No. 12 catheter passed without much diffi- culty. The inflammation increased until an abscess formed just anterior to the scrotum, and discharged urine and pus, leav- ing about four inches from the meatus, a fistulous opening through the raphe into the canal. From this time the acute symptoms subsided, the nephritis gradually ceased, and con- valescence was established with the fistula remaining. May 19th, ult. Operated to relieve the Strictures anterior to fistu- lous opening, of which there was one at 3f inches, calibre 34, one at 2 inches, 35, and another at il inches contracted to 34, cutting them all to 36. May 29th. All bleeding having ceased upon the passage of the sound, I operated to close the fistula, which was suc- cessfully done over a 36 sound. BY PROF. PEASE. 26l An examination on the 18th inst., gave passage to a 36 sound, without obstruction. No prostatic enlargement. The forty-five cases tabulated comprise less than one- half of those I have operated upon in private and hospital practice. My record shows over 100 cases, but many are now under treatment, and others have passed so far beyond my observation, that I have not included them in this state- ment ; but I may say, that I am yet to meet with the patient who complains of results attained, while to the medical gen- tlemen who have observed some of these cases to their con- clusion, it has brought convincing proof that we have entered upon a new era in urethral surgery ; that the opprobrium may be removed of pronouncing a patient cured of a disa- greeable malady, and yet dooming him to the constant use of an instrument, always more or less painful, and often dan- gerous in its employment. There has been a remarkable immunity from accidents. In but one case have I seen urethral fever; in but two severe haemorrhage ; in but two cases have anaesthetics been used ; in but two cases have the patients been confined to their rooms beyond one day, and, on the whole, I am confident that accidents occur less frequently by this method than even by gradual dilatation. There is good reason for this. Nearly all, in fact all the authorities state, that Strictures more fre- quently occur near the bulbo-membranous portion, and, con- sequently, sounds are passed the whole length of the urethral canal, whereas my statistics show that but a small propor- tion of Strictures occur in this vicinity, and when those anterior to the bulb are divided thoroughly, those in the bulbo-membranous portion are found to have been spasmodic. Another fact—all but five of my cases have a his- tory of gonorrhcea, many of them mild cases, yet they left their mark on the delicate tissues leading to the bladder, and finally developed into dangerous maladies. I will close my paper by calling attention to a few facts elicited by my tabulated record : 262 SYNOPSIS OF RESULTS IN 45 CASES. Normal Urethral Calibre. No. of Times. No. of Times. 32 mm. in circumference......... 8 38 mm. in circumference......... 1 33 " " ......... 5 40 " " ......... 4 34 " ......... 15 ---- 35 " " ......... 4 Total.................... 45 36 " " ......... 10 Locality of Strictures. First quarter inch.........---- 26 4i~5t in....................... 7 J-iiin...................... i8 5}-6Jin...................... 2 i^-2jin...................... 25 6^-7jin....................... 7 2f-3}in..................... 37 ---- 3^-4^ in..................... 21 Total...................... 143 Cures reexamined ; no recontraction................................ 24 Cures—Patient perfectly well when last heard from ; no reexamination . 14 Perfect relief for a length of time , return of symptoms ; reexaminations ; Stricture recontracted .....................,................. I Relief of most symptoms ; some remaining ; patient still under treatment. 5 Partial relief.................................................... 1 Total...................................................... 45 Date of reexamination. Cures reexamined. No recontractions. One month...................................................... I Two months.................................................... I Four months.................................................... I Six months....................................................... 4 Eight months.................................................... I Nine months.........................................w.......... 2 One year....................................................... 8 One and one-quarter years......................................... 2 One and one-half years............................................. 3 Two years........................................................ T Total, 24 AUTHOR'S NOTE. 263 The practical value of Prof. Pease's experience as shown in the foregoing 45 Tabulated Cases of Urethral Stricture, appears to me to be very great. All were operated on by the method of Dilating Urethrotomy, and in exact conformity with the plans and requirements which have been described and enforced in the pre- vious pages of this volume. Prof. Pease had received no individual instruction from me in regard to the operative measures. Our only personal association at that time consisted in three or four consultations in special cases. Beyond this his only opportunities for becoming familiar with my views, experience, and modes of procedure, were through my contributions to the various medical journals, to which the entire profession equally had access. Prof. Pease brought to the sub- ject a ripe surgical experience ; an earnest and generous spirit; and a willingness to test fairly the truth or falsity of statements in regard to vital points in genito- urinary surgery which I had made with such positiveness that they became simple questions of veracity. The results of the independent experience of Prof. Pease, thus acquired, is shown to have been productive of success, even better than I have ever claimed, and to have confirmed every statement of mine in the minutest particulars. Located in an interior city where the persons operated on were res- idents, many of whom had also been under his personal observation and treat- ment by old methods, for a long time previous to operation, his facilities for learning the antecedents of cases, and for making re-examinations were superior to mine, and he has been thus able to confirm, in the most positive manner, my claims as to the radical cure of Urethral Stricture. In evidence of increasing interest in the subject, since the reading of his pa- per before the State Medical Society, in 1877, I am able to state that in May, 1878, during a transient stay in Vienna, Prof. Pease gave demonstrations of my views, and of the capacity and uses of my instruments, and that, during the same month, he operated by Dilating Urethrotomy, with success, in the Clinique of Prof. M. Verneuil, of Paris. F. N. O. STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. Cause and Date of. 26 34 rt J3 i> £> m O 1 9 z Condition at Date of Operation. 29 Gonorrhoea ii 1870, '72, '73 First attack 5 years pre vious. Gonorrhce a 1866, 9 years previous. Had gonor- rhoea once when nine- teen. Had been an ona- nist, had also been addict- ed to excess- ive venery. Two attacks gono r r h ce a First, 13 yrs. previous, the second 11. Meatus. 22 I Meat. 24 2 if in. 29 3 2j in. 30 I Meat. IQ 2 2\ in. 24 3 3 m- 34 4 3\ m. 34 5 Mem- 34 bran- ous por- tion. I 2\ in. 30 2 3\ m. 29 3 3\ ">■ 24 4 6| in. 32 34,Gleet................. Gleet 35 Desire to frequently uri- nate, rising two o r three times nightly. Slight gleet. 36 Involuntary discharge o f water. Complete loss of virility, having had no erection for nearly a year.* 33(Gleet. At times muco- purulent discharge. Gleet Enlarged prostate. Partial paralysis of neck of bladder. Gleet. Results. Cure Complete cure Entire removal of stricture, restora- tion of virility, con- st a n t improvement in tone of bladder. Cure One year after. Perfect relief. 2 years after. No change. March, 1877. Cure com- plete. Seen also by Doctor Otis's assist- ant. to * Additional treatment in Number 3 : Galvanism to neck of bladder. 5 22 4i Had gonor- rhoea twice. First attack two years previous, last attack just before opera- tion. Gonorrhcea 3 times. First, 16 years be- fore opera- tion. Second and third, re spectively, g and 5 yeart ago. lad gonor- rhoea. First attack 23 yrs. previous, the second when 22 yrs. of age. gonorrhoea five years before examination. 5 in. 3i in- 1 Meat. 2 2\ in. 3 4f in- 4 7 in. 24 34 I Meat. 2 11 in. 3 2| in. 4 32 in- 1 Meat. 2 2 in. 3 3i in. 4 4»- in. 5 5i in- Gleet 40 19 34 During five years pre- vious to operation, there was a constant gleety discharge. Urine passed " stilli- cidium," loaded with mucus. Is lame. Strength impaired. General condition very much reduced. Meatus passed N o. 19, but 3 inches pos- terior to this nothing but a filiform bougie can pass.f Difficulty in micturition, Frequent desire to urinate. 32 Frequent retention of urine. Gleet constant and persistent. t In case 6 : At first urethra was so strictured as not to admit the urethrametre. accurately defined. A filiform bougie was passed, and over ita'Gouley's Dilator. Gleet 1 18 months after. Cure perma- nent. O < Gleet..... 3 Constant improve- Have not seen 1 Cystitis. ment. Three months after opera- him since, and hence < tion left, although cannot state greatly improved, present condi- n > not entirely cured. tion. W O a w H X 70 1 Since died of cancer of stomach. > an H 7i a H Gleet..... 3 Greatly improved, but treatment in- a terrupted by attack of typhoid fever. Symptoms all re- Ni lieved. consequently, althou^ ' By this means a n E ;h there were many other strictures they wore nevei was introduced as preliminary to the final operation. STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. to Cause and Date of. ni jS V D 4) O 3 i> .n rt VI U O F. U N i/3 z 34 37 32 Had gonor- rhoea fifteen years before, also eight. Gonorrhoea. First attack 15 years pre- vious, second attack a few months be- fore. First attack gonorrhoea 2 years before, last I year. 1 Meat. 2 2^ in. 3 3i in. 4 6£ in. Meatus. 7 1 Meat. 2 i-J- in. 3 *\ in. 4'2f in. 5 3i in- 6 4-£ in. 7 f>i in. Condition at Date of Operation. 34 36 At times retention of Gleet urine. Gleet. Suffering from gleety dis- charge since last attack, 40 Gleet. Frequent calls to urinate at night. At times no control over bladder. Smarting sen- sations. Gleet Gleet. Results. Believe him to be cured, although he has not reported since dis- charged. Cured............... Every Stricture relieved except one at bl in. which now admits 38. Will operate again when patient, who is out of town, returns. Gleet, as also every other symptom, com pletely relieved. Six months after operation. No recontraction. 12 45 13 35 14 3§ 15 35 Gonorrhoea 23 yrs. ago, also 20 yrs. since, and probably 2 yrs. ago. Gonorrhcea 16 yrs. previous, also 15. Had gonor- rhcea 8 years since, second attack 18 months ago, la-t time, 3 or 4 months since. Gonorrhoea one year before. r Meat. 2 2f in. 3 3| in- 1 3f m 1 Meat. 2 1} in. 3 3 in. 4 t\ in. 1 1 in. 2 4 in. 34 36 40 Interiiiption of stream in urinating. Tickling sensation in urethra. Has had syphilis. Suffer- ing intense pain in tes tides. Has had gleety discharge for last two months. Gleety discharge Gleet. Balanitis and phy- mosis, re- quiring an opera tion to relieve adhesion of the foreskin. Gleet..... Gleet. Grow- ing out of 2d op- era- tion. there is a slight down- ward curva- ture of penis. Cured Very much hemor- rhage, slight curva- ture. Neuralgia of testicles greatly relieved. Man of irregular habits, and treatment inter- rupted. However, being now treated. Gleet entirely ceased. Cure One year after operation. Completely cured. Curv- ature rapidly -disappearing. » One year, sixteen days after op- eration. Re- exammat lon detects no Strictures. 9 months after. No return. < w n > an M 'Ji O *3 M H X > f XT. H 50 p—i O H a STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. j3 4) Cause and u 3 0 u 3 0 0 0 Condition at Date of c d OJ u !E '5 0 < a ni X U 0) Oi 16 24 Gonorrhoea 3 years ago, 3 1 32 Frequent retention of Gleet .... 1 One and a half years after. Cure perfect. 2 2 in. urine. Persistent gleet. second attack 3 61 in. 20 Had been treated for 2 years, last nearly 3 years by bou- attack 3 mos. gies. before opera- tion. i; 23 Had gonor-rhoea in 1 Meatus. 24 36 Gleet ... I Rapidly recovered..... 6 months after. Cure. spring and fall of year previous. 18 28 Gonorrhcea 7 years previ- 4 I Meat. 22 24 32 Persistent gleety d i s -charge. Gleet, 2 One year after operation. No 2 1 in. ous to exami- 3 H in. 29 recontraction. nation. Also 4 2$ in. 29 5 years, and Also again con- several tracted it bands nearly a year b'tween ago. H & 2j inches. : to ON 00 19 35 4i 47 23 6o Gonorrhoea one year before operation. Gonorrhoea u years previ- ous. Had gonor- rhcea 30 yrs, before. Gonorrhoea six years before, again 4, and lastly 1 or 2 years ago Gonorrhoea years ago. 40 I i in- 29 35 3 1 2} in 22 36 2 3 m. 22 3 5 m- 35 3 1 Meat. 19 34 2 1 in. 21 3 2f in. 24 4 1 Meat. 21 36 2 | in. 27 3 2 in. 30 4 3 m 30 2 1 Meat. 19 34 2 2\ in. 32 Gleety discharge, appear- ing and disappearing. For about five months had been pestered with frequent desire to uri- nate. Must rise al night. Had been treated for last ten years with bougies Has had gleety discharge since last attack gon orrhcea. Has for some years been troubled both in pass- ing and with retention of urine. Had been treated for cystitis and enlarged prostate. Orchitis Gleet. Phymo- sis which was re- lieved prior to operation for strict- ure. Cured Symptoms completely relieved. Complete cure. Strict- ure apparently a t membranous portion proved to be spas modic. Cure Cured A little more than one year after. Cure permanent. One year after, when I find slight recon- tractions at 3 and 5 in. Not yet relieved. 6 months after. Cure perfect. t\ years after. Complete cure. Nine mos. after. Cured. *1 O H h> I h-i < W n > o el w H X > rO w H o H a 10 VO STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. i XL c 0 T. cu c cS .2 u '0 CJ B a X 0) "z. < 1 Z J ! i^ £ O Z < <* 24 38 Gonorrhcea 10 years previ- 6 I Meat. 28 34 Since last attack of gonor-rhoea there has been a Gleet .... 1 Was cured, but has had gonorrhoea since, with 2 11- in. ous, again 1 3 ii in. 26 constant gleet. At that either the formation year before 4 H in. 27 time examined him by of a new Stricture or present e x - 5 H in. 2S old method and thought recontraction of old amination. 6 3 in. 32 that I discovered a Stricture at bulbo-mem-branous portion, and another in the spongy. Was treated then with sound, and greatly re-lieved, but now returns, suffering from a renewal of the gleet. one at 2^ in. 25 33 Gonorrhoea 3 years ago. 4 1 \ in. 2 i| in. 19 22 36 Has had more or less gleety discharge since Gleet. I 8 months after. Cure com- Again 1 year 3 2 in. 22 last gonorrhoeal attack. plete. later. 4 3 in. 28 to O 2&53 Had gonor rhcea 20 yrs ago. 27 28 29 3° 19 25 39 Gonorrhoea 11 yrs. previous. also 9 vs. since, and again month before operation. Gonorrhoea one year before. Had gonor rhcea 8 years previous. Gonorrhoea 16 years ago, several linie^ 1 Meat. 2 i£ in. 3 2j in. 4 3i in 1 H 2 2 33 1 f in 2 2\ in 3 3 in 1 Meat. 2 2\ in. 3 2| 4 3i 1 f 2 2j 3 5 34 35 32 34 35 Urethra very sensitive. Sense of constriction over hypogastric region. Frequent desire to mic- turate. Gleety discharge. Gleet Has had an induration in left groin extending from lower part of the femor- al ring to ant. sup. spin- ous process of ilium. Also has had a constant gleet since last attack gonorrhoea. Persistent gleet. Fre- quently passing into mu- co-purulent discharge, resisting all medication and injections. Meatus contracted by syphilitic ulcer. Hem- Cure of Stricture. Re lief of diabetes ; how much is due to Strict- ure I cannot say. Cure Cure Cure All anterior to 5 inches, cured. This one re- contracted. Will op- erate soon. Gleet cured. Since died of cirrhosis of the liver. One year and a quarter years after. No re- turn. O H i<; I <—< < w n > o *j a M H X Pi > r in H 7i o H C *> w to STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. W to Cause and Date of. 31 40 Gonorrhoea 13 years before, again I year later, and fi nally, just prior to op eration. 1 34 2 2\ 3 3| 4 5| in 1 Z Condition at Date of Operation. 6 0 a 0 H O 2 I 32 47 33 34 27 35 36 37 38 39 33 24 Congenital nar- rowing of meatus. Gonorrhcea 3 years previ- Has had gonor r h ce a three times : 7, and 3 years respect i ve 1) before exami nation. Gonorrhoea sev- eral times. Gonorrhoea six years before. 23 35 26 Gonorrhcea mild attack 3 years ago. Thirteen mos since had gonorrhcea. Gonorrhcea sev eral times. 1 Meatus. 1 Meat. 2 2\ in I Meat 18 33 3 2| 44 1 Meat 2 if in 1 \ in 2 \\ in 3 2^ in. I Meat. 2 t\ in. 3 2^ in 4 3| i" 1 Meat 2 \ in. 3 2f in. 4 3l in. 32 32 33 Feeling of titillation along urethra, believes it to be due to retention of a few drops of urine after mic- turition. A recurring gleety dis- charge. There is a membranous bridge across the meatus, which in micturating produces a double stream. Constantly recurring gleety discharge. Gleety discharge. 32 33 36 34 Burning sensation in pass- ing water; stream con t r a c t e d ; gleety dis charge. Great difficulty in uri nating and also some smarting. Gleet. Gleety discharge. Had not subsided since at- tack gonorrhcea. Persistent charge. gleety d i s Syphilis Syphilis Gleet. Gleet. Gleet. Gleet. Gleet. Complete relief every symptom. from Cure Cure Cure Cure Cure Still under treatment. Gleet ceased. Six mos. after. Recurrence of no bad symp toms. One year after. No return of any contrac- tion or symp- tom. Four months after. No change. One year after. Cure perma- nent. Three m on th s after. Reveals complete cure. O pi H I h-l < M n > W in O a *j w H pi > in H pi O H a Pi M to STATISTICAL TABLES OF FORTY-FIVE CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. to 4>- Cause and Date of. 2 X H O 3 40 4i 23 48 Never had gon- orrhoea. Pro- bably of trau- matic origin. Never had spe- cific urethritis 1 2{ in. 2 3X in 3 3? in I Meat. 2 2# in. 36Could not expel all of urine from urethra; what remained scalded him. Any indulgence in ale or stimulating food induced smarting. Meatus had been cut before seeing; me. 34 For ten or fifteen yrs. has suffered with constant desire to urinate. Find a membranous band ex- tending over upper part of meatus, contracting its orifice by one-half. Cured Patient not ready for cutting posterior Stricture. Greatly relieved by first op eration. 42 6o 43 44 25 4? Thirty years ago had gon- orrhoea. 45 49 Gonorrhoea four times Last attack in 1876. Has had gonor rhcea several times within last 23 years Gonor rhcea Last attack two years since. 1 I* 2 2 3 JT 4 4s I f in. 2 if in. 3 2f in. 4 3i in. 1 I in. 2 3f in. 3 4i in. 3 3 24 36 40 Ten months before opera- tion, had an attack of cystitis. Frequent de- sire to micturate. Al- bumen and casts in urine. Urethral hem- orrhage ; resulting in perforation of urethra and formation of fistula at 41 inches. Incontinence of urine. Gleet. When first ex- amined, contraction so close as to require dila- tation several days prior to operation. Nine years before had an attack of paraplegia. Since this attack, has had paralysis of neck of bladder requiring the daily use of the cath- eter. Scalding sensation on passing urine. At times retention ; must arise three times nightly. 1 1 1 1 Operation to close fistu- lous opening made May 29, 1877, entirely successful. At present no albumen or casts in urine. Apparently a cure. Still under treatment. Begins to pass urine slightly without cath eter. Considerably improved. Cure All present indi- cations point to a perfect cure. to Or CHAPTER XIV. MEMOIR TO THE FRENCH ACADEMY. IN July 1877, through the courtesy of M. Verneuil, of Paris, a Memoir was sent by me to the National Academy of France, embodying, in a form as brief as was consistent with fairness, the views, experience and discussions which are given at length in the foregoing pages. The results of the further study and experience in the nature and treatment of urethral Strictures, from the date of my address to the New York State Medical Society, in February, 1865, up to May, 1877, were also added. In order to place fully upon record in this country the views and statements contained in this Memoir, I have thought it best to reproduce them in this place, making such alterations and additions as are necessary to bring the subject in full up to this date, July, 1878. My experience in the division of Strictures by the methods described, cover at this date (July, 1878), a period of nearly seven years, during which time I have operated by internal urethrotomy over six hundred times. In ninety-six cases at my clinique at the College of Physicians and Sur- geons ; fifty in my service at the Strangers, Charity and St. Elizabeth Hospitals, and the remainder in my private practice. One hundred of these cases comprising 203 opera- tions, carefully tabulated from my private records by my then assistant, Dr. J. Fuhs, were reported to the New York State Medical Society in 1875, and appear on page 106, et seq., of this volume. One hundred and thirty-six additional cases recently tabulated from the same source and in the same manner will be found at the close of this volume, making a PLAN OF M. REYBARD. 277 total of 236 tabulated cases which include the results of 373 operations on urethral Strictures. The total number which I have performed and recorded up to June 20, 1878, is 635.* Thus far in operating with the dilating urethrotome (which was the instrument employed in every case, except when the Stricture was at the meatus), / have not met with a single death resulting from, or attributable in any way to, the opera- tion. This statement will, I presume, be received with sur- prise by surgeons who are practically unfamiliar with the operation by means of the dilating urethrotome. It must, however, be borne in mind ; 1. That, in the greater propor- tion of cases, the Stricture did not encroach upon the urethral calibre sufficiently to interfere markedly with the flow of urine, and hence were not complicated to any great extent by disease of the bladder or kidney; 2. That vastly the greater number were anterior to the bulbo-membranous junction ; 3. That the incisions were never made zvith a blade exceeding 2 mm. in breadth. Dilating urethrotomy in France is necessarily associated with the name of M. Reybard, who first recognized the neces- sity of complete division of Stricture as essential to radical cure. By M. Reybard's plan deep and long incisions were deemed essential, and the knife of his instrument measured nearly two centimetres on its cutting edge. Serious results after operation with this instrument were said to have been frequent. My dilating urethrotome, the blade of which should never exceed 2 mm. in width, was invented by me to meet special cases occurring in my practice. It was made and had been in use for nearly two years before I knew of the invention of M. Reybard. My first idea, and which has not yet been materially departed from up to the present time, was, by means of a dilating apparatus, to fix and thin the Stricture, so that a slight incision would suffice to sunder it. My plan has been alzvays to avoid deep incis- ions, and as far as practicable to avoid dividing healthy tis- * I have also operated upon quite a number of cases in the practice»of other surgeons, the records of which are not included in this number. 278 DILATING URETHROTOMY. sues. To these facts and to the peculiar character of my ope- rations I attribute my great immunity from surgical accidents. Between the years 1874 and 1876 I made various changes in minor points about my dilating urethrotome, with a view to increasing its ease of application, and the safety of its use. The chief alteration from the original was the attachment of a guard to the summit of the blade, in order, after the plan of M. Maisonneuve, to divide only stricture-tissue. After a time, however, it was found that slight and resilient Strictures often escaped complete division, and always unless the over- distension was very great. I therefore removed the guard and concealed the blade in a slit at the end of the shaft. I likewise had the instrument made straight and short, for more convenient use in the straight portion of the canal THE AUTHOR'S STRAIGHT DILATING URETHROTOME. where, fortunately, according to my observations, much the greater proportion of Strictures are to be found. Heretofore all operations by internal urethrotomy have been performed as a last resort, after failure to obtain relief by other methods. It thus happens that a very large proportion of such cases have been the subject of advanced disease of the bladder and kidneys. The simple introduction of a sound or catheter where such organic disease is present has not un- frequently caused urethral fever, suppression of urine and death. It has therefore come to pass that the operation of internal urethrotomy, necessitated in these desperate cases, has been held responsible for fatal issues which were likely to result from any mode of interference. I am able to state with confidence, that complete division of all Strictures anterior to the bulbous urethra, (i. e. from five to six inches) by dilating urethrotomy properly performed, is one of the simplest and safest of all surgical operations ; that in the very largest pro- SAFETY OF THE OPERATION. 279 portion of cases it is uncomplicated by a simple accompani- ment which can be termed an accident, and that the recovery- is, as a rule, practically complete in from three days to a fort- night after the operation—the variation depending upon the number, depth and calibre of the Strictures. Even in cases of organic disease of the bladder and kidneys, division of Stricture in the ante-bulbous urethra, (strictly avoiding the passage of any instrument into the blad- der) is less perilous than the passage of a catheter or sound through the deep urethra either for relieving a retention, or for purposes of dilatation. I am able to state, still farther, that the very great majority of all supposed deep Strictures presenting for treatment are anterior to the bulbous urethra. In the ist series, (one hundred tabulated cases,) Stricture was found beyond five inches from the urethral orifice, fourteen times (page 97). In the second series, 137 cases, only eleven times. Prof. Brown (page 243) states that " out of nearly 100 Strict- ures, including many that are usually considered impermeable at least 75 per cent, zvere found within the anterior 4\ inches." Prof. Pease (page 262) shows that " out of 129 Strictures but 7 were at or posterior to the bulbo-membranous junction." It is greatly due to an appreciation of this fact, that opera- tion in the deep urethra is so rarely necessary ; this renders the risk of operation for by far the greatest number of ure- thral Strictures, comparatively insignificant. This statement is eminently proved by my own experience with not a death in over 635 consecutive operations. Dr. Mastin's experience p. 248 in 296 " Prof. Brown's, page 237, over 300 Prof. Pease, p. 262 over 100 " " Thus making a grand total of 1331 operations, consecutive- ly, without a single death or permanent disability of any sort. While, however, it is true that very much the largest proportion of cases in which Strictures are divided by dilating urethrotomy are quite free from complications, yet from the 28o DILATING URETHROTOMY. very nature of the structures involved it will be seen that care, judgment, and experience, are necessary in the procedure, to anticipate possible accidents. A certain amount of haemor- rhage of necessity occurs where vascular tissues are incised. This is so certain and so readily controlled, and so often ceas- ing spontaneously in a few moments, that it cannot be looked upon as an accident, unless in spite of the ordinary measures used to control it, an excessive quantity of blood is lost. In the summary of the 236 tabulated cases at pp. 106 and 324, it will be seen that this accident occurred only four times, and that in each instance the operation was in the deep urethra, always posterior to five inches. Inasmuch, however, as such cases are liable to occur in the practice of others, I shall present my entire experience in this accident, and also in the other acci- dents or complications which may be met in operations look- ing to the complete restoration of contracted urethrae in every part of their course. 1st. Haemorrhage. This is likely to be most free where the Strictures divided are narrow and resilient. In these over dis- tension to an unusual extent is occasionally required in order to divide the Stricture completely. The wound may thus extend well into the trabecular structure of the corpus spon- giosum. In such cases, the haemorrhage does not usually occur at once, but during a subsequent engorgement or partial erection of the penis, hence most commonly at night. To guard against this accident all patients should be required to remain in bed or on a lounge for a day or two subsequent to operations on the anterior portion of the urethra, say as far back as three inches from the meatus. In all cases where the operation is in the near vicinity of the bulb, or in the curved portion of the canal, the recumbent position should be insisted on for three or four days and a strict surveillance until all danger of haemorrhage has passed, which I do not consider to be less than one week. When an attendant is not available a soft rubber tube one or two sizes smaller than the normal calibre of the canal, may be inserted and retained by a light bandage for one, two or three days, according to the necessities HEMORRHAGE PREVENTED. 28l in any given case. If the tube is not worn from the first it may be introduced to protect the surface of the wound during urination, for a day or two. In very sensitive persons, I have had the bladder habitually emptied by means of a small soft-rubber catheter. Contact of the urine with the fresh incisions, often painful, may be thus avoided, with the addi- tional benefit of preventing the liability to urethral fever. The occurrence of urethral fever, however, rarely follows operations in the penile urethra. An admirable method of arresting haemorrhage in the pendulous urethra and especially at or near the meatus urinarius has been devised by Dr. George K. Smith, Prof, of and encircled, when in position, by half-a-dozen narrow India- rubber bands. Small notches in the splints keep the bands from slipping and the amount of pressure may be easily regu- lated by the number or size of the bands. I have never found it necessary to make enough pressure to give the patient any discomfort. Simple separation of the splints is sufficient to permit urination without removing them. Haemorrhage from division of Stricture in the deeper por- tions of the canal, from the difficulty in retaining a tube, or in making efficient external pressure, is sometimes embarrassing, especially so as the efforts to arrest it may cause the blood to be forced backward into the bladder. I have never failed to appreciate the liability to this complication whenever operating near the bulb or in the curved portion of the urethra, and have been so fortunate as to have met with but four cases in my own experience : three from internal ure- throtomy, and one from combined internal urethrotomy and 282 DILATING URETHROTOMY. external perineal section. The first case was in 1874, in a patient, at the Roosevelt Hospital, who had a close Stricture extending quite to the prostatic urethra. A heavily guarded Maisonneuve blade 6 mm. in breadth was adapted to my first urethrotome and used in the expectation that nothing but Stricture tissue would be divided. The operation was fol- lowed by haemorrhage into the surrounding urethral tissue and into the bladder, and was soon complicated with reten- tion of urine. To relieve this, and to afford exit to the ex- travasated blood, and also to effectually command the point of haemorrhage, I made the perineal section. The patient made a slow but complete recovery, and wrote me a year after that he had no return of his Stricture. This was the first and last use of so broad a blade. Two to three millimetres breadth have since been found sufficient for a guarded blade and two for a blade unguarded. The second case occurred in February, 1877, after external perineal section for devep-seated Stricture, and internal dilat- ing urethrotomy for several Strictures in the penile urethra. On the 12th day, the external wound having nearly healed, copious haemorrhage from the deep urethra occurred several times, but was readily controlled by a few moments' pressure against the perineum, and by means of a finger in the rec- tum. Recurrence took place, however, frequently, and on the third day (i. e. the 15 th after the operation) I was called in consultation, and found the bladder distended with blood nearly up to the umbilicus. Introducing a No. 34 F. silver catheter, I emptied the bladder of nearly three pints of clotted blood and urine, and left the catheter in. No further haemorrhage occurred, the catheter was retained, without great discomfort, for nearly three days, and beyond setting up profuse urethral discharge produced apparently no bad effects. The third case occurred in June, 1877, where two very resilient Strictures of large calibre (defined by a 34 F. bulb in a urethra of 40 F.) were divided, at five and six inches from the meatus. The haemorrhage came on about an hour after THE PERINEAL CRUTCH. 283 the operation, during an attempt at urination. The patient was absolutely intolerant of a sound in his urethra, and resisted the introduction of ice into the rectum. No external application of ice, nor any pressure with the finger or by compresses retained by bandages passing around the hips, nor the free internal use of matico could effect more than a temporary arrest of the haemorrhage. This was quite free, alarmingly so at times, issuing externally with a gush, at intervals of several hours, and also oozing more or less steadily into the bladder. During the two days of its con- tinuance the bladder was thrice emptied of clots which caused severe and persistent vesical tenesmus. By this time the patient was considerably exsanguinated, and it became evident that a fatal issue threatened unless the haemorrhage was soon arrested. Preparations were then made for an external G.HtMANH &CO Y\ PERINEAL CRUTCH. perineal section, in order to gain direct access to the bleeding point, when the sight of an old crutch in the adjoining bath- room suggested a mode of relief which proved efficient. A folded towel was placed in the perineum, and to it the curved shoulder piece of the crutch was applied, bringing its other end down against the foot-board of the bed. The weight of the patient's body gave the desired counter pressure which he could regulate at will. Not the slightest oozing of blood occurred after this, and the patient made a prompt recovery. A board of proper length and width sufficiently padded would answer the same purpose in a similar case. The fourth instance was in a man who had been operated on in Syracuse, by Prof. Pease, for close and dense Strictures at various points in the canal, from the meatus to the pros- tate. Re-contraction had occurred, and a second operation was done in one of the principal New York hospitals with like result. Through the invitation of the visiting surgeon in 284 DILATING URETHROTOMY. charge of the case, I was invited to do the third operation, in March, 1877. All the anterior Strictures were divided, raising the urethral calibre from a filiform size, to which the urethra had re-contracted, up to 36 F. The operation was commenced with the urethrotome of M. Maisonneuve and completed as far as the bulb with my straight dilating ure- throtome. Two Strictures were ascertained to be present, at six and six and a half inches, of a calibre of 30 F. The danger of haemorrhage from the division of these Strictures was fully recognized, but the crutch used in the previous case with so much success was relied upon to arrest it, and the deep Strictures divided to 36 F. Quite free bleeding followed and was thought to come chiefly from the anterior incisions. Pressure wras made by a broad bandage around the penis, and the patient was taken from the operating room to his bed in the ward. An attempt was made to apply pressure in the perineum by means of the crutch but in- stead of a foot-board there was only an iron rod at the foot of the bed and so much delay ensued in arranging a rest- ing place for the lower end of the crutch that the bladder became distended with blood nearly to the umbilicus, and solidly coagulated. Perineal section was considered but the man's pulse was good, and it was thought that the pressure of the distended bladder might act as a preventive of farther serious loss. An hour later my large 34 F. silver catheter was introduced and retained without trouble, for twenty-four hours, when a sharp urethral chill set in ; this passed off, however, and the catheter was retained for 24 hours longer; when re- moved, some twenty ounces of clots were discharged from the bladder. The patient did perfectly well, and when re- examined by me about a month after, presented no trace of Stricture. In order to prevent as far as possible the recurrence of em- barrassment and trouble from lack of suitable appliances and their ready adaptation in cases of deep haemorrhage, I con- trived an apparatus which I have termed the perineal tour- niquet. By reference to the accompanying cut it will be THE PERINEAL TOURNIQUET. 285 THE AUTHOR S PERINEAL TOURNIQUET. seen that any desired amount of pressure may be brought to bear upon the perineal urethra by means of the thumb screw attached to the hard rubber perineal pad, counter-pressure being secured through the attachment of the perineal straps to a band around the body just above the hips. I have al-1 ready had occasion to test the efficiency of this apparatus in a case, (the only one of the kind in my experience,) where a haemorrhage came on ten days after the operation. It occurred in the daytime and im- mediately following urination, and about four ounces of blood were lost. The introduction of a rubber-tube stopped the haemorrhage at once and completely, but as the deepest Stricture operated on was at about four inches, in order to leave the patient in secur- ity in charge of an attendant I applied the perineal tourniquet. Its action was simply perfect. Placing a folded napkin on the perineum, the apparatus was adjusted and pressure by means of the rub- ber pad was brought to bear upon the urethra at this point. A pressure, more than sufficient to cut off all possible com- munication between the bladder and the urethra as far as the membranous portion, was borne with comfort, and the degree of pressure was fully under the control of the patient by means of the thumb-screw which was within his easy reach. The security against danger from haemorrhage which this appara- tus is capable of affording, is apparently complete in all cases where the division of urethral tissues is not beyond the membranous urethra. It also prevents any haemorrhage into the bladder from division of tissues anterior to this point, as might occur through pressure from any cause, anterior to the bleeding point. The tendency to haemorrhage in all cases is greatly lessened by an application of cold water by means of cloths or, what is better, through the cold water coil.* * Note.—Cold water coil, p. 104. 286 DILATING URETHROTOMY. In the two cases of severe haemorrhage, following internal division of Stricture in the deep urethra, the operation was done with my small straight urethro- tome, with the curved probe-point at- tached to facilitate its passage beyond curved-probe point. the triangular ligament. While this urethrotome, according to my experience, is the most efficient for complete division of Strictures in all parts of the urethra, I have sometimes used the bulbous urethrotome first used in 1874, and presented to the profession in my pamphlet on " Instruments and Appa- ratus," May, 1875. This in shape is like the bulbous sound, so constructed that, after passage through a Strict- ure, a broad blade two to three mm. in breadth concealed in the bulb is drawn forward through the contracted point, by means of a handle which traverses the hollow shaft of the instru- ment. The blade is then pushed back through the Stricture into its place of concealment, and the instrument withdrawn. If the bulb has been of sufficient size to make firm resistance on attempted withdrawal before, and meets with none after incision, it is probable that the test by a bulbous sound of the size of the normal canal will show that the division has been com- plete. The bulbs of this urethrotome are readily changed, and range in size from 20 F. to 40 F. For the division of narrow and dense Strict- ures in the deep urethra, this instrument is often efficient, but it lacks the certainty of action which characterizes the dilating urethrotome. Where, however, it is employed, the incisions are confined more completely to the cicatricial tissue, and, consequently, are less often followed author's bulbous urethrotome. by troublesome haemorrhage. URETHRAL FEVER. 287 A somewhat similar instrument, devised by Prof. S. W. Gross, of Philadelphia, and described in the second edition of "Gross on the Urinary Organs,"i875, is highly commended. My own experience is against the complete efficiency of the instrument in any but exceptional cases; at the same time, I would endorse it as safest in the division of deep Strictures, since it does less violence to the parts, and even is less likely to cause constitutional disturbance, while occasionally it effects a complete sundering of the Stricture. I have been thus particular in considering the accident of haemorrhage in connection with dilating urethrotomy, not because it is frequent, for it will be seen that only two grave cases have occurred from internal urethrotomy alone out of more than 600 operations (I exclude the Roosevelt Hospital case, as this was due to the error of too wide a blade, since corrected), and that in none was the haemorrhage fatal. I am thus strenuous in calling attention to this matter because such an accident may occur in any case of division of deep Strictures and it therefore becomes important to manage every such case as if haemorrhage were expected, and to have in readiness and be familiar with all the measures which are found efficacious in relieving anxiety and danger from this cause. URETHRAL FEVER perhaps stands second in the order of accidents or annoyances occasionally following dilating ure- throtomy. In 375 operations, tabulated on pages 98 and 317, it was noted in 18 cases. This condition, or epi-phenomenon, if it maybe so called, is ushered in with a chill which lasts from a few minutes to an hour, and is followed by a rapid rise in tem- perature, sometimes to 1050. This continues for a few hours, when it declines rapidly, and is succeeded by a more or less copious perspiration. The return to a normal condition and temperature ensues in different cases in from 12 to 48 hours. In a word urethral fever is, in its symptoms and phases, the perfect analogue of periodic malarial fever, and is to be treated in the same manner. I quite agree with Prof. Thomas R. Brown, in the state- 288 DILATING URETHROTOMY. ment in his interesting paper on Urethral Fever published in the N. Y. Med. Journal for Feb. 1878, that it is purely of re- flex origin, and depends upon local irritation, and that when following upon a urethral operation is usually caused by the contact of the urine with the wounded surfaces. This is evi- dent from the fact that the chill rarely comes on until after urination, although this may be delayed for 10 or 12 hours after the operation, and moreover, it may frequently be prevented entirely by drawing off the urine with a small soft rubber catheter, for two or three days. The fact, however, that the simple, easy and bloodless passage of a catheter may be, and not infrequently is, followed by an access of urethral fever, shows that any sort of irritation may induce it. I do not coincide in the opinion that " no condition of health appears to exempt from, or predispose to the attack." I should say that in persons of highly nervous temperament the predis- position to urethral fever is the rule, and any slight mechanical interference may give rise to it. Malarious antecedents in- crease in a marked degree the probability of its occurrence. The presence, likewise, of any disease, acute or chronic, of the deep urethra, prostate gland, bladder or kidneys, is a very great and unmistakable predisposing cause. I, therefore, hold that the previous recognition of any of these conditions is of the highest importance in the treatment of urethral Stricture by any method, and, further that, in cases of long standing urethral trouble, and in all elderly persons, the pas- sage of any instrument through the urethra into the bladder should never be attempted without a preliminary examination of the patient's urine to determine the state of the bladder and kidneys. The predisposition to urethral fever in persons as above described, suggests that all possible precautionary methods should be used to prevent this accident whenever, as is some- times the case, surgical interference becomes imperative. To this end rest in the recumbent position for a day or two is of value. Hot sitz baths, temp., 110 for 3 or 4 minutes morning and night. Muriated tincture of iron and tonic doses of qui- SUPPRESSION OF URINE. 289 nine in persons of debilitated habits. Immediately previous to the proposed operative procedure I am in the habit of ad- ministering five to ten grains of quinine (preferably 10) in pill or capsule, or instead of this, a suppository composed of ten grains of the bisulphate of quinine and a quarter of a grain of the acetate of morphine.* It is not from the fact that urethral fever in such cases is more likely to occur, and with possibly greater severity, than in healthy persons that this predisposi- tion is important, but because when it does occur, the danger of the reflex irritation extending to the ureters and kidneys, and inducing a suppression of urine, is greatly increased, and that suppression so induced is frequently and rapidly fatal. Suppression of urine is recorded in one case, as result- ing from the combined operation of dilating urethrotomy and perineal section. Here it may be interesting to note that the operation was done in the face of the fact (ascertained by repeated examination of the urine) that the patient was suffering from Bright's disease of the kidney, as shown by the presence of hyaline and granular casts with albumen * Opinions of authors, in regard to the value of quinine in averting urethral fever, are greatly at variance, some placing great reliance upon it, others again denying it the least possible influence. My own opinion is, that while this as well as any other known agent occasionally fails to prevent its accession, in the great majority of cases its favorable influence is demonstrable. I will cite a single in- stance. Mr. Y. was a sufferer from traumatic Stricture at six inches from the meatus. He had been under treatment by dilatation for several years, and stated to me that in every instance when dilatation was made by solid sounds or soft bougies, unless he took five grains of quinine at the same time, it was followed, within a few hours, by a severe chill sometimes lasting an hour or more, and suc- ceeded by fever and sweating. That whenever he took quinine he invariably escaped. From that time until the present, some six years, he has been subjected by me to the periodical introduction of instruments, usually soft bougies. On about a dozen different occasions during this period he has forgotten to take the quinine, and each time, the dilatation has been followed by an attack of urethral fever. The dilatation in this case has usually been carried from 20 F. to 30 F. (in a penis of 3 in. circum.) during a period of ten days, instrumentation every other day. Then a period of about three months would be allowed to elapse, by which time recon- traction to about 20 F. would take place and the same round of dilatation would require to be repeated. The nature of this patient's business, necessitating daily attendance, has, for this long period, prevented resort to the operation of dilating urethrotomy. 19 290 DILATING URETHROTOMY. in the urine ; also that he had been confined to his bed with abscesses (caused by extravasation of urine behind Stricture) for nearly two years.* The recovery was complete, re-examination 3 years later demonstrated the radical cure of the Strictures. An occasional annoyance associated with the operation, and most liable to occur in patients of hypersensitive organ- ization, especially subjects of prostatorrhoea or sexual irrita- bility is from painful erections, coming on chiefly at night, and similar to those of acute gonorrhoea. INCURVATION of the PENIS during erection is an occa- sional sequel, being caused by an inflammatory thickening along the superior surface of the urethra at the point of op- eration, where more or less discomfort may be experienced, as during erection this part becomes tense and salient. In 4 cases out of 136 this condition persisted for several weeks, in one for about four months, finally disappearing with- out special treatment. In one case, after the incurvation had lasted a year, I succeeded in relieving the tension by operative measures. Taking advantage of the knowledge gained by M. Reybard in his experiments on dogs (i. e. that transverse sections of the urethral tissues resulted in Stricture, while longitudinal incisions were not open to that objection) I de- vised an instrument, or, rather, I modified my first dilating urethrotome (page 35) so that while distending and fixing the urethral tissues firmly, I might divide them in a diagonal line across the superior aspect of the canal. The accompanying cut will give an idea of the modified instrument. With this, I succeded in dividing the cord com- pletely, giving immedi- ate and perfect relief in onal division. * In this case, after complete suppression for 24 hours, resisting treatment by cups over the loins, hot air baths, hot fomentation, etc., the secretion was appa- rently restored by the administration of 20 grains of calomel, in accordance with a suggestion in regard to such cases from Prof. Willard Parker. DIAGONAL INCISION. 29I one case (when the incurvation was so great as to prevent connection), and immediate though only partial relief to the other, which, however, was finally restored through absorption following the operation. It may be interesting to note here that the diagonal incision was not followed by Stricture. In the four cases, where the incurvation persisted, the operation causing it, was done during the existence of high in- flammatory action ; in one case the acute stage of a gonorrhcea had been prolonged by the presence of Stricture, for more than four months. In two cases deeply seated Strictures had necessitated unusually deep incisions into the urethral and un- derlying tissues. Usually this result of inflammation gradu- ally passes off after a few days, as in an ordinary gonorrhoeal chordee. Occasionally, however, the plastic exudation thrown out becomes more firmly organized; several weeks may occur before the deposit is completely removed. In such cases it is common for the gleet to persist until the erections no longer occasion discomfort. The external application of a ten per cent solution of the oleate of mercury has seemed to hasten the disappearance of the plastic deposit. I have met with certain rare cases where the tendency to forma- tion of inodular tissue, at points of injury, was excessive, resulting in overgrowth which, when occurring at the site of a urethral Stricture, has produced more or less permanent deformity where no operation (except dilating with bougies) has been performed. SPONGIO-CORPORITIS.—In four cases I have seen a slight swelling and soreness at the point of operation apparently due to inflammatory swelling of the corpus spongiosum in the immediate vicinity of the wound. This I have ventured to call a spongio-corporitis; and while I have always felt some anxiety lest a localized abscess might result, the complication has passed off entirely within a few days, under the ordinary treatment used after all operations. Stilling, a German author of celebrity, in speaking of cases of urethrotomy by the old methods has observed something similar, and attributes it to the action of urine or pus or to a localized infiltration of 292 DILATING URETHROTOMY. urine in the tissues of the corpus spongiosum. Stilling's ex- perience has evidently coincided with mine in regard to its temporary character. In his great work on Stricture of the Urethra (Cassel, 1870), page 1013, chapter on Rational Treat- ment, he says " infiltration of urine after urethrotomy can only occur if the flow of urine is prevented by coagulated blood or other causes. It is therefore of the greatest importance to remove any obstacle which might prevent the free escape of urine. This can easily be done, and if infiltration of urine should occur after internal urethrotomy, it is the surgeon's fault and not a necessary consequence of the operation. The same may be said of pus. The introduction of a catheter into the urethra prevents all these consequences, urine and pus escaping between it and the urethra." If infiltration of urine has ever followed any operation by dilating urethrotomy with my instrument, it has only been of the limited degree producing a temporary and localized spongio-corporitis such as that just described. Bearing in mind however the very positive statements of Stilling as to the secu- rity against such accidents by keeping the urethra patent after operation, I have been in the habit of introducing a full sized sound daily for the first three or four days, and on the occur- rence of any swelling, in addition to this to draw off the urine with a soft catheter, and wash out the urethra with a weak solution of carbolic acid until the swelling and tenderness have subsided. My own opinion in regard to the localized swelling is that it is caused by irritation of the parts in im- mediate locality of the incision by contact with acrid urine, and has been so rare, of so little discomfort and apparently of so little importance that I have not noticed it in the tabula- tion of cases. CHAPTER XV. STRICTURES OF LARGE CALIBRE. IN this place I desire to call attention to the pernicious effects of Strictures but slightly invading the urethral lumen, and for the purpose shall relate a single typical case which is fresh in my experience. Mr. A. D., aged sixty-four, came under my care complain- ing of a slight urethral discharge and a sense of irritation at the neck of the bladder. He had had no recent venereal con- tact, but had experienced several gonorrhoeal attacks in early life. Examination showed a penis 3] inches in circumference, and a meatus urinarius of a capacity of 32 mm. Examination with the urethra-metre demonstrated a normal urethral calibre of 36 mm., and detected three narrow bands of Strictures at between two and three and a half inches from the meatus, each of the value of 6 mm. I advised immediate division of these comparatively insignificant Strictures, explaining and asserting my belief that the urethral discharge and the irritation re- ferred to the neck of the bladder were a legitimate result of the holding and detention of gouty urine or its debris behind these barriers. Mr. D. declined any operative procedure with considerable warmth, and a palliative treatment (al- kaline and diluent) addressed to his gouty diathesis was adopted. Improvement in the quality of the urine, which soon took place, caused a temporary relief from the irrita- tion, and the discharge, which had never been profuse, grad- ually disappeared. The irritation returned, however, at the least indiscretion, and I was consulted about it every few weeks until February 2d, 1877, when he again presented, not only with return of the discharge and irritation at the neck 294 STRICTURES OF LARGE CALIBRE. of the bladder, but with pain in the glans penis and frequent painful urination. A small amount of pus was also found in the urine. Recognizing the fact that the urethral inflam- mation had extended to the bladder, I at once put Mr. D. to bed, and by posture, milk diet, local and general sedation, did what I could to afford relief. Notwithstanding this, a general cystitis supervened with great prostration, and came very near terminating his existence. He finally recovered (after some six weeks in bed), so that pus was no longer seen as a sediment in his urine, and urination occurred only once in six hours. Mr. D. was then sent to the seashore; there he improved in general condition up to June 2d, when he returned, complaining of a recurrence of old irritation and a gradually increasing frequency of micturition. This, as on former occasions, was preceded by, and now associated with, a slight, painless, purulent discharge. I advised a prompt di- vision of the Strictures, claimed by me at the outset to be the cause of the urethral and vesical trouble, and now believed by me to be restoring the grave perils from which my patient had scarcely escaped. The gravity of any operative proce- dure in the face of threatened or advancing cystitis was fully appreciated. Professor Thos. M. Markoe (who previously had seen the patient with me during the height of the acute inflammation of the bladder) was called in consultation. Notwithstanding the age of the patient (sixty-four), and his still somewhat feeble condition, resulting from previous disease, and the imminent threatening of another attack of acute cystitis, it appeared so evident that the return of trou- ble depended upon the presence of the Strictures that an im- mediate operation was decided upon. In the presence and with the fullest approval of Professor Markoe, I divided the meatus from 32 mm., so that a bulbous sound of 38 mm. was freely admitted. No. 36 was then passed easily down 2\ inches, where it was arrested by the first Stricture. The (my) dilating urethrotome was then intro- duced so that when dilated its blade would rise just behind the posterior of the three Strictures previously measured and CAUSING CYSTITIS. 295 located between 2\ and 3 J- inches. The instrument was then turned up to 38 and the Strictures divided. No. 36 bulb was then passed easily through the entire canal to the bulbo- membranous junction, and, on withdrawal, demonstrated an entire freedom from Stricture. The urine was then drawn off with a soft catheter and six grains of quinine administered. The haemorrhage following the operation was insignificant. A slight chill occurred about six hours afterwards, immedi- ately following the act of urination; this apparently occa- sioned a rise in temperature of two degrees (101) for a few hours. Aside from this there was not the least constitutional disturbance and but slight pain on urination. Within twenty- four hours the intervals between the acts of urination had in- creased from two to three hours, and by the fourth day to six hours. On the seventh day after the operation he was dressed and walking about, and claimed not to have been so wholly free from discomfort since his original irritation, more than a year previous. The intervals between acts of urination grad- ually increased. The urine became more and more free from pus without other treatment than that directed to general health, so that in a month he was apparently well in every respect; micturition once in five or six hours, and urine free from pus as a visible sediment. A few pus cells still found by microscopic examination. October 7, 1877, Mr. D. called at my request for a reex- amination of his urethra. The urethra-metre was introduced, closed, to the bulbo-membranous junction, turned up to 36 F., and by gentle traction drawn through the length of the pendulous urethra without meeting with the slightest resist- ance, thus demonstrating the complete absence of Strict- ure, over three months from the date of operation, no instru- ment having been introduced in the interval. Recovery from the cystitis may be said to have been complete, although under the microscope a few pus cells are still found. There are also a few hyaline casts, but the case appears to me to prove fully the possible influence of Strictures of large calibre 296 STRICTURES OF LARGE CALIBRE in producing urethral inflammation, which, extending by con- tinuity of surface, may produce a cystitis, and even a nephritis. In the foregoing case I feel confident that an early divis- ion of the Strictures would have cured the urethral inflam- mation by removing its cause, and that this would have pre- vented the cystitis in the first instance as surely as it subse- quently did. The urethral discharge, which had been more or less profuse for the year previous, disappeared entirely a short time after the division of the Strictures, and has not been seen since. Up to June 1878, this gentleman has remained well in every respect, not the least trace of pus or casts in the urine, and a critical examination of the urethra gave not the slightest evidence of re-contraction at the site of former Strictures. Urinary Infiltration and perineal abscess not unfre- quently occur as the result of Strictures which do not greatly impede the passage of urine, and through which an ordinary sound can be easily passed. The rupture of the urethra behind a Stricture, from urinary pressure, rarely if ever occurs. A urethral follicle constantly bathed in the irritating debris behind even a slight contraction, finally becomes involved in an inflammation of its deeper structure, suppuration follows, the urethral wall is penetrated and urine finds its way through the minute opening thus formed into the surrounding cellu- lar tissue. Let me cite a case, which will serve to exemplify this statement in a striking manner. Mr. Z., aged twenty-seven, a patient of the well known and accomplished surgeon, the late Dr. Julius Thebaud, was seen by me in consultation in February 1875, with the following history. Gonorrhcea twelve years previous, recurring gleet for four years, urethral Stricture recognized, treatment by steel sounds, size No. 24 passed with some pain. This was repeated at intervals of several days for a month; dilatation not well borne, pain and increase of discharge following. A few days previous some uneasiness in the perineum was com- plained of and a slight swelling was detected in that locality. Circumference of penis 3^. Strictures defined, one at 2 CAUSING PERINEAL ABSCESS. 297 and another at 3 inches, 24 F., one at 4 inches, 28 F. It was my opinion that a follicular ulceration had occur- red behind the deepest and largest Stricture (size 28 F.) ; that in this manner the urethral wall had been perforated ; and that extravasation of a limited amount of urine had taken place (an accident similar to that described by Dittel in Pithaand Billroth's Handbook of General and Special Surgery 3d vol., 2d div., 6th Book, page —.) In this case immediate external perineal section was imperative for security against possible sub-fascial extravasation. A general consultation was at once called, consisting of three more surgeons. After careful examination the presence of pus was considered proba- ble, but doubts were expressed as to the origin of the abscess in the urethra. After a brief discussion it was decided to pur- sue a medium course by operating at once and thus to avoid the danger of a possible grave urinary infiltration, but to limit the incision to the peri-urethral tissues. The requisite operation was performed by Dr. Thebaud. A little bloody serum exuded from the engorged deep tissues, but no pus was found. The case went on for a week without much dim- inution of the swelling or of the aching in the testicles after urination, which had been a source of complaint previous to the operation. Another general consultation was called ; consist- ing of the same gentlemen previously associated in the case. Before convening some 48 hours had elapsed, during which, without apparent cause, a favorable change had taken place; the swelling had begun to decline and the perineal wound pre- sented a more healthy aspect. The improvement being fully recognized it was deemed best to avoid interference. At the end of a fortnight the perineal opening had healed completely when there was a sudden accession of discomfort and the swel- ling was found to have reappeared. The case was again seen by me in consultation with Dr. Thebaud and Dr. Reynolds (Dr. Thebaud's partner), some 48 hours after the discovery of the recurrent swelling. External perineal urethrotomy was again advised and promptly done by Dr. Thebaud and the Stricture at 4 inches (just anterior to the perineal incision) was 298 STRICTURES OF LARGE CALIBRE divided with a blunt pointed bistoury. An ounce or so of pus and grumous blood was evacuated. Immediate relief of pain succeeded and the wound healed kindly and perfectly. The aching in the testicles previously spoken of as occurring after urination did not entirely disappear. This was attrib- uted to the presence of the anterior Strictures at three and two inches from the meatus. These were thoroughly divided with the dilating urethrotome to 32 F., the previously ascer- tained normal calibre of the canal. A slight spongio-corpori- tis followed the operation, which delayed the progress of the case about a week ; after which, recovery was steady and rap- id, resulting in a complete cure of all trouble. A reexamina- tion three years after showed complete freedom from any trace of Stricture. This case appears to me to demonstrate the occurrence of urinary infiltration behind a slight Stricture, though in quantity so slight that a slowly forming abscess only resulted. The persistence of the trouble until the urethra was laid open, and the prompt recovery after that was effected, served to clear up any doubts that might have been enter- tained in regard to the urinary origin of trouble. The case of Mr. X.,* detailed in my forthcoming volume on Reflex Irritations and Neuroses, may be referred to as one proving the follicular origin of a urinary infiltration of small but persistent character. In this instance an enormous swel- ling of the scrotum was caused by it, and persisted for five and a half years before it terminated in the series of abscesses through which the final character of the difficulty was ascer- tained. The statements of Dittel in Pitha's and Billroth's Handbook of General and Special Surgery, confirm in the fullest manner the foregoing views and cases. Thus in vol. iii, 2d div., 6th Book, " On Strictures of the Urethra " he says : " A remarkable follicular ulceration of the urethral mucous membrane is found in some cases of infiltration of urine. " The ulceration of the follicle is preceded by catarrh. The signs of catarrh are the threads washed out by the urine which escapes first. They are sometimes single, sometimes ring- * Originally published in the New York Medical Journal of Feb., 1875. CAUSING URINARY INFILTRATION. 299 shaped or in masses, suspended in the urine. Though these threads are harmless, we must not forget, that the urethra is in a diseased state as long as these threads are found, and that this sequel of gonorrhcea, which is not unfrequent, may pro- duce death by infiltration of urine and pyaemia, if the catarrh degenerates to a catarrhal ulceration of the follicles, even if only one follicle is involved. " The following case is an instructive illustration. Count L. R., 59 years of age, had gonorrhoea repeatedly. An at- tack, from which he suffered 20 years ago, lasted nine months. Since then he had a burning sensation during micturition. March 5th, 1863, he suffered from occasional stinging pain at the perineum, which did not prevent him from continuing his former mode of life. On the next day, a red, somewhat tender diffuse swelling of the perineum, scrotum, skin of the penis and prepuce appeared, with moderate febrile re- action. " March 13th he came under my care. The patient is a well developed and well nourished man. The scrotum forms a tumor of the size of a child's head, covered by a red, tender and tense skin which is connected anteriorly with the cedemat- ous bloated up integument of the penis. Thecedematous pre- puce was phymotic in the highest degree. A bright redness extended even above the symphysis towards the anterior and lateral regions of the abdomen, which had become hard and tender. The patient is conscious, but is inclined to sleep. Skin, tongue, lips are dry. Great thirst. Pulse 96. " Urine escapes in drops. Catheter No. 2 can be introduced, though with difficulty and some pressure, into the bladder, and meets an obstruction at the bulb. On the same day I made deep incisions into all swollen parts and used moderately cold applications, which did not prevent gangrene attacking the parts around the incisions. The pulse rose to 108. Tongue, pharynx, lips are as hard as a board. On the 16th a pretty large quantity of pus of urinous odor escaped from the wound ; the redness extended up to the axillae. There is fluc- tuation at a point above the symphysis. This was opened on the same day. Soon after he had a chill. " On the 19th, after repeated rigors, he fell into a constant soporous condition. The integument is deeply yellow, the eyes have lost their lustre. The dryness of the mouth has increased wherever it was possible, the integument covering the abdomen is hard and bloated up, especially at the right iliac region. Thin and profuse purulent discharge from the 300 STRICTURES OF LARGE CALIBRE wounds ; urine acid, containing chlorides, sulphates, albumen, and carbonate of ammonia, hyaline casts, renal epithelium. " Patient died March 2ist. " At the bulbous portion of the urethra there is a Stricture, thin and callous, which extends to the membranous portion, and admits catheter No. 2. At the middle of the inferior wall of the urethra there is a perfectly round opening as large as the head of a pin, surrounded by a round and smooth margin which evidently corresponds to the mouth of a mu- cous follicle. If a thin sound is passed into this opening, we come to a very narrow passage in the spongy tissue, and ulti- mately reach the cavity of a large abscess in the subcutaneous connective tissue. From this point the infiltrated and gan- grenous tissues extended in all directions. " Every competent anatomist, after seeing this specimen, had a decided impression, that the infiltration was caused by the perforation of a single follicle. In this case, the mucous membrane is healthy, neither gangrenous nor softened all around the follicle. Only the ulceration of a single follicle caused the infiltration terminating in death. " It is obvious, that even without the existence of Stricture the ulceration of one or several follicles may progress to per- foration. I remember a young man twenty-five years of age, who had a bridle as thick as a knitting needle (after a gonor- rhcea) which, running obliquely forwards from the fossa navicularis, terminated at the inferior wall of the urethra, leav- ing an opening as large as the point of a needle through which urine escaped.* " The ulceration may be confined to one follicle or may extend over an entire group of follicles which occurs, as we know from experience, most frequently at the bulb. " If perforation occurs in a group of follicles there appears a larger inflammatory swelling (accompanied by pretty in- tense phenomena) in which the various follicular perforations unite, to confluate in one abscess, or which may cause infiltra- tion of urine before an abscess could be formed. " From one follicle one passage only may be produced, or several channels may result. The same is the case if perfora- tions occur in several follicles." It is interesting to note the fact that Dittel in his pre- face to the recital of the foregoing cases very distinctly * Since that time I have had three patients with perforating follicular ulcer- ations at the bulb after blennorrhcea without Stricture. CAUSING REFLEX IRRITATIONS. 301 recognizes the connection between the perforating follicular ulceration and a urethral catarrh which is associated with "threads of mucus sometimes single, sometimes ring shaped, zvhich are washed out of the urethra by the urine" " Though these are harmless," he says, " we must not forget that the urethra is in a diseased state as long as these threads are found and that this sequel of gonorrhcea, which is not infre- quent, may produce death by infiltration of urine and pyaemia if the catarrh degenerates into a catarrhal ulceration of the follicles, even if only one follicle is involved." Since the efficient examination of the urethra behind a contracted meatus or a Stricture has been possible through the use of the urethra-metre, we now find that the threads of mucus re- ferred toby Dittel "sometimes single, sometimes ring-shaped" are, in all cases, accumulations behind urethral co-arctations— Strictures more or less salient, which keep up the gleet and hold behind them the threads of inspissated mucus and pus, and, finally, in such cases as are referred to, induce a folliculitis with occasional results of the character so graphically de- scribed by Dittel. Reflex Irritations and Neuroses, resulting from slight Strictures: The importance of recognizing the earlier stages of urethral Stricture has not hitherto been conceded, and the statement of Mr. Berkeley Hill, if accepted as true, will render this obvious. He says, (see page 216) " If the balance between the natural expulsive force of the bladder and the friction of the stream along the urethra is disturbed, the bladder is irritated, the kidneys are affected, and the be- ginning of the long chain of events which terminates not in- frequently in death is made." It is true that in many cases no apparent trouble is experienced until the calibre of the urethra is infringed upon to the extent of interfering with micturition, and yet in other cases, slight Strictures, reducing the urethral calibre not more than three or four millimetres in circumference, are capable of producing frequent micturi- tion, inflammation of the bladder, and various neuralgic dis- turbances. Deep organic urethral Stricture is often simulated 302 STRICTURES OF LARGE CALIBRE by muscular spasm the result of irritation caused by slight anterior Strictures, even by a slight contraction of the meatus urinarius alone. The great proportion of cases treated by gradual dilatation are treated for deep Stricture zvhich does not exist. The presence of a contracted meatus urinarius or a Stricture of large calibre, often unnoticed, is capable of exciting chronic spasmodic closure of the membranous urethra quite undistinguishable from true organic Stricture, but which dis- appears completely on the thorough division of the anterior contraction. A large number of cases of this character may be found described in my volume on " Refl.ex Irritations and Neuroses throughout the Genito-urinary Tract," published by Putnam's Sons, 1878. In some of these cases, frequent reten- tions of urine are proved to have been the consequence of a contracted meatus which would easily admit what has been considered a large or full sized sound. Two of these cases,* are so significant and suggestive that I shall take the liberty of quoting them in full. Case 1. J. W., frontiersman, aged 45, presented Novem- ber, 1874, with a history of first gonorrhcea 20 years previously and several subsequent attacks. Five years ago began to have difficulty in passing his urine; stream grew gradually smaller, until, after a debauch, he had complete retention, and was obliged to seek relief at a neighboring military post. After 36 hours suffering, he was relieved by the passage of a very small, flexible catheter, in the hands of the post surgeon. After this he submitted to treatment, by gradual dilatation, for several months. He then learned to pass No. 12 Eng- lish soft bougie. From neglect, he has had some half a dozen attacks of retention during the past year. At last only the smallest instrument could be passed by the military sur- geon, and he was advised to go East and have a radical opera- tion performed, as there were no instruments at the post suit- able to operate upon so small a Stricture. His habit for a long time has been to pass his water very frequently during "■ Extracted from Reflex Irritations and Neuroses throughout the Genito-urin- ary Tract, by F. N. Otis, M. D. Putnam's Sons, New York, 1878. A cursory glance over the two hundred and eighty one tabulated cases to be found at pages 106 and 324, will show the frequency of reflex irritations, more 01 less grave, connected with urethral Stricture. CAUSING RETENTION OF URINE. 303 the day, in a very fine, irregular stream, and several times during the night. Examination. Is of large stature, looking like a strong man, who had endured much exposure and hard- ship. Made his water in my presence, in fine, short jets, chiefly dribbling. Circumference of the penis, three and one- half inches; size of meatus, 23 F. No. 23 F. steel sound passed easily through a very sensitive urethra to the bulbo- membranous junction, where it was arrested. Gradually de- creasing bougies were introduced, until, finally, No. 12 F. passed into the bladder, closely hugged in the deep urethra. Allowing it to remain for a few moments, I found it free. I then withdrew it, divided the contracted meatus and Strict- ure, extending for nearly half an inch back, and passed 34 F. solid steel sound slowly down to the bulbo-membranous junction, when it slipped by its own weight into the bladder. After the withdrawal of the sound the patient passed his water in a full large stream. From this moment he had no further trouble in urination, passing his water at intervals of six or eight hours during the day, and not at all at night, for the week subsequent to the operation, when he left for his home in the far West, apparently well in every respect. Case 2. Mr. W., aged 27, had first gonorrhcea four years previous, lasting in acute form for one month, and with pain- less discharge for six months longer. He had frequent re- turns of the discharge without fresh exposure; had been under treatment for close, deep Stricture for the past year, by several surgeons. Passed his urine in a small irregular stream, once in two or three hours. His last surgical attendant, after two months' treatment by injections and internal remedies, sent him to me, not being able at any time to pass an instru- ment into the bladder. Examination showed external organs large, meatus contracted to 24 F., red and pouting, and bathed in a profuse muco-purulent discharge. Twenty-four F. sound is arrested at five inches. Only fine filiform will pass, and that is closely hugged. Three days after, pass filiform with ease and follow with No. 10 F. ; then, with some effort, with No. 16 F. After this the filiform was again snugly held in the membranous urethra. I divided the Stricture at the meatus freely, and introduced No. 30 F. steel sound, which passed, literally by its own weight, through into the bladder. The results of my earlier observation on the influence of slight contraction of the urethra in producing various forms of reflex troubles were first published in Dr. Brown-Sequard's Archives of Medicine in 1874. Since that date I have in published cases and in reports to societies claimed a credit for originality in the 304 m. civiale's VIEWS Among the 136 cases which may be found tabulated at the end of this volume, Strictures beyond 5 inches from the meatus occurred in only five. In 136 cases (see page 317) it is shown that of Strictures of the meatus alone, eleven had been under a prolonged treatment by dilatation for deep urethral Stricture, and seven of these were cured by simply dividing discovery of a direct influence exerted by slight urethral contraction in producing varied and grave disturbances throughout the genito-urinary tract, even in certain cases extending to distant parts of the entire economy. Within a few weeks, however, (May 1878) a careful search through the published writings of M. Civiale of Paris, (made at my suggestion by my accomplished friend, Dr. M. J. De Rosset, of New York,) I have found my claims to priority in this matter to have been with- out foundation. Now while I claim my own published views and observations prior to this date to have been original with myself, I hasten to concede the honor of priority in this field, to the distinguished French surgeon to whom it fairly be- longs. The following quotations are from M. Civiale's Traite" Pratique des Mala- dies Ge'nito-urinaires, 2d edition. At page 45, et seq., of his work, M. Civiale writes thus: " Independent of its local sensitiveness the urethra possesses another kind which may be termed sympa- thetic. * * * When this sensitiveness is aggravated it may awaken sympathetic response in every or^an and function of the body* * In many cases the sympa- thetic (reflex) phenomena were manifest in the lower extremities, particularly in the soles of the feet. Again, at page 354, et se., " It is not rare to observe that slight encroachments upon the urethral calibre induce marked difficulty in micturi- tion, those at the meatus having this effect not less than those located farther in." Again at page 160, " Strictures seldom exist for a long time without exciting a series of disorders of the genito-urinary functions and, consecutively, in remote parts of the body, * * * among these, gleet, retention of urine, difficult mic- turition, catarrh, swelling and induration of the penis.* * * That which has struck me forcibly in dividing a meatus often only slightly contracted, is the sud- den and complete change effected in the general condition of the patient. The constriction which seemed hardly to impede the flow of urine is no sooner divided than all morbid symptoms vanish ; the urethral walls, which were rigid, hard and inelastic, immediately recover their normal condition ; the bougie which at first passed only with difficulty and pain, slips into the bladder with ease, and in five or six days the slight incision in the meatus heals perfectly, and the patient finds himself in a state so satisfactory that it would be incredible but for the fact that the instances are again and again repeated. An effect so prompt, through means of which the significance is plain, shows that the slightest obstruction in the urethra is able to produce the gravest symptoms, local and general." Why the important teachings contained in these writings have, until now, been literally ignored in the medical literature of the English language, I leave it for the various English speaking authors of subsequent works on genito-urinary diseases and affections of the nervous system to explain. OF SLIGHT URETHRAL CONTRACTIONS. 305 the meatus. A still greater number were only treated for deep Stricture, exclusively when careful and conclusive ex- plorations showed them to be present only in the anterior portion of .the canal. It may now be claimed that any treatment of urethral Strict- ure that is not based upon a knowledge of the locality and ex- tent of the Stricture is thoroughly empirical, and, while often mischievous, is never better than palliative in its results. One of the grave objections to gradual dilatation is, that in order to be sure to reach all the possible points of Strict- ure, it must be carried throughout the entire course of the urethra and into the bladder. In the absence of exact infor- mation as to the locality and extent of the contractions the judgment is formed from its effect on micturition, the fallacy of which is strikingly illustrated in the cases just cited. Urethral narrowings, or obstructions, are not considered by dilationists of any importance until they begin to interfere with urination, which often, in cases of true Stricture, does not occur until the foundation of fatal disease of the bladder or kidneys has been la"id. The lack of exact knowledge implies not only a necessity for treatment of the entire urethra for trouble limited perhaps to some one small point, but gives the general impression that all cases of Stricture are much the same in point of gravity, so that operative procedure, (beyond the palliative use of bougies and sounds,) is discouraged until the life of the patient is imperilled, it may be by an obstinate retention of urine, or by an extravasation of urine into the perineum. This latter accident not rarely takes place be- hind Strictures of large size, the urine burrowing through the urethral walls, resulting in perineal or scrotal fistulae, and pos- sibly in fatal extravasation of urine into the general subfascial cellular tissues, as shown at pages 296, et seq. This loose and unscientific treatment of Stricture leaves the patient in com- plete ignorance of his peril from the early inception of his trouble until his life is endangered, when any operation look- ing to radical relief is approached under the most unfavorable circumstances. The results of such operations, if unfavorable, 306 STRICTURES OF LARGE CALIBRE CONCLUDED. are made to discredit all operations, and are scored as an ar- gument in favor of gradual dilatation, when, in point of fact, the insidious and fatal peril has been nursed and encouraged, from its inception to its culmination, by the treatment which was carried on in ignorance of the extent or exact locality of the Strictures. CHAPTER XVI. STRICTURES OF SMALL CALIBRE. IN every other disease or difficulty it is considered the duty of the surgeon as far as possible to recognize the approach of danger, and'to attack the trouble in its inception. Ure- thral Stricture, however, appears hitherto to have been the exception to this rule. The causes of Stricture have long been appreciated. It is known to result upon an inflammatory process usually of gonorrhoeal origin. So frequently does Stricture to a greater or less extent follow an attack of gonor- rhcea that it is the rule rather than the exception, and yet, it is common for persons, the known subjects of repeated attacks of gonorrhcea, to suffer from what are termed obscure troubles of the genito-urinary organs, such as recurring orchitis, recurring cystitis, supra pubic, and sciatic neuroses, gleet, frequent micturition, etc. These troubles may and do exist under the very eye of the surgeon, without any attempt having been made to test intelligently the presence or absence of urethral Stricture. It may then be broadly stated, that while urethral Stricture is the result of inflammatory action from various causes, close urethral Stricture, as a rule to which there are few exceptions, is the result of neglect to discover and treat this disease in its early stages, during which, with the means at present within the reach of every surgeon, it may be promptly cured with but little inconvenience and still less risk to the patient. " Chronic urethral discharge, commonly called gleet, is the signal which nature hangs out to notify the intelligent surgeon that an obstruction to the normal working of the muscular ap- paratus of the urethra has occurred, and that Stricture has been 308 STRICTURES OF SMALL CALIBRE. initiated at some point in the course of the urethral canal. Plas- tic material laid down in the antecedent inflammatory condi- tion has begun to contract the normal urethral calibre, whether it be 20 or 40 millimetres in circumference. Sandal oil may stop the gleet for a time; injections of innumerable variety may, any one of them, temporarily remove it, but a little vinous or venereal excess zvill reproduce it, and thus the case goes on, getting, as many so afflicted will affirm, a new clap for every woman they look at, until finally an attack of retention of urine calls attention to the fact that the patient has a strictured urethra " {page 75). Strictures of small calibre are thus initiated, pursuing their course implacably from their inception, to their culmination in greater or less embarrassment to the passage of urine. Dur- ing this period, it has been intimated that a recurring gleet is the early result of the strictured condition ; perhaps the earli- est. In many instances this is the only outward sign of mis- chief; but habitual interruption to the flow of urine not un- frequently produces irritation of the bladder and kidneys, which, long neglected, constitutes the gravest peril in any at- tempted measures of relief. Hence in all Strictures of small calibre it becomes necessary to make a careful examination of the urine in order to ascertain to what extent the bladder and kidneys have participated in the damage caused by the Stricture in order to guard against avoidable perils in treat- ment. (See p. 287, et seq. on urethral fever.) The division I have been accustomed to make between Strictures of large calibre and Strictures of small calibre is based upon their size in relation to my dilating urethrotomes which, as at present constructed, have a circumference of 18 to 20 millimetres. All at or above that measurement are in- cluded in the class of Strictures of Large Calibre, and may be the subject of immediate operation by dilating urethrotomy. All ranging below 18 millimetres down to a point of practical impermeability, fall into the class of Strictures of Small Cali- bre, necessitating the use of various methods of treatment in order to bring them up to a size which will permit the pas- PREPARATORY TREATMENT. 309 sage of the dilating urethrotome with a view to eventual radical cure. When Strictures of small calibre are situated in the penile urethra, where the greatest proportion of all Strictures are found, there need be but little apprehension of danger from the use of immediate measures to bring them at once up to the size requisite for the passage of the dilating urethrotome. Divulsion may be made with the instrument of Thompson or Perreve, or with modifications of the latter by Holt, Voillemier and myself. Division by means of the urethrotome of M. Maisonneuve has, in my hands, often proved equally serviceable. In all cases, however, where there is no necessity for immediate operation, I have preferred to use gradual dilatation by means of the soft French bougies. In this way a larger surface of mucous membrane presents when the urethra is restored to its normal calibre by dilating urethrotomy. The especial advantage of this latter procedure has seemed to be a more rapid recovery from the associated gleet by the diminished amount of new mucous membrane necessary to supply the new surface which the restored canal has acquired. The treatment after dilating urethrotomy in these cases does not vary from that applicable to Strict- ures of large calibre. Strictures of small calibre in the deep urethra, that is, beyond the bulbous portion, are fortu- nately rare ; those so frequently met in the ordi- nary treatment by dilatation being for the most part spasmodic and promptly relieved by the re- moval of anterior contractions, often but slight. It is therefore the first and highest duty of the surgeon in all cases of suspected Stricture in the deep urethra, to ascertain and remove all ante- rior contractions. After this is efficiently ac- complished, and when, by healing, all irritation author s di- vulsing ure- throtome. 310 STRICTURES OF SMALL CALIBRE from the wounds of operation has passed away, if then an ob- struction remains which firmly engages or (if of sufficient size to allow its passage) firmly grasps a small instrument, it must be accepted as a true deep organic Stricture. Close organic Stricture* within or beyond the membranous urethra is always a matter for grave consideration on account of the frequency with which it is associated with disease of the bladder or kidneys, and hence the greater liability to constitutional and serious functional disturbance following operative procedure, and this is not less in the aggregate zvhere this procedure con- sists in the attempt at gradual dilatation. Haemorrhage too, is here much more liable to prove serious in any operation of internal urethrotomy than at any other point, from the diffi- culty with which it is controlled. For these reasons in all long standing cases of deep close organic Stricture I consider the operation of external perineal section preferable to inter- nal urethrotomy by any plan. Free exit is thus made for the urine and the products of the operative procedure, and free access is secured to any bleeding point, while I feel quite cer- tain that the dangers of suppression, pyelo-nephritis and pyaemia are not greater after the external section than after the internal. Except in cases of traumatic origin, deep ure- thral Strictures are always associated with Strictures more or less numerous and extensive in the anterior portion of the canal. Operation by external perineal section may here be supplemented by dilating urethrotomy for the anterior Strict- ures, and thus the entire urethra be restored at once to its original calibre without adding materially to the risks of op- eration. I have to record eighteen such cases operated on by me within the last eight years with but two deaths, as follows :— Case I. Had numerous close Strictures of sixteen years duration complicated with chronic cystitis and pyelitis. Seen in consultation with me by Dr. Geo. A. Peters, who also rendered valued assistance during the operation. Deep * See cases of spasmodic Stricture accompanied by frequent retentions of urine from contracted meatus urinarius, page 302. COMPLICATED WITH OTHER DISEASES. 3H Stricture divided by the external perineal section—and five anterior Strictures by dilating urethrotomy. Complete heal- ing of the wounds ; death on the sixteenth day from pyelo- nephritis and abscess of the kidney. Case II. Broome St. Age fifty-eight. Old, close, very extensive and deep Strictures; frequent and painful reten- tion complicated with Bright's disease of the kidney (albumen in urine, granular and hyaline casts) combined operation, di- viding deep cartilaginous Strictures by the perineal section, and several anterior close Strictures by dilating urethrotomy. Suppression of urine second day after, relief on the fourth, death on the sixth from uremia—no autopsy.* * Besides the above reported cases only two other deaths have occurred in any way associated with my practice from causes in any degree attributable to opera- tions on the genito-urinary apparatus. One aged seventy-eight at Paterson, N. J., (whose history may be found in Otis on Reflex Irritations and Neuroses. Putnam's Sons, 1878.) Here long continued and painful disease of the bladder was relieved by dilating urethrotomy. Recontraction and a more extensive di- vision of Strictures resulted in relief a second time. A week after this operation, a catheter was left in the bladder for forty-eight hours by the family attendant. A chill with suppression of urine followed and subsequently death by uremia: distinctly not from the cutting operation, over a week previous, but from the urethral irritation caused by a prolonged retention of the catheter for relief of frequent troublesome micturition. This was found on post-mortem examination to be due to a small phosphatic calculus which had escaped detection during life. The second case, a man of forty or thereabouts suffering from close, chronic, deep, Stricture, came under my observation during a recent visit to Syracuse. Re- peated efforts by several surgeons during a long period had failed to pass any in- strument into the bladder. The case had become urgent on account of retentions and severe suffering. Etherization was effected with great difficulty. Spas- modic tremor of limbs continued after profound anaesthesia, so that there was much embarrassment in the introduction of instruments. After waiting and careful trial, at the end of an hour and a half I succeeded in introducing a Mai- sonneuve staff well into the bladder. This was followed by a medium-sized blade, subsequent to the withdrawal of which, a gum elastic catheter was intro- duced and the urine drawn off. The case was left in charge of the two surgeons previously in attendance. About a month later I learned that the patient had died on the third day after the operation, in a comatose condition, after having taken- largely of morphine and chloral to control nervousness and pain. There was no suppression of urine. No autopsy was made. I have been thus circumstantial in presenting the record of deaths in any way implicated with operative procedures at ray hands, because it has been stated, by at least one prominent surgeon in this country, that all the deaths occurring from urethrotomy in my practice had not been reported, and I have also had an 312 STRICTURES OF SMALL CALIBRE It sometimes happens that Strictures both in the penile and in the deep urethra are met with which are practically impermeable, that is to say, in which, from the tortuous course of the urethral canal at the seat of Stricture, or from a lack of instruments of sufficient tenuity or flexibility, either or both, no permeability can be demonstrated such as will per- mit the introduction of means through which the bladder may be emptied or the division or divulsion of the Stricture can be accomplished. In this sense Strictures may be per- meable to-day and impermeable to-morrow. There are, I think, few surgeons who have not demonstrated the patency of a Stricture by the easy introduction of a filiform bougie, and, in a day or two after, when preparing to operate by in- ternal rupture or division, have not found the filiform guide refuse to pass the Stricture, and even under complete anaes- thesia, neither be coaxed nor compelled to lead the way for the shaft of the cutting or divulsing instrument. Under such circumstances no proper course is left but to allow the patient quietly to awake to the consciousness of a great disappoint- ment, and to wait for a more favorable day. Unfortunately, it is not always that such an operation can be postponed. For instance, in cases of Stricture where, in usual health, the urethra will admit a bougie of eight or ten millimetres in circumference ; in any such, a sudden cold, an excess at table, or other comparatively slight cause, may bring about a retention of urine that will not yield to general measures; and, finally, when the agony of accumulation in the bladder has gone on to the last degree of endurance, should no immediate passage through the Stricture be effected, a resort to tapping above the pubis, or through the rectum, alone can save the sufferer from death. This great misfor- tune, and that lesser one, previously described, are often due, not to a want of skill, or intelligent effort, on the part of the inquiry to the same effect made of me by several amiable friends. It is due to the operation of dilating urethrotomy, to humanity, to myself, and that further misunderstanding in this matter should be prevented, and I will say in regard to it, still farther, that the foregoing statements cover a period of the sixteen years during which I have been a public teacher of diseases of the genito-urinary organs. OFTEN PRACTICALLY IMPERMEABLE. 313 surgeon, but simply a lack of suitable instruments with which to afford relief. The divulsing instruments of Thompson and Holt and the urethrotome of M. Maisonneuve are usually, any one of them, efficient in cases of close Stricture requiring immediate opera- tion. Occasionally, however, the surgeon will fail in the most intelligent and patient efforts to pass them through the Strict- ure and into the bladder, without which no divulsing or inter- nal cutting operation is justifiable. Sir Henry Thompson's smallest divulsor has a circumfer- ence of 12 millimetres, Mr. Holt's 10, M. Maisonneuve's ure- throtome 7 millimetres. Now, to make an operation possible by any one of these instruments, its shaft must first pass cer- tainly and entirely through the Stricture. For the purpose of facilitating and securing this passage, the filiform guide of M. Maisonneuve, of a somewhat smaller calibre, is attached to each by means of a delicate screw, the male thread of which is upon the extremity of the shaft, the female thread upon the filiform guide. This fine flexible bougie has but to be gently slipped along within the urethra, easily avoiding here and there the natural obstacles which oppose its passage ; as these guides are manufactured as small as three millimetres in circumference, few, indeed, are the Strictures so close as to forbid their entrance through them into the bladder. Unfortunately, however, the smallest female screw, of either foreign or domestic manufacture, which can be relied on as of sufficient strength to attach the filiform to the operating shaft, is quite seven millimetres in circumference. After the passage of the filiform guide—say of four, five, or six milli- metres in size—through the Stricture into the bladder, the next step in the operation is to screw on the operating shaft of whatever instrument it is decided best to employ. This now readily follows the guide until arrested at the point of Stricture by the female screw of seven millimetres in circumfer- ence. The filiform has easily passed the obstruction, and its distal extremity is coiled up in the bladder; but the shaft of the instrument will not readily follow. An important ques- 314 STRICTURES OF SMALL CALIBRE tion now arises: How much force may safely be used in advancing the shaft? and, further, how shall we determine the direction in which it may be exercised? Although the guide may be well in the bladder at the commencement of the operation, this is no sufficient guarantee against a subsequent deflection of the operating shaft, as the filiform may be dragged out of the bladder, and doubled back upon it, which must take place should the shaft be forced out of the canal anterior to the Stricture. This is an accident which may occur without the use of any very great amount of force. With the view of affording aid in the preparatory dilatation of Strictures too small to admit the necessary in- struments for immediate operation, I have designed the accompanying modification of Sir Henry Thompson's probe-pointed catheter. It consists simply of a fine probe-pointed silver tube, eleven inches in length and three millimetres in circumference at its point, gradually increasing in size, so that at six inches it is six millimetres. This tube is traversed by a steel stylet throughout its length. Carefully in- sinuated through close Stricture, by the aid of a finger in the rectum, until its point may be supposed to have reached the bladder, the stylet is re- moved and a small syringe is applied to its proximal opening. If the instru- ment has passed the sphincter vesicae, on a withdrawal of the piston, the urine will appear in the barrel of the syringe. The instrument may then be confi- dently pressed onward until the Strict- ure is dilated to the largest capacity of the tube—a second tube, of correspond- AUTHOR'S DILATING CATH ETER. ENLARGED BY DILATING CATHETER. 315 ing form, but with dimensions ranging from four millimetres at the point to eight millimetres, may then be similarly used. In cases where, on account of the extreme closeness of the Stricture, or from its divergent or tortuous course, a dif- ficulty in passing the instrument occurs, Dr. Gouley's whale- bone guide-bougies will prove serviceable. These are used as in his grooved, canulated stiff, viz., by the previous introduc- tion of the guide-bougie into the bladder, threading the dila- ting catheter upon it and following it down through the Strict- ure. Succeeding in this manoeuvre, the guide-bougie may be removed—the presence of the dilating catheter in the bladder tested by aid of the syringe—the stylet introduced and the Stricture dilated, as previously described. The whalebone guide-bougies, to be used in this manner, require to be from sixteen to eighteen inches in length. They are easily made of any desired length and fineness, and, by passing them rapidly through the flame of an alcohol lamp, may be moulded at the extremity to any curve or angle deemed most likely to adapt itself to the eccentricity of the Stricture. In comparison with all other instruments for the same purpose, the relatively smaller calibre of the dilating catheter must give it an important advantage in cases of Stricture of extreme tenuity. From its stiff and diminutive point it should never be used without the whalebone guide, nor even then with any degree of force, until the presence of its point in the bladder has been verified by the passage of urine through it. In several instances the dilating catheter in my hands has made way for the operating shaft of various instru- ments for immediate operation where other means had failed, notably in a case at the University College Hospital, London, in the service of Mr. Berkeley Hill. Repeated attempts to enter the bladder had been made in several hospitals with- out success. A final attempt had resulted similarly, and the patient was about to undergo the perineal section when Mr. Hill proposed a trial of the Dilating Catheter. The fine whalebone guide 2 mm. in circumference passed easily, the catheter was threaded upon it, and after reaching the blad- 316 STRICTURES OF SMALL CALIBRE. der was pressed on to its full size. On withdrawal, the shaft of M. Maisonneuve's urethrotome passed readily and Mr. Hill completed the restoration of the urethra by the Maisonneuve blade, supplemented with his own modification of the dilat- ing urethrotome. On several occasions I have passed a small Stricture with it without the least force, (following the whale- bone guide,) and using it only as a catheter, by attaching its proximal extremity to the aspirator or to an ordinary syringe, have emptied the bladder through it without dilating the Stricture. The aspirator will in the same way frequently be « found of service during the use of small gum catheters. The risks attendant upon the operation of urethrotomy vary necessarily with the gravity of the difficulties present in each case. It may be alleged that the cases which I have reported are chiefly those where the Strictures were of com- paratively large calibre and for the most part in the penile portion of the urethra. In reply, I would say that the cases have been taken in the order of their presentation in my prac- tice, and that a very large proportion had been under treat- ment by other surgeons, some of them for years, for Strictures supposed to be in the deep urethra. The treatment had been carried out in many cases by dilatation and by various cutting and divulsing measures, in accordance with the methods in vogue before any introduction of dilating urethrotomy. That the Strictures were more often situated in the anterior por- tion of the canal, and were less important than had been sup- posed, should be credited to my methods of exploration. That the results which I have obtained are favorable beyond any before presented to the profession, I claim to be due to the complete division of Strictures in manner calculated to produce the least possible disturbance of the healthy tissues. The fact that during the period, and in the great number of cases covered by my report, I have found it necessary to op- erate by external urethrotomy 18 times (n times without a guide) is a sufficient proof that the range of my practice has not been limited to insignificant troubles, but that it has in- cluded every variety and degree of urethral contraction. 136 CASES OF STRICTURE 2D SERIES. 317 The accompanying tables* present the salient points in one hundred and thirty-six cases of urethral Stricture treated upon the principles presented and maintained in the previous pages of this volume. The form of tabulation is the same as that used in presenting the 100 cases operated on previous to March, 1875. Sixty-five out of these later one hundred and thirty-six cases were tabulated from my private case books by my former assistant, Dr. J. Fuhs, the remaining seventy-one cases were extracted from the same source by my associate Dr. L. Bolton Bangs, to whose faithful and in- telligent assistance in nearly every operation, (in many shar- ing with me the labor and responsibility of the after treat- ment.) I owe not a little of the success which the following summary of these operations serves to demonstrate. Whole Number of Cases Tabulated in 2D Series................. 136 Number of Strictures........ ........................ 357 " " Operations................ ................ 186 Number with organic Stricture deeper than 5 inches. ...,„„......... 5 " treated by other surgeons for supposed deep Stricture....... 13 " of these cured by division of the meatus alone............. 7 Accidents after Operation. Haemorrhage, exceptional....................................... 6 Of these, serious, (one being combined with external perineal section). 2 Chills or Urethral Fever........................................ 11 Suppression of Urine (external perineal urethrotomy combined)....... 1 Incurvation of Penis—slight, lasting short time.....................3 " 1J month...................... 1 " 4 months...................... I " 1 year.... .................. 1 6 Results. Cases—Re-examined. No Recontraction......................... 38 " Not re-examined.—Continued relief to all symptoms, including cures after secondary operation—reported cured........... 65 * See p. 324, et seq. 3i8 RESULTS OF OPERATION IN Reported improved. Not re-examined........................... 20 Not improved " ................................... 4 Lost sight of.............................. ................. 3 Still under observation.......................................... 4 33 136 Number of cases of Gleet—78—Cured........................... 61 Improved....................... 13 Not Improved.................... 4 78 Number of cases of reflex trouble—48 —Cured...................... 2g Improved.................. II Not improved............... 8 48 The point of greatest importance claimed as the result of complete division of Strictures, followed by suitable after treatment, is the Radical Cure of Stricture. Since my first re-examination of urethrae, the subject of operation by dilating urethrotomy, I have embraced every opportunity to test the presence or absence of recontractions of the divided Strict- ures ; in each case carefully noting the results in my book of daily record. From 1872 to 1875, out of the one hundred cases operated on, thirty-five cases were re-examined at periods varying from six months to three years from the date of last operation. Of these thirty-five cases recontraction of the Strictures occurred in but four cases. Leaving thirty-one claimed as radical cures out of thirty-five cases operated on. From 1875 to 1878 there-examinations as seen by following statement have amounted to eighty-two. In this number are included all cases presenting, previously operated on, without regard to any previous re-examinations. In the following record of the eighty-two re-examinations above alluded to, in no case has more than a single re-examination been recorded (and that the last) in any one case. The results showing seventy-four cures out of the eighty-two cases re examined I36 CASES OF STRICTURE 2D SERIES. 319 prove in a striking degree all that has been heretofore claimed by me in regard to the radical cure of the Stricture. Thus: RE-EXAMINATIONS. No Re-contraction...............67 CASES. 6 years and 6 months after operation.............................3 cases. 5 " " 2 " " 4 " " 9 " tt 4 " 3 " <> and 8 months a 3 " " 4 " 3 " " 2 " 3 " 2 " tt and 6 months " 2 " " 3 " 2 " " 1 month " 2 " it 1 year and 10 months " 1 " " 9 " et 1 " " 8 " tt I " " 5 " " I " tt 4 " 3 " tt r " tt 2 " 1 month a I year 10 mon (t ths.. tt 9 " 7 " 6 " u a „ 5 " 4 " 2 " „ tt h . (( I mon « 1 case. . 1 " , 2 cases. 1 case. . I " , 1 " 7 cases. • 3 " 2 " 1 case. 7 cases. 1 case. I " 1 " 3 cases, 2 " 4 " 1 case. 1 " 7 cases 2 " 2 " 2 " 4 " 3 " 1 case. I " 1 " 3 years after operation 3 " 1 year 10 m'ths 6 " 4 " 3 " RE-CONTRACTIONS. 1 case. At 2J in. No return of symptoms. j At meatus. Return of symptoms. 2d op- ( eration. Cure. .1 case. At meatus. 2d operation. Cure. ( At meatus and at 4 inches. Partial return ( of symptoms. 2d operation, with relief. . 1 case. . 1 case. At meatus. 2d operation . 1 case. At meatus. 2d operation. . 1 case. Return of symptoms. Cure. Relief. 320 RESULTS OF OPERATION. 2 m'ths after operation 2 " 2 " I month " Time not noted. Total 4 .lease. At 3 \ in. 2d operation. Cure. .1 case. At meatus. 2d operation. Great relief. At 5^ in. 2d operation. Cure. Remains well for 2\ years. ..lease. At meatus. 2d operation. Great relief. j At meatus. 2d operation. Cure. Remains ..lease. | Well for 2^ years. .. 1 case. At meatus. Partial return of symptoms. (1. At meatus. 3d operation. Relief. 2 cases. 1 At 6 inches. Return of symptoms. 15 cases. Out of the 15 cases of re-contraction, 9 were at the meatus alone. " " " Return of symptoms. Secondary operation. Cure. 6 Return of symptoms. " Relief. No symptoms. Well when last heard from......5 Return of symptoms. No secondary operation.....3 No return of symptoms..........................I CHAPTER XVII. CONCLUSION. THE points which are claimed to have been established by my observations are: I. That the urethra is an individuality, and hence to obtain the true normal calibre of any urethra, it must be measured, or estimated, independently of any other. 2. That the meatus urinarius is worthless as a guide to the normal urethral calibre, and that its abnormal contraction is the cause of the pouch-like dilatation of the urethra behind it, known as the fossa navicularis. 3. That Stricture is a relative term. Hence its extent must always be estimated by comparison with the previously ascertained normal calibre of the urethra under consideration. 4. That the slightest abnormal contraction of the urethra, at any point, constitutes a Stricture. 5. That a Stricture, in this sense, is always a point of friction, the legitimate tendency of which is to produce inflam- mation ; and hence the slightest appreciable Stricture be- comes worthy of consideration. That serious trouble often results from Strictures which but slightly contract the calibre of the urethra and which do not markedly interfere with the passage of urine ; and that among such troubles spasmodic Stricture, simulating true organic Stricture in every respect, is often caused by such slight contractions. 6. That Stricture is a cause though not the only cause of gleet; and is, when present, always a cause of its per- sistence. 7. That true Stricture always embraces the entire circum- ference of the urethra at some point. 21 322 IN CONCLUSION. 8. That complete division of Stricture at any point results in the immediate disappearance of the Stricture. 9. That separation of the sundered ends of the Stricture, suitably maintained until the healing of the wound, prevents the return of the Stricture, and finally results in the complete absorption of the stricture-tissue. 10. That Stricture is, strictly speaking, an inflammatory product, and that any acute or chronic inflammation may pro- duce it. 11. That Stricture is often present as a result of inflamma- tion caused by lithiasis, masturbation, or urethral laceration, (by gravel, etc.,) though usually the sequel of a gonorrhoea. 12. That Stricture occurs most frequently in the anterior portion of the canal; and with increasing frequency when approaching the meatus where a gonorrhoeal inflammation begins the earliest, rages the hottest, and lasts the longest. From authorities and their followers who have hitherto denied the possibility of radical cure of urethral Stricture, I an- ticipate continued denial, until they shall have conscientiously and exactly carried out the plans and procedures through which my success has been attained, and have had the oppor- tunity of testing the results by years of observation as I have done. In the meantime others, distinguished as teachers of surgery, and recognized as independent, honest and capable observers, like Professor Pease, Professor Brown and Dr. Mastin, will aid me in educating the general profession up to the point of departing so far from established doctrines as to give the rational treatment of Stricture a fair trial. This effected, I believe the day will not be far distant when close Stricture will be esteemed a surgical opprobrium, and the continuous treatment by dilatation, except under rare and peculiar circumstances, will be relegated to physicians or to the patient, and this only as a temporary expedient to be practiced until competent surgical aid is attainable. I am prepared to assert that such results as I have recorded, are not exceptional and may be attained by any surgeon who CONCLUSION. 323 will provide himself with the necessary instruments for the performance of dilating urethrotomy, and use them in accord- ance with the plans and principles previously enforced and zvith the exercise of such judgment and skill as are considered essential to success in any other operation of like importance. New York, July ist, 1878. Cause and Date of. 62! Gon. 43 years previo u s 1 y several a t tacks since. u J= V £> U-. « 0 p u 0 £ t/2 <*H | . °j £ N O C/5 z Condition at Date of Operation. O Result. Gon. 7ys. pre^ vious ; several times since, Gon. 2 years previous. Mastur- bation. Meat. 2 in. 28 30 30 3 m. 3i in. Meatus. in. in. 34 Frequent micturition every 30 minutes. Pain after urination Meatus. 3° in. 34 in. 34 34 37 34 38 Gleet for seven years. Frequent micturition. Pain when urine is retained. Erections imperfect. Frequent micturition during day and night. Pain in back and hy- pogastrium. " Scald- ing " in urethra. Spasmodic Strict, at 6 inches. False pas sage. Erections imperfect. Purulent urine with spermatoza I Chill Divided Stricture at Meat. only. Imme- diately after opera- tion urinated once in 10 hours, habitu- ally once in 6 hrs. No pain after mic- turition. Relief for 4 mos. Recontraction to 29 ; 2d operation, immediate relief. Curva- Cure of gleet. Curva- ture of ture of Penis cured Penis. in 1^ months. Immediate cure of frequency of mictu- rition and of pain. 1 Urethrit. Cure of frequent mic- dipth'tic. deposit at Meat turition and pain, Erections perfect. Remarks. Had been treated for deep Strict- ure by oth- er surgeons. 00 to Pi w m c| H m C o ft Pi > H 1—1 O 31 Meatus for I in 4 in. Meat. 2 in. 2i in. Meat. 3$ m. 24(36 34 28 24 34 36 32 Urinates every \ to ^ hour. Throbbing pain along urethra; con- stant pain along back and over pubes. Dis- charge off and on fo over a year. Urinates 4 to 5 times at night. Pain in perine um and testes ; mucus extruded with pain after urinating. Gleet four years. Frequent and difficult micturition and at night. Gleet. Painful mictu- rition and erections. Frequent urination. Purulent . 1 urine. Seminal emissions frequent. Throbbing in testicles. Spasmodic contraction of penis. Pains in thighs and legs. Urine muddy. Frequent seminal emissions and im- perfect erections. Curva- ture of Penis 4 months. Immediate relief to frequent and pain- ful micturition and pain. Entire cure in one month. Cure immediate.... Cure Cure in two weeks. Great improvement. 3 years and t mos. after op eration. N o recontraction. 3 years after, no recontraction Curvature lasting four mos. result- ing i° great measure from loss of erec- t i 1 e power present be- fore opera- tion. O W X C O Pi W O > o H X Pi H < I Cause and Date of. £> V o 3 ■e J= V) U <*- o fi an Z Condition at Date of Operation. Results. oi Remarks. 47 25 13 Mastur- bation. Gon. 27 years ago. Gon. 12 years ago and sev- e r a 1 times since. Mastu'bation. Gon. 19 years before, and several times 3 Meatus. 21 32 2j in. 24 3 m. 24 3 Meatus. 36 3 in. 33 4 in. 33 4 Meatus. 28 32 2\ in. ) 3 in. J 24 4 in. 28 4i in. 32 I Meatus. \ in. 23 38 Pain over pubes and in testicles. Great de- spondency. Frequent urination. Intense pain at coitus. Constant pain i n thighs and perineum, robbing him of sleep Gleet 4 years. Pain in testes. Follicular ulceration of urethra Frequent seminal emissions ; premature ejaculation ; soreness along urethra. Frequent seminal emissions. Perineal abscess. Hemor- rhage easily control- led. Cure Much improved. Cure Cure of urethral trouble. Relief to seminal trouble. 10 mos. after No recontrac- tion. 3 years after No recontrac- tion. 4 Meatus. 32 36 3i in. 32 3lr in. 34 2f in. 34 4 2 in. 3i in-4 in. 4^ in. 24 3b 2 Meatus. 2.3 34 3 in. 28 3 Meatus. 30 34 k in- 28 2^ in. 33 3 Meatus. 27 34 i in. 27 2 in. 27 2 Meatus. 34 2 in. 28 Gleet.............. Frequent micturition. Gleet Gleet for one year. Discharge without ex- posure. Painful and frequent micturition (every £ hour) ; pain in penis and testicles. Constant burning pain at neck of bladder and along urethra. Fre- quent painful micturi- tion. Has had reten- tion. Gleet.............. acute gon- orrhcea of 4 months standing. Chron. hydroch (double) Cut for stone I yr. previously with no re- lief; blad- der t'ouble Smart hemor- rhage. Curva- ture of Penis. Cure Cure............ Curvature of pehf. (one year). Cure Cure No relief. Meatus only divided. Cure 9 months after n o recontrac- tion. 3 years after continues well. Operation during acute inflamm'tory condi tion , resulting in prompt re- lief of this cond iti o n, which had existed for 4 mos. previ- ously. Final complete dis- appearan ce of the incur- vation and cure. Trouble sub- sequently found to be depe n d e n t upon pyel- itis. / Cause and Date of. ni JC rt w u <*- o R i> U \n fc! Condition at Date of Operation. 20 39 23 45 2423 Con. 19 years previo u s 1 y, and several times since. Gon. Mastur- bation. Gon. 20 years previo u s 1 y, and gleet occasionally since. No venereal. Meatu> I in. bands h t0 2 in. i- to 3\ 2 Meatus. 24 in. Meatus. i£ in. 32 34 34 Frequent micturition Pricking and numb- ness in anus and legs. Gleet 34 Seminal weakness. 34 34 Pain at penis after urinating. Attacks of frequent urination. Pains in thighs and hips. Frequent micturition (every -| hour). Pains in hypogas tri um, thighs and down legs. V. c _0 cs •> Q ^ tT a b >• C 5 o :=! :>,siS.. -o .a ca m 13 years previously patient was operated on for supposed deep Strict, without re- lief, and since then frequent unsuccessful attempts at catheterism had been made Frequent attacks of retention urine be- fore present operation, relieved at night by involuntary enuresis. J S >N o (-. 3 *S o ..H°*..v.Q a .. in c E5 c Siai^o i av u o c .- C (** , .j* o '2 j; — i-, ■; ^, g 2 S'S '-'Sag3 m u o m -a i> .a w vi w in es rt 3 o 6 13 u .a rt rt D.O >-3 o a 9> fc! « 3 rt u V IU > OJ Q t: u a a rt "rt C o a a >> "a a OJ g a o h-i a. IS 8 n >- rt OJ E rt rt u a 0 o >, li 0 a r/> -C H c o u c a .a u fc/3 rt a 13 rt CM J rt 1m 3 u d e* a' 013 ■- a Em cr > .a u u rt 1- o CO vO 0» 0) 2 a a rt ""■ "7. ii « g 3 o U E l- rt o. m M rt ^P g - ■£ ^ — ^ -d a rt i2 >, S^a.SSrt^s y " rt u jc «*« -° u d U ■». O o u J2 c/5 d U V- o K u c/5 2 Condition at Date of Operation. 39 34 40 41 36 24 Gon. Gon. 16 and 7 years pre viously. Gon. 4 and i\ years pre- viously. 1 Meatus. 24 34 Gleet............. Syphilis Meatus. 1 in. 2| in. 3 in. 4l in. Meatus. 3 in. 3a- in- 34 36 Painful micturition. Drawing sensation behind scrotum, at thigh and groin. Burning sensation in rectum and rectal tenesmus. Gleet Enlarged prostate. Syphilis. Results. 1 chill. Cure Cure of his troubles. Recontraction twice at meatus, causing a temporary return of his symptoms. After 3d operation disappearance of all his symptoms. Cure Oil_______ 2 years after op- eration. No recontraction. 1 year after last operation. No recontraction. 2\ years after, remains well of Stricture. Has tertiary syphi lis. Remarks. 42 47 Gon. 23 years previously. 43 35 44 Gon. 15 years previously. Gon. 8 and 4 years previ ously. Meatus. 4 bands in pen- dulous part bands in mem- branous part Meatus. 2 in. 2\ in. 3\ in. 2 bands at 4 in. 38 24 32 30 Painful and frequent micturition. Most of urine escapes through fistulous openings. Painful and frequent micturition. Drib- bling. Nervous feel- ing in testicles. Gleet 3 urethral fistuloe. Kidney disease. 2 chills. Suppres- sion of urine lasting one day Diph- theritic deposit at meatus. Cure Much improved. Re- lief of troubles for about one month. Recontraction at meatus with return of some difficulty in micturition. Temporary improve- ment. Cure. 15 months after operation n o recontraction No fistulae. 6 months after operation. No recontraction. Operated on by perineal sec. ad yr. previously by Dr. Agnew, of Phil. Present operation con- sisted in a div. of deep Strict. by external and of the anterior bands by inter- nal urethrot'my (comb'd opera- tion). Nearly 2 ys. after (Oct. '77) recontract. to 28 at iin. with sw'llingin peri- neum. Ope tion with disappear- ance of sw lling and great relief Jan. 187S 2 yrs. after operation 1 fistula reope'd while run down from malaria. Circumcision was perform- ed, besides urethrotomy. Had been treated for deep Stricture by other sur- geons. 00 OJ 6 d U <~ o V J2 R V 3 bit 2 < < Cause and Date of. ni r. HI & V o 1 u x> c?5 d w. o fi u N c7) 2 Condition at Date of Operation. 45 46 47 48 49 19 Mastur- bation. Gon. Gon. 8 years previously 10 mos. pre- viously had gon. Gon. Meatus. Meacus. Meatus. Meatus. 3 in. Meatus. 4 in. 6 in. 31 34 14 31 23 30 23 35 30 23 0 0 34 ft 0 0 n Frequent s e m i n a emissions. Gleet for 4 years Frequent and painful micturition for twelve years. Gleet............... Tenesmus and pain over pubes, penis and perineum. Spasmodic deep Stricture. Stone in bladder. Cystitis. Chills severe. Results. Cure Cure. Recontraction and return of trou- ble 1 year after. 2d operation and re- lief immediate. Cure............. Lost sight of. Reontraction. Re- covery from cystitis. Postponing 2d op- eration, continues treatment by dila- tation on his own account. Remained well for one year, then had an- other gon. Remarks. Had been treated for deep Strict- ure by other surgeons. Stricture at 6 in. divided by Maisonneuve urethrotome. 5070 5i 35 52 3° 53 54 £5 Denies Gon. Gon. 13 years previously. Gon. 2\ years previously Gon. Mastur- bation. 4 Meatus. I in. 2\ in. 3 in- Meatus. Meatus. Meatus. Meatus. 32 27 34 35 34 34 26 Can pass urine only t h rough catheter. Pain in penis. Much pus and blood i urine. Passes h i urine every half an hour. Uleet Gleet. Frequent in- voluntary seminal discharges. Pain in groins around rectum Dribbling after urin- ation. Micturition every half an hour acid very painful. Dccasional nocturnal incontinence. Semi- nal emissions every night. Cure........... Constant improve- ment since opera- tion. Passed his urine without cath- eter, about one in 2 hours, 1^ months after operation. Cure of gleet...... 2 years after No recontrac tion. Cure perfect Much improved. Temporary relief of headache and epi- leptic attacks. Re- turn of trouble. 2 years operation recontraction Cure perfect. Deep Strict, re- peatedly divid- ed by other sur- geons by exter- nal and internal incision, with short and in- considerable I relief. afterj Circumcision No was perform- ed also. Perineal sect. performed by other surgeon Jan., 1876, to relieve cystit- is. External wound n o t healed. X d u o l-V E 3 Z c .4J d O < Cause and Date of. > "d 0 O U t-3 O W V. 0 N in d t-J= -d W Pi > H O 2 31 69 70 7i 3i 24 72 73 26 16 Mastur- bation. Gon. 3 mos previously. Gon. 9 years previously Gon. 6 years and also months pre- viously. Gon. 6 years previously and several times since. No cause given, 2 Meatus. 25 32 3i »». 29 2 Meatus. 16 34 i| in. 28 4 Meatus. 30 34 i| in. 24 2\ in. 24 4|in. 18 1 Meatus. 25 36 2f in. 34 4 Meatus. 18 36 2 3 0 3* 03 <* 3 I Meatus. 22 34 Imperfect erection Nocturnal seminal emissions. Retention of urine Gleet. Vesical ten esmus. No. 7 only passes in bladder. Gleet. Small and di vided stream. Drib- bling. Frequent and painful micturition. Transparent discharge, Gleet. Reflex pains over pubes and peri- neum. Frequent and painful urination. Slight in curva tion of penis. Chills. 2| weeks after op- eration has perfect erections. Cure, Cure 1 yr. and 8 mos. after no recon- traction. Cure complete Cure........... Excess only causes return of gleet. 2d operation for deep Stricture. Still un- der treatment. Cure No improvement. 5 months after operation. No recontraction Meat, divided at 1st opera- tion. About 2 yrs. after 1st operation re- turned for di- vision of deep Stricture. O M X c o Pi W a OJ OJ VI VJ Number of case. Co to +. to ~-4 vi .£. o Age of Patient. M° OB P C rt rt O p .~>s a. No cause given. Gon. 6 years previously. Gon. one year previously. Gon. 15 years previously. M M Ki Number of Strictures. Mea u.-,. Meatus. 3 in. Meatus. Meatus. Localitv of Stricture. to CO v CO ( M u ^ to O OO M Size of Stricture. >> Ol LO d ° Condition at Date of 1- Operation. "d E 0 Z Great difficulty of start-ing the act of urina-tion. Frequent mic-turition. Frequent and painful urination. Small stream. Tain in peri-neum, rectum and supra pubic region. Feeling of fullness in pelvis. Gleet. Dribbling after urination. Painful "tickling" sensation at glans penis. Gleet. Frequent mic-turition. Complications. MM mm Number of Operations. Accidents after Operation. O a P T 2 % -1 =r re P a-0 -I FT ■5 r. : rt Pi a B. 4 months after operation no recontraction. 5 months after operation no recontraction. 3 ° " 0 « 3 p p 0 0 3 5* •3§ 3 c 3 /I a 2 Re-examination. to ^ ' n < B " -> 1 ? -*> Pi n 3 p ni NoixvHadO ao sxTnsan—saigas aNOoas ote 78 79 6o 3S 80 81 82 83 84 32 24 29 23 25 Gon. about 6 months pre- viously. Masturbation Excessive venereal in- dulgence. Ulcers in ure- thra 3 years previously. Gon. 5 years previously, and several times since. Gon. 12 years previously, and several times since. Gon. 6 mos. previously. Mastur- bation. 4 Meatus. Mem- branous portion 3 bands 2 Meatus. 2i in. i\ in. to Meatus. Meatus. Meatus. 3 in. 3f in. Meatus. 3i in. 3 bands Meatus, 28 34 27 32 26 24 31 23 32 36 38 34 34 Micturition prolonged Imperfect erections Premature emissions. Gleet Gleet 2 years. tenesmus. Vesical Burning sensation it deep urethra. Gleet. Gleet. Pain in glans penis, back and testi- cles. Frequent and painful micturition. Dribbling after urina- tion. Frequent sem- inal discharges. Im- perfect erection. Pre- mature emission. De- spondency. Perineal abscess. Rectal fistula. Syphilis. Frostatic enlarge- ment. Prostatic enlarge- ment. Cystitis. Long pre- puce. 2 Haemor- rhage. Haemor- rhage. Cure Lost sight of. Cure Much improved.... Discharge disap- peared. Much im- proved generally. Cure after 3 months. 4 months after operation. No recontraction Much improved. The combin- ed operation was perform- ed. One year after operation con tinues well. Circumcision was also per- formed. O % w X a 0 Pi W d > a H X Pi H < I m O > m w in OJ 4^ u .a 3 1. 3 £> > 71 U J3 R 3 bet .a R 3 "d o °| 6 0) ^ ompli z <; ✓. J C/3 Z O 85 35 Mastur- bation. 862 8726 50 Gon. 10 mos previously. Gon. 4 and 2 years previ- ously. Gon. Meatus. in. Meatus. Iin. from \ in. to 3 in. Sev- eral bands. Meatus. Close Strict at mem- branous urethra. 32 32 30 Frequent seminal emissions. Tremul- ous sensation in lower extremities. Imper- fect erections. Drib- bling. Persistent pain in hypogastric region aggravated by seminal emissions. Gleet............... Dribbles. Pain in back and lower extremities Dribbling. F'requent micturition. Gleet. c 0 d V a O 0 OJ R 3 z e 0 d y external division. No guide. 00 4- Gon. 20 and 18 years pre- viously. Gon. 3 and 2 years previ- ously. Gon. 'On. 2 years previously. Gon. 3 years also 3 mos. previously. Gon. 12 years previously. i '"• 18 30 4^ in. 21 Meatus. 29 34 2$ m. 27 zf in. 29 3 in. 2q Meatus. 32 36 2 in. 32 2i 'n-3* «». 32 32 Meatus. 25 32 4 in- 30 2 in. 30 2| in. 26 3i in. Meatus. 28 32 3 in. 26 Meatus. 2 5 40 from 1 34 to 2 in. 3 to 4 28 3 bands. Frequent micturition. Sense of obstruction at end of penis. Drib- bling. jleet. Discharge ap peared 1^ year previ ously apparently with out cause. Gleet. Irritability of bladder. Gleet. Sense of ob- struction in urethra, Seminal weakness. Imperfect erections. Premature discharge. Hyperesthesia of tes- ticles. Atrophy of one testicle. Gleet. Pain in righi hypogastric region and groin. Gleet. Frequent at- tacks of retention re- quiring aspiration Frequent micturition. Bladder habitually distended to umbili cus. Cannot retain urine when standing. Slight en- largement of prostate Cystitis. 1 Slight curvature ot pen Cure Improved. Recon- traction found 3 months after op eration. Cure perfect . Cure Pain disappeared after operation. Cure of e;leet. Relief for 10 mos. perfect. Vol unt'y micturition every 4 hrs. Large stream im- mediately after opera- tion and continued. 10 mos.after recontraction to j4 at Meat, and at 4 in. Return of frequent and difficult urination. No retention, jil opera- tion with immediate re- lief. 3 months after, recontraction One year after operation. No recontraction. One year after perfectly well. The anterior contraction only was divided. Had been treated for deep Stricture by other sur- geons. Two weeks later laticnt writes t lint troubles again threat- 1. Not since heard from. z < Cause and Date of. 95 96 39 40 97 28 Gon. 18 and 10 years also one month previously, Traumatic in jury 17 yrs and Gon. 4 yrs. previous- ly and since. Gon. 11 and 7 years pre- viously. I .Meatus. Meatus. Meatus. 2 in. 3 in. -C u t> <+- 0 0 n in d O 0 R u. in Z Condition at Date of Operation. Results. 25 34 14 32 32 Gleet (profuse). Pros- tatic tenderness. Ii ritability of neck o bladder. Strainin and pain after urina tion. Gleet. Sense of weight in perineum. Gleet. Burning sensa- tion in urethra after urination. Frequent micturition. Drib bling. Frequent sem- inal emissions. Imper- fect erections. Severe pain in lumbar region. Pain in testicles and groin. Great depres- sion of spirits with suicidal tendency. Enlarge- ment of right lobe of prostate Redund- ant pre- puce. Diph- theritic deposit on wound. Much improved. Much improved. Much improved. 1 months after operation no recontraction. Remarks. Circumsion was also per- formed. £ 28 Gon. 16 years previously and several times since. Masturbation Gon. 32 years previously. Gon. 3 yrs. & 2h >rs- pre" viously. Gon. 2\ years ago. Mastur- bation. Mastur- bation. Gon. Gon. several times. Meatus. 1 \ in. 3\ in. 4^ in. Meatus. 3 in. Meatus to 1 in. 2 in. Meatus to f- in. Meatus to \ in. Meatus to 1 in. Meatus. 3 in. 3^ in. Meatus. 2} in. 11 in. more or less for 3 inches. 15 36 25 II 36 30 32 26 25 35 30 25 34 26 32 26 32 26 34 31 31 15 32 22 22 36 Gleet. Divided stream Gleet. Griping pain above pubes after sex- ual intercourse. Gleet for 2\ yrs. Severe pain at ^in. from Meat tenes. and dribbling. Gleet for two years ... Urination hesitating. Dribbles. Urethra very sensitive. Frequent seminal emissions. Dribbling. Retentions. In bed for yr. Frequent and dif- ficult urination. Dilat- ed for perineal Strict, Gleet............. "Petit Mai," con- vulsion every day, or once week. Unable t read. Calculus. Slight haemor- rhage. Recontraction. 2d operation 2 months later. Final cure Cure Cure Urethral fever on 4 day after operation on passing sound into bladder. Relief in five days Lost sight of. 1 yr. and 5 mos. after op'tion no recontraction. 6 months after operation no recontraction. Marriage two months after 2d operation. Cure Immediate cure of urinary trouble. No attack of Petit Mai for 2 mos. Recon- traction ; operation 3 mos. after reports only slight "faint- ings." Great improvement Cure Cure Dolbeau's op- eration. Cal- culus weighed drachms. Gleet gave va- ginitis to wife 4 days after marriage. O w 33 C o Pi M O > o H 33 Pi H 00 4^ 6 Cause and 3 u 3 6 d 1-.a ■ "d O 3 t« 0 N 'tn U R 0 Operation. c .2 d "a. B 0 O r. 38 years previously 5 Meatus. 2 in. 2^ in. 3 in. 4f in. 2 Meatus. 6 Meatus. 3 m. 4 in. I 4t in. Meatus. Meatus. 1 in. 3i in- Meatus. | in. 3i in. Meatus. 28 32 30 26 26 28 30 39 36 18 34 20 20 20 18 18 20 38 25 32 18 36 20 30 18 34 20 30 2S 32 Involuntaiy and pre- mature emissions. Frequent and painful urination eveiy 15 or 20 minutes. Gleet for 18 years. Intense pain in urethra and at neck of blad- der. Frequent urination. Difficulty in starting urine. Dribbling very marked. Gleet four months. Gleet five months. Pain in penis and ab- domen. Irritation at neck of bladder. Ilribblinsi. Redundant prepuce with phy- mosis. Pains at end of spine, ir penis and perineum and down legs. Prostate tender and swollen. Prepuce long and narrow. Prostate slightly en- larged and tender. Haemor- rhage. Urethritis followin neglect and expos- ure at night. Immediate relief. Cure. Cure. One month after operation writes that he is perfectly well. Immediate relief for four mo. Recontrac- tion. 2d operation with complete relief Much improved. Passed from obser- vation. Relief to prostate in 6 days. No record further. Cm Constant and great improvement. Recontraction. One month after no recontrac- tion. Operation of circumcision and division of Meatus done first. O M 33 C d Pi W 0 > d H 33 00 Cause and Date of. rf a o & r— -• Xi " . ^^I^^iff?' x 0- #.T#- J^,.-, X *^j* 0.^0 x«x ^ 0: ESS.; fit