ON STRICTURE OF THE MALE URETHRA, ITS RADICAL CURE. By FESSENDEN N. OTIS, M. I)., Clinical Professor of Genito-Urinary Diseases, College of Physicians and Surgeons, New York. NEW YORK: G. P. PUTNAM’S SONS, Fourth Aye. and Twenty-Third St. 1875. ON STRICTURE OF THE MALE URETHRA, ITS RADICAL CURE. By FESSENDEN N. OTIS, M. D., Clinical Professor of Genito-Urinary Diseases, College of Physicians and Surgeons, New York. NEW YORK: G. P. PUTNAM’S SONS, Fourth Ave. and Twenty-Third St. 1875. ON STRICTURE OF THE MALE URETHRA, ITS RADICAL CURE. By Fessekden N. Otis, M.D., Clinical Professor of Genito-Urinary Diseases, College of Physicians and Surgeons, New York. Mr. President and Gentlemen : In a paper which I had the honor to read before this Society, in February, 1873, the impor- tance of the recognition and treatment of comparatively slight contractions of the urethral canal, was insisted on. The entire incapacity of all urethral instruments, in general use, to reach such cases, was demonstrated, and a new instrument, one which com- bined in its operation the principles of dilatation with complete division, was presented. This instrument had been invented but little more than a year, and had been used in operation upon fifty- eight strictures, occurring in twenty-seven patients. The results, in six oases (comprising eighteen bands of stricture), had been critically examined by a competent committee of surgeons, at periods varying from one year to four months after operation. In every case, without exception, the most careful examination with the full sized bulbous sound had failed to detect the slightest trace of stricture. In closing my paper I ventured the hope that future experience with this plan of operation on urethral stricture, by complete division, might be found to result in radical cure. I come before you to-day, gentlemen, with the results of a more extended and intelligent experience, bearing upon this important subject My first dilating urethrotome was presented to the profession at a meeting of the Medical Library and Journal Association of New York, November 24, 1871. Up to this time there were no means of efficiently treating strictures of large calibre. In point of fact, strictures of the urethra above nine of the English scale, according to English authorities, or twenty-one of the French, according to French authorities, were not considered as requiring treatment In my paper on strictures of large calibre, read before the New York Medical Journal and Library Association, in November, 1871, and published in the New York Medical Journal, in February, 1872, I claimed, that “ the slightest encroachment upon the normal calibre of the urethral canal, at any point in its course, was cause sufficient 4 FESSENDEN N. OTIS. to prolong an existing urethral discharge, or even to establish it de novo without venereal contact.” This important proposition, based upon the constant association of stricture or strictures, more or less pronounced, with every case of chronic urethritis, and supported by conclusions which the consideration of a persistent mechanical interference with the act of urination rendered inevitable, has found a necessary practical acceptance by all surgeons who have seriously considered it. As a consequence, a very large class of strictures of the urethra—greatly the largest—once utterly unsought and ig- nored, have come to be recognized as the mechanical cause not alone of urethral discharges, which defied the most persistent and varied treatment by internal remedial measures and injections, but of reflected nervous disturbance, throughout the genito-urinary tract, and even extending, in well authenticated cases, to distant parts of the economy. The term “ Stricture” is, of necessity, a purely relative one, and can convey no intelligible idea of its value as a disturbing element, until the calibre of the constricted tube has been ascertained. As long as difficulty of micturition was the earliest recognized evidence of a strictured urethra, considered of any value, and the mechanical obstruction to the passage of urine the only direct result of stric- ture, it was jierhaps pardonable to neglect the investigation of the exact mechanical relations existing between the stricture and the urethra in any given case, and to assume a definite standard for the size of all urethrae. In this view of the matter it was perhaps proper to assert, with the French school,* that seven millimetres diameter is the standard size of the normal male urethra, and to claim that this is quite sufficient for the purposes of micturition ; or, with the English, that when eight or nine of their scale can be passed through a given urethra, no stricture can be said to exist ;f or with the authors of the American scale,:}: who limit urethral measure- ments to 31£ m. in circumference. But when it comes to be recog- nized, (as has been proven beyond the possibility of contradiction,) that the capacity of the human male urethra, bears always a con- stant relation to the size of the penis with which it is associated, and that this organ varies greatly in size in different individuals, it will be at once seen, that no average standard can be arrived a% which will be of practical utility in diagnosis and treatment of * Curtis. f Thompson: Stricture of the Urethra, p. 147. London, 1869. % Van Buren and Keyes, p. 112. New York, 1874. STRICTURE OF THE MALE URETHRA. 5 stricture, any more than an average standard can be adopted by your shoemaker for the normal human foot. Nothing is now easier than to prove this statement. I have said that there exists a constant relation between the size of the flaccid penis and the capacity of the urethral canal. During the past year I have subjected more than one hundred urethrae to a careful examination on this point, with the follow- ing results, to which there has not been found a single excep- tion, viz.: That, when the circumference of the flaccid penis was 3 inches, the circumference of the urethral canal was found to be at least 30 of the French scale. When it was 3|- inches the urethra had a capacity of 32. When it was 3|-, the capacity would be 34 — 3f = 36; 4 inches = 38. When it was 4|- to 4£ inches in cir- cumference the capacity of the urethra would equal 40, or more. In every case the urethral calibre was over rather than under the figures above given. In a considerable ma- jority, contraction of the meatus (either congenital or from previous inflammatory changes) was present, and in these cases the measure- ments were made with the urethra-meter or after division of the contraction. The value of the urethra-meter in ascertaining the actual calibre of the urethra, notwithstanding the presence of stricture or contraction of the meatus, cannot be overrated; it is with this instrument that the proportionate relations of the urethral calibre and the size of the flaccid penis have been confirmed. K B *7 F. G. Orro & Sons, N. Y. URETHRA-METER. With it and the metallic bulbous sound, the thorough examination of any presenting urethra may be made, and the precise locality and value of every deviation from its normal calibre be positively determined. Having then, in any given case, made out the num- ber, size, and locality of strictures, the desideratum is to find an instrument which will completely divide them, with as little injury to the adjacent healthy structures as the possibilities of the case will admit. 6 FESSENDEN N. OTIS. Stricture tissue is simply cicatricial material, deposited in accord- ance with the accepted pathological law, that persistent irritation of living tissue results in the aggregation of cells and the develop- ment of connective tissue corpuscles, at the point of irritation, which, becoming organized in the sub-mucous cellular tissue and the adjacent muscular structure of the corpus spongiosum, results • in a more or less resilient band or bands always completely sur- rounding the urethra. We have then always to deal with a resil- ient band, constricting the urethra more or less, at a given point or points. It may here be urged that stricture is not always a band surrounding the urethra, but that it may be on one side or the other, or above or below, according to many authorities. To this I answer, that a true stricture, always and of necessity, com- pletely surrounds the urethra. That it may have its origin, its commencement, at a single point in the circumference of the canal, I grant; but as soon as the calibre of the urethra becomes lessened at any point, the resistance to the flow of urine which it neces- sarily occasions, and the resulting interference with the harmo- nious muscular action, produces an irritation in its whole circum- ference at the point of contraction, resulting sooner or later in an aggregation of fibro-plastic material, not confined to a single point in its circumference, but around the entire canal; and this fact renders it necessary for us, in all cases of strictured urethrae, to ac- cept the difficulty as one of stricture, in its true sense, and not of obstruction at a single point. Aside from the evident probabilities in such cases, the fact that stricture of the urethra may always be released by division at any point in its circumference, would be greatly in favor of this proposition. Practically, then, we may ac- cept the stricture as constricting the entire canal. We have then a more or less dense, more or less extensive resilient band of fibrous tissue, contracting the urethral calibre at one or more points. Now, if we found a band of any sort of elastic material sur- rounding the penis, constricting the urethra, even to a very slight extent, the immediate removal of such a band would at once sug- gest itself as the best method of getting rid of the irritation caused by it. It would not be considered sufficient to put the patient in the best possible condition to bear it, nor to dilate it frequently, with the same idea ; the known resilient property of such a constricting band would suggest the transient character of the relief to be expected from such procedure. But one thought would occur to any person in such a case, viz., to divide the band STRICTURE OF THE MALE URETHRA. 7 completely at some point. Practically we have an analogous con- dition of things in every case of urethral stricture, with the simple difference that the constricting band is resilient fibrous tissue and surrounds the urethral canal, contracting its calibre at one or more points, while the intervening portions of the urethra remain equal to or exceeding their normal capacity. The graver consequences of such contractions were recognized at a very early period in the history of surgery, viz., difficulty of micturition, retention of urine more or less complete, urinary abscess and fistulse; urinary infiltration, causing death, in other cases causing disease of the bladder and kidneys, which proceeded with almost equal certainty, if not with equal celerity, in terminating existence. For the resto- ration of the urethral calibre, simple mechanical distension prom- ised the easiest and most natural solution of the difficulty. Thus, bougies and sounds were invented and used at a very early period. The exact point of the contraction, in this method of treatment, it was not necessary to ascertain, as these instruments could be passed through the entire urethra, thus including every point of contraction. As this plan resulted in the temporary relief of a large majority of cases, it came to be considered the method, par excellence, to be adopted in all cases of urethral stricture. After a time, however, it was found that, while, by the use of instruments skilfully graduated from the smallest filiform bougies to a size deemed sufficient for the easy performance of micturition, the pressing and threatening troubles resulting from stricture could be relieved in a large number of cases, there were many, where, from the delay which this method necessitated and the irritation caused by its use, instead of the relief hoped for, the gravest consequences supervened. It was then that more immediate and forcible means of relief were devised, such as rupture or division of the constricted points. The divulsors Perreve, Holt, Thompson, Thebaud, and others— the urethrotomes of Maissonneuve, Civiale, Ricord, etc., came into notice. These were each so successfully used in the hands of dif- ferent eminent surgeons, that while at first resorted to only when the milder treatment by the different forms of dilatation had proved unsuccessful, advocates arose urging their indiscriminate use in all cases of urethral stricture. It was claimed that when the strictured urethra was raised to the accepted normal standard by a single blow, there were, on the average, less unfavorable results than where, through a long period, the systematic use of gradual dilata- 8 FESSENDEN N. OTIS. tion was resorted to ; and besides, that the results of the divulsion and division were of a more permanent character. These claims were stoutly resisted by the advocates of a gradual dilatation, and all the possible benefits and advantages accruing from every other mode of treatment were asserted to be possessed, in superior de- gree, by their more conservative proceedings. Besides this contest between the advocates of gradual dilatation and immediate opera- tion, we now have this latter class divided into those who believe that all strictures are best treated by divulsion, and those who claim that the best results are produced only by division of stric- ture, with some one or other of the various urethrotomes in use. Each party, however, accepting the necessity of keeping up the re- sults of their operations, by the systematic use of dilating sounds or bougies, for the remaining lifetime of the patient so operated on. It would, therefore, seem to be not so very much matter after all, in the very great majority of cases, whether the little risks, and much trouble and expense, of the patient, in gradual dilatation, were a little less or a little greater in the aggregate, than by one de- cisive blow, to reach the No. 12 of the English scale, and then start out with it for the lifetime journey. To this complexion do all ap- pear to come at last, the ultimate necessity for continuance of instrumental measures, throughout the lifetime of the patient. In this respect, then, whether the plan of treatment for stricture be that of gradual dilatation, rapid distension, divulsion, or simple urethrotomy, the patient (whatever the surgeon may say) is never cured. By each one of these modes life may be saved and much suffering averted. Thousands, to-day, live in comparative comfort, who, but for the intelligent surgical aid afforded by these instrumental procedures for the relief of urethral stricture, would be in their graves. Yet the opprobrium, medicorum rests upon the treatment of stricture, and why ? Because after the patient is pronounced cured by his surgeon, he is obliged to continue the systematic use (always re- pulsive, and often hazardous), of a sound or flexible bougie, for the rest of his life.* Far be it from me to undervalue the skill, the study, and the experience which have brought relief to those under the very shadow of death, nor the teachings that have enabled the least practised surgeon to operate, with fair assurance of a successful issue, out of difficulties, which, twenty years ago * Wade on Stricture of the Urethra. London, 1860, p. 352. STRICTURE OF THE MALE URETHRA. 9 would have required a Mott or a Fergusson to combat. I wish to be distinctly understood as appreciating and valuing, to the full all the advances in urethral surgery, and they are many and great, which have been made in Europe and America within the last twenty years. It is not possible for me, however, to accept these as the ultima Thule, while the patient cured (?) of stricture still car- ries a steel sound in his pocket. I am a believer in the true curability of urethral stricture, not- withstanding that authorities are a unit to the contrary. I think I can bring evidence, that will be convincing, that, in the great majority of cases of urethral stricture, a complete eradication of the trouble is within the reach of every competent surgeon. You are incredulous ; you have scarcely patience to listen to such an innovation as a plan for the radical cure of stricture. If such a plan were possible, why have the many surgeons who have devoted years to the studious investigation of the subject of urethral stric- ture, coincided in the unanimous verdict against the curability of stricture, by any method ? Simply, I answer, because there has been a very curious and important oversight in the investigation of the subject, viz—The mechanical relations of the stricture to the urethra have not been considered. Strictures have been dilated, or rapidly distended, or divulsed or divided, up to a purely imaginary and arbitrary standard. No inquiry has been intelligently insti- tuted to ascertain the natural dimensions of the urethrae examined for stricture. If the presenting urethra admit No. 9 of the Eng- lish scale, or 21 of the French, no stricture is present. If the urethra is below the accepted standard, stricture is present. After raising the urethral calibre, by any one of the methods in vogue, up to what the books lay down as the normal standard, or what the surgeon thinks is about right, the stricture is cured ; that the patient is not, is his own misfortune. The favorite expression of some surgeons, when concluding the examination of a case which has been systematically treated, cured up to an imaginary point, is, “ that the size of the urethral canal is about right." An ancient defini- tion of this term may not be inapplicable in this case—“Right is the centre of a circle, and about right is the circumference.” No such term as “ about right ” can be accepted in such a case ; either the urethra is of the calibre that nature furnished, suited to the patient’s own person, or it is not. No man, surgeon, or otherwise, can guess at this matter. If a urethra presents, the normal calibre of which is equal to a circumference of 30m of the French scale, and only 10 FESSENDEN N. OTIS. 29f bulbous sound, will pass, without detecting obstruction, then the urethra is not “about right” It is strictured to the extent of one millimetre in circumference, and can never be a healthy urethra, while that stricture remains. Complete freedom from stricture can only be demonstrated by the easy passage of a bulbous sound of a size fully equal to the normal calibre of the presenting urethra. This is what I alluded to when I stated that the mechanical relations of stricture to ureth- ral calibre had not been considered. Strictures are dilated, di- vulsed, or divided, up to a fictitious imaginary standard, or what is, if possible, even worse, viz., up to the size of the meatus urina- rius, and then operative procedure is turned over to the patient to be continued ever after. Now, if there is any one point more variable and inconsistent with the calibre of the urethra than the guess as to its probable size, it is the opening of the meatus urina- ries. It is more variable, in different individuals, than the length of the prepuce, and bears no constant, or even general relation, to the size of the urethra. In point of fact, besides varying, con- genitally, more than any other orifice of the body, it is more often strictured from disease than any other portion of the urethra, and yet it is assumed by authorities, as a guide to the normal urethral calibre. How, then, can it excite surprise that no radical cure for stricture has been found ? To warrant the reasonable ex- pectation of cure, the stricture must be completely divided at some one point, and this cannot be with certainty accomplished without a knowledge of the normal urethral calibre. The normal calibre once ascertained by means of the urethra-metre, or by measurement of the flaccid penis, the method by which the sundering of the stricture, at some one point, is accomplished, may vary, and rest in the judgment of the operator. If dilatation, or divulsion, be selected as the medium through which to effect this result, the procedure must be carried far enough to completely rupture every fibre of the contraction; if division, every fibre must be complete- ly severed, or subsequent re-contraction is certain. Neither di- vulsion alone, nor simple urethrotomy, is capaple of effecting this with any certainty. It requires a combination of these two methods to accomplish the desired result. My first dilating urethrotome was constructed for the purpose of meeting these necessary re- quirements. The results of the use of this, and other instruments involving the same principles, which were reported to your Society in February, 1872, have, as far as could be ascertained, proved STRICTU RE OF THU MALE URETHRA. 11 permanent. The six cases then cited have each been carefully re-examined, within the last year, by myself and others, without being able to detect a trace of stricture. One case, that of J. C., (operated on for five strictures between December, 1871, and March, 1872), was re-examined, at a meeting of the Medical Lib- rary and Journal Association, of New York, in June, 1874 (more than two years after the final operation), by a committee of sur- geons, consisting of Professor Alfred C. Post, Drs. Miner and De Forrest Woodruff, of New York, who reported complete ab- sence of even a trace of stricture. Since my report of the above-mentioned cases to your Society, I have operated on a very large number of strictures, with various instruments, but chiefly, and latterly almost solely, (except in stric- tures at the meatus,) with the dilating urethrotomes. One hundred cases of urethral strictures, comprising two hundred and three operations, upon two hundred and fifty-eight strictures, have been carefully collated, from my books of daily record, by my assistant, Dr. J. Fox, and subjected to a subsequent critical revision by myself. The careful tabular analysis of these cases, which is presented with this paper, embraces the following points: 1. Age of patient 2. Cause of stricture. 3. Locality and size. 4. Number in each case. 5. Normal calibre of urethra. 6. Complicating diseases or conditions at date of operation. 7. Symptoms at date of opera- tion. 8. Accidents following operation. 9. Results of operation, as determined by a subsequent re-examination with the full-sized bulbous sound, at periods varying from three w'eeks to three years. 10. Results as shown by continued relief from all symptoms, where no instrumental re-examination has been practicable. Not to absorb too much of the valuable time of this Society, I will only allude now to a few points of greatest importance in con- nection with the facts which are developed by this summary : 1st. It will be found that out of the 258 strictures, 52 were in the first quarter inch of the urethra; 63 in the following inch, viz., from to 1^; 48 from to 2^-; 48 from 2£ to ; 19 from 3|- to 4^-; 14 from to 5|-; 8 from 5£ to 6^; 6 from to 7£. Authorities claim that the great majority of urethral strictures is found in the vicinity of the bulbo-membranous junction, and cite various possible causes for their frequency in this locality. By the above statement it will be seen that they occur, as would naturally be expected, in greatest frequency where the inflamma- tion begins the earliest, and rages the hottest, and gradually dimin- ishes in frequency in the deeper portions of the canal. 12 FESSENDEN N. OTIS. 2d. Of the normal calibre of the urethra: 22 Mm. circumference 1 36 Mm. circumference 1 28 3 37 “ “ 2 29 U it 1 38 “ “ 6 30 18 40 “ “ 1 31 it it 25 Not noted .... 4 32 it (t 19 — 33 U it 3 100 34 ti U 16 Thus, it will be seen that in ninety-nine carefully measured cases, the average normal calibre was 81.84 (deducting the case of child of ten years, 22m), nearly 32 of the French scale. 3d. Of the accidents following operations: Hemorrhage in four cases ; prostatic abscess in three cases; curvature of penis during erection in three cases ; urethritis in two cases ; diphtheritic deposit of wound in three cases; urethral fever in seven cases; retention in one case. In a small proportion of cases hemorrhage has been quite pro- fuse ; not during or immediately following the operative procedure, but coming on after urination, or more commonly, during erection. Especially from the latter cause, it is sudden, and sometimes co- pious, but readily controlled. The fact that hemorrhage, of any moment, ever occurs (although in the one hundred cases cited there were only four), leads me to use, and to advise, such precautionary measures, in all cases, as will give complete security against harm from this accident. My usual plan is to have an intelligent atten- dant instructed to watch the patient during sleep, (when erections are most likely to occur), and to make prompt pressure of the penis at the incised locality. This is usually sufficient to arrest the flow. Applications of ice are also of value for the same purpose. In some cases I have found it necessary to introduce a tube into the urethra, making pressure upon it by means of a light bandage, and to have it retained until the haemorrhagic tendency has passed. author’s endoscopic tube. An ordinary endoscopic tube answers well in such cases. Di- vision of strictures, at or near the meatus, is most likely to be fol- lowed by hemorrhage. Here xi shorter tube will suffice. When the bleeding is from the vicinity of the meatus, it results from the division of a small artery near the frenum. When in the deeper STRICTURES OF THE MALE URETHRA. 13 portions of the urethra, it arises, probably, from incision into the trabecular spaces. In either case, the danger of recurrence is not entirely over before the fourth or fifth day. 4th. Slight urethral fever has followed the operation but seven times. Six times, when for stricture in the curved portion of the urethra; once only, when the operations were in the pendulous portion of the organ, and this occurred in a malarious subject. This leads me to remark, that, in my experience, operations confined to the pendulous urethra, are, as a rule, never followed by constitution- al disturbance, even when six or seven strictures are divided at the same sitting. But, to insure this result, no instrument, not even a sound for exploratory purposes, should be passed into the bladder, during, or immediately subsequent, to the operation. 5th. Three operations were followed by prostatic abscess. In one of these cases, the patient, who was a physician, sailed for the West Indies in about a week after the operation, (which was for a single stricture near the meatus,) and reported trouble of the pros- tate coming on soon after, he, meanwhile, using a.sound himself, to prevent recontraction. In the second case the patient, who was accompanied by his physician, left my care three days after operation, and one week after reaching home, (during which a sound was passed every day or two,) the prostatic trouble came on, which ended in abscess. In the third case, the patient, who had been operated on for five stric- tures, of a very dense character, passed from my observation immediately after the operation. Prostatic trouble came on insid- iously during the next ten days, while the sound was being occa- sionally passed to prevent recontraction. I will not criticise, nor attempt to explain, the causes which led to the prostatic trouble in these cases. I recognize the fact, that the simple introduction of a sound, through the deep urethra, even with the utmost skill and care, may, of itself, give rise to an irritation which may terminate in abscess of the prostate. But I will state that no such accident has befallen any case which has remained under my own per- sonal care, until healing of the wound has taken place. 6th. Curvature of the penis downward, followed in three cases where numerous strictures were divided, but this trouble occurring during erections was unattended with pain and passed off entirely ■within from two to six months after the operation, in two cases. In one case, at the end of a }*ear, there was slight curvature, but gave no trouble. 14 FESSENDEN N. OTIS. 7th. Urethritis in two cases ; one follow7eel an operation at the meatus, and was set np by forcible use of a tube, by the patient, to prevent reeontraction. It lasted acutely for three weeks, and was followed by a gleet, lasting four months, which finally ceased after a second operation, required by the reeontraction which had taken place. The third followed an operation upon four strictures, and oc- curred within a week. This was complicated by the presence of a diphtheritic deposit, upon the wound, near the meatus. It was supposed to have resulted from a similar action in the wound of the deeper portions of the canal. 8th. Diphtheritic deposit occurred upon the wound, in two other cases, lasting, under treatment by iron and quinine generally, and applications of the strong acetic acid locally, about two weeks, and was followed, in both instances, by a reeontraction of the stricture. Cures. Re-examinations. No reeontraction. Thirty-one cases. TABLE. Time after Operation. No. of Oases. No of Strictures. Time after Operation. No of Cases. No. of Strictures. 1 4 5 months 1 7 2*" <• 1 7 4 “ __ 1 3 2 8 3 “ 4 15 3 14 2| “ ] 10 4 7 2* “ 4 11 1 2 1 month 1 1 9 “ 1 i 3 weeks 1 5 8 “ 1 i 2 “ 1 1 2 10 G “ 7 21 37 128 In thirty-one cases none of the strictures had recontracted. In six cases most of them had been absorbed, while some remained. RESULTS. Cures. Re-examined. No reeontraction 31 cases. Cure. Patient perfectly well when last heard from. No re- examination 52 “ Perfect relief for a length of time. Return of symptoms. Re-examination. Stricture found to have recontracted 4 “ Perfect relief for a length of time. Return of symptoms. No re-examination 5 “ STRICTURES OF THK MALE URETHRA 15 Relief of most symptoms. Some remaining. Patient still under treatment 4 cases. Partial relief 3 “ Result not known 1 case. It will be seen from these statistics that the results of treatment justify in the completest manner all that has been heretofore claimed by me for the method. In point of gravity it will be seen that cutting operations for the division of stricture in the pendulous por- tion of the urethra (where the great majority of strictures are found), compare most favorably with all other modes of treating stricture, and cannot be considered as exposing the patient to more peril or inconvenience than simple gradual dilatation by means of graduated soft bougies or sounds. In regard to the advantages of operations as quoted, they are manifold, to the patient as well as to the surgeon, Comparatively painless, except near the meatus ; speedily per- formed, involving at most but a few days loss of time (often not even a day, where the stricture is single and recent). The after treatment, consisting only of separation of the wound throughout its extent by the easy passage of a full-sized steel sound daily, or every other day, until healing is complete. If by this time no other stricture is discovered, the patient may be dismissed as cured. Sometimes, however, after the division of a single stricture other bands of larger calibre in the vicinity, which had been so stretched during the operation that they eluded detection, may be found. But this will always be ascertained within the few days which suffice sor the tissues to recover from the dilatation consequent upon the operation. In such cases these bands must be divided in the same manner as the first. Absolute division of all bands which in the least contract the canal is necessary for complete immunity from after trouble. Failure in obtaining perfect freedom in the passage of a full-sized bulb is due to the imperfection of the means used, and not to any fault in the method. In certain long-standing, dense, fibrous strictures, I have some- times experienced great difficulty in effecting their thorough divi- sion, and this is especially the case in regard to strictures caused by masturbation, or by traumatism. I have occasionally had to use several different kinds of cutting and dilating instruments be- fore the desired object was effected. No one instrument can ever be depended on to succeed with, completely, in all cases. In or- dinary strictures, what I term my improved dilating urethrotome, will be found the most easy of management, and is, as a 16 KKSSKNDKN N. OTIS. rule, thoroughly effective. It is constructed with a dilating apparatus, which is introduced, closed to a size equal to about 20 of the French scale. Upon its su- perior aspect, a blade, guarded at the top (after the manner of the , urethrotome of M. Maisonneuve), 'is slid down through a grove to the end of the shaft, possibly nick- ing the smaller strictures in its passage. The screw at the handle is then slowly turned until thehand on the dial indicates that the in- strument is dilated up to two or three millimetres beyond the previ- ously ascertained normal calibre of the canal. The blade is then slow- ly withdrawn—cutting through all the strictures on the superior as- pect. The strain of the dilatation falling almost solely on the stric- tures, they are thus made the most salient points,—receiving the ante- rior edge of the blade, while the normal portions of the canal are protected completely, or nearly so, by the guard on the top of the knife. In this way the division of the strictures is accomplished with the least possible injury to the mucous membrane covering the sound portions of the urethra. The instrument is then withdrawn and an examination for results is instituted with a full-sized bulb. If any fibres of stricture are then detected, the operation must be repeated, at the contracted point, until perfect freedom to the passage of the bulb is secured. IMPROVED DILATING URETHROTOME.* * A modification of the above instrument, known by the maker as “ Dilating Ure- throtome No. 4,” is shorter and straight, and is found better adapted to strictures iu the straight portion of the urethra. STRICTURES OF THE MALE URETHRA. 17 For a second operation, I not unfreqnently use one of my earlier urethrotomes,* which cut only at a single predetermined point, and SMALL DILATING URETHROTOME. the blades of which are not protected by a guard. In all these in- struments the incisions are comparatively slight. The tension to which the strictures are subjected renders them thin, and brings them into condition to be completely severed by an incision of the least possible depth. Cutting always upon the superior wall of the urethra and in the median line, hemorrhage is usually slight, and ceases almost immediately. In all cases of stricture, at or near the meatus, I am accustomed to divide them on the inferior wall of the canal, and very thoroughly, with a straight bulb-pointed bistoury. 7It MANN CO NV' BULB-POINTED MEATOTOME. The utmost freedom to the passage of the bulbous sound must here be insisted on, and not a single trace of contraction left uncut. The after treatment of this class of strictures requires much more care to prevent recontraction than those in the deeper parts of the urethra. Every possible means must be used, such as rest and cold water applications, etc., to prevent the least supervention of inflammatory process ; otherwise a recontraction is liable to occur. The very hast return of obstruction is often sufficient to prevent the cessation of the gleet or of the reflex troubles, for the cure of which this operation is usually performed. * The dilating urethrotomes are known to the makers (Messrs. Tieman & Co., No. 67 Chatham Street, and Messrs. Otto & Sons, 64 Chatham Street), as Nos. 1, 2, 3, 4, in the order of their invention—Nos. 1 and 2 dilating and cutting at a single prede- termined point, while Nos. 3 and 4 dilate the entire canal. Each has advantages which cannot be combined in the other—but either one will answer in all cases of single stricture. When several strictures are present, especially if close together, the latter numbers are to be preferred. No. 4 has the advantage of being adapted to any stricture in the straight urethra without distending the curved portion of the canal. 18 FESSENDEN N. OTIS. As a means of avoiding inflammatory action after operations upon the penis, I am in the habit of insisting upon a constant ap- plication of cold water by means of an apparatus of small india- rubber tubing, arranged so as to encircle the penis, and through which, Water of any desired temperature is carried by syphonic action.* The healing process is thus facilitated ; painful erections, (which sometimes follow operations upon the pendulous urethra,) are allayed, and the chances of urethritis avoided. By proper ar- rangement of the vessels containing the water the patient can use the cold water coil while in bed, sitting, or the water bottles may be so arranged in an upper and a lower pocket, that the patient may, if necessary, even walk about and attend to pressing business without removing it. The above directions refer entirely to opera- tions within the pendulous urethra. Surgical operations in the curved portion of the canal demand rest in bed, until the healing process is complete. In none of the cases above reported has any dilatation been at- tempted after the healing of the wound made during the operation. The use of soundsf subsequent to the operations, is simply to separate the cut surfaces, and not for purposes of dilatation, and their use is discontinued as soon as a full-sized bulb can be passed * The apparatus which I have designated the “Cold Water Coil ” is formed of a line of the small-sized India-rubber tubing of one-sixteenth of an inch calibre, and six or seven yards in length. At the middle portion this tubing is coiled upon itself, so that, by half a dozen turns or more, it presents sufficient capacity to loosely encir- cle the entire penis or scrotum. This coil, with the length of tubing proceeding from it, forms an apparatus through which, on placing one extremity of the tubing in a bowl or tumbler of ice water, ex. hausting its contained air (by suction, or by drawing the tube through the finger), a syphonic current is established through the coil. The discharge pipe being placed on a lower plane than the water supply, the current may be kept up until the vessel is emptied. The rapidity of the flow can be regulated either by raising or lowering the end of either tube, which is the simpler plan, but the more convenient one is by a tapering, double silver tube, attached to the discharge pipe, a sponge being fitted to the inner tube. This sponge, when the inner tube is pushed down into the smaller end ot the outer tube, becomes compressed, and gradually obstructs the flow of water, until not a drop will exude. This contrivance may be regulated so that either a free stream can pass, or that the single drops shall follow each other, more or less rapidly, with the regularity and precision of a timepiece. f I prefer the solid steel sound, with short curve, as represented in the cut, and use Nos. 30f. to 40f. STRICTURES OF THE MALE URETHRA. 19 through and beyond the previous site of stricture, and withdrawn without a trace of blood accompanying or following the use of the instrument. SOLID STEEL SOUND—SHORT CURVE. Recontraction of stricture, after operation, is simply due to in- complete division, and this will, as a rule, be detected within one week, or at most two weeks, by which time stricture tissue distended—not divided—will sufficiently recontract to become readily recognizable by the full-sized bulb. If, then, no stricture can be recognized, the cure of the difficulty may be considered complete, and no further treatment, by sounds, or otherwise, will usually be required. Strictures of a calibre of less than 16 or 18 of the French scale, (7 or 9 of the English) and hence below the capacity of the dilating urethrotomes, as at present constructed, require enlargement by gradual dilatation, with soft bougies when this is well borne, if not, by divulsion, or by the urethrotome of M. Maisonneuve. After having been brought, by any one of the methods above referred to, up to a capacity permitting the passage of the dilating urethro- tome,* complete division of the strictures by means of this instru- ment may be readily effected. 108 West Thirty-fourth street, New York, March 25, 1875. * The dilating urethrotomes are very perfectly manufactured by Messrs. Tieman & Co., and also by Messrs. Otto & Sons, of New York, through whose intelligent co- operation these, as well as all the other instruments I have designed, have been brought to their present completeness. F. N. 0. FESSENDEN N. OTIS. ONE HUNDRED CASES OF URETHRAL STRICTURE. Number of Case. Age. o §•§ • 8 c g ’'E. Number of Strictures. 1 Locality of Stricture. Size of Strictures. C3 a Condition at date of £ Operation. 5 A Complications. Number of Operations. Accidents after Operation. Results. Re-cxamination. 1 6C 2 38 Congenital con- traction. Gonorrhoea fifteen years ago. Sev- e r a 1 times since. Last at- tack four years 1 in. 24 •' in. 28 • 2 in. 28 2£ in. 28 8 Frequent and painful mictu- rition. Pain in penis, scrotum, perineum, ab- domen. Urine puru'enl and mixed with blood. Cystitis, small calculus in bladder. Gleet Relief from all trouble. Recon- traction. Second operation. Relief up to date. m mediate relief, following oper- ation. Recurrence of symp- toms reported. No re-examina- tion. scrotum, thighs, knees, legs, feet, groins. Pain- ful movements of the tes- ticles. 3j3i 4 5^ 5 6f ago. > Gonorrhoea ten years ago. Gonorrhoea twen- ty eight and eight years ago. forty- .. j seven and forty I years previous- 1 iy- Meat._ 22 i in. 26 1 in. 24 2 in. 28 Meat.. 29 21 in. 29 11 Gleet. jleet I 3ure in six weeks.. !1 Frequent micturition. Pain in urethra, perineum, scrotum and thighs. Urine purulent and mixed with blood. 2 Gleet. Lumbar and peri- neal pain. Frequent mic- turition. detention re- immediate relief Cure of reflex peated by gravel. symptoms. titis. En- larged Epi- dymis. 1 month. - k- v 6 5 7 3 1 1 in. 29 1 in. 33 Gleet 11 Cure, complete in two weeks. Thirteen months after operation no recoutrac- tion. One month after operation no recontraction. Three months 4 Gonorrhoea 3 Gonorrhoea several 1 times during the last ten years. 33 Gleet for five years 31! Frequent and painful mictu- rition. Pain in perineum 32 Gleet. Irritation in urethra. Gleet.. Enlarged pro- state. Cure in two weeks. Perfectly well one month after opera- tion. 8 2 7 Gonorrhoea seven years previous. 3 3 J in. 20 1 in. 19 lj in. 19 Cure after last oper- ation. Nore- contraction. Perfectly well One year after operation. No recontraction. 9 1 Meat. 20 37 Frequent micturition. Gleet Granular spots in urethra Painful erections. 34 Pain in perineum, left hip over the region of lei kidney. 2 31 Frequent micturition. Iir perfect erections. Slight gleety discharge remain ing ten days after operation Not since heard from. Ctrnnnlar spots disappeared afte 10 50 Gonorrhoea four years previous. 9 i in.'23 1 in. 28 liin. 28 2\ in. 30 3 in. 3( 3± in. 30 4 in. 28 4§ in. 28 5£ in. 28 . Painful erec tions. . Redundent t prepuce. C ircum- cision. - Imperfect er- ections. o 11 37 Gonorrhoea nine years ago. 1 Meat. \22 operation. Painful erection | still persist. s 12 Gonorrhoea twelve years previous. 2 i in. 2( 2$ in. 2 \ ineum, hip and back. One year after 13 46 Gonorrhoea twenty years previous. 1 Meat 2 operation. No recontraction. Sexual power perfect. STATISTICAL TABLES OF ONE HUNDRED CASES OF URETHRAL STRICTURE TREATED BY INTERNAL URETHROTOMY. FESSENDEN N. OTIS. ONE HUNDRED CASES OF URETHRAL STRICTURE i c5 o £ P fa a t-. i a> u fl *5 s e£ t-. a* ■ £ o o> Jb £ O U < Cause and date of OD O u c X: S s <*-> o 'c5 8 © c N © *3 O S Condition fit date of Operation. g a o o © 1 i- X> g Accidents after Operation. Results. cl a S a X © © 55 o £ 14 45 Gonorrhoea fifteen 1 1£ in. 30 32 Gleet for twelve and a half Gleet... 1 Cure of gleet in one month years previous. Several times years. since. 15 42 Congenital con- 1 £ in. 34 Irritability of vesical neck. Imperfect erections. Imperfect er- ections. 4 11 e m o r - Cure. Recontraction three times. traction. r h a g e controlled by tube. Perfectly well two and a half months after last operation. 16 Gonorrhoea four 1 Meat. 21 32 Gleet Gleet 1 months previous one month 17 24 Masturbation 5 Meat. 18 32 Frequent micturition Weekly semi- nal emis- ? Durva t u r e Cure of all trouble H in. 29 of penis after operation 2\ in. 24 sions. during no trace of 2i in. 23 erections. stricture. 3 j in. 23 18 25 Gonorrhoea one 1 £ in. 20 34 Frequent and painful mic- turition. Pain in perine- Gleet.. 5 Cure. Four re-contractions with half a year pre partial return of symptoms. # vious. um. Gleet. Final cure after last operation ten months ago. 19 48 Gonorrhoea twen- 1 Meat. 22 31 Frequemt seminal emis- sions. Incomplete erec- Frequen t. 1 Cure ty years pre- seminal vious. tions. emissi o n s. Imper fe ct 0 erections. .. <•_ A- < jionorrhoea three li in. 31 1 Dure of gleet. Deep stricture not divided. 20 j 25 2 23 j Gleet one >ear UJ IvJC t— — — — — — — 25 years previous. 6 in. 21 24 30 9 Dure fen months also 21 Gonorrhoea one 4 two and three and a half and 4£ in. 24 vears after op- one year pre- 4£ in. 24 eration. No vious. 5 in. 24 recontraction. 22 20 Gonorrhoea. Mas- i in 24 30 Gleet 9 Cure. Remains perfectly well Dne year after two years and three months operation no turbatiou. 3 li in 24 31 31 9 after last operation. recontraction. 23 30 Gonorrhoea ten | in. Gleet years previous. 2£ in. 31 H in 31 29 Painful and frequent mictu- rition. Gleet. 9 Cure Recontraction after six 24 50 Gonorrhoea thirty 1 i in- 18 months. Second operation. and twenty-five years previous. 2 £ in. 3 in. 16 31 9 Relief, which after two years remains permanent. Cure, which remains complete three years after last operation. Irritability of vesical neck. 25 54 Gonorrhoea twelve 26 20 r' Gleet. Frequent and painful mictu- 2 Chills Six months after 26 40 5 £ in. last operation, years previous. 2 in. 28 rition. no recontrac- 2£ in. 28 tion. 2£ in. 28 Masturbation. — 2J in 28 IS 31 Chronic discharge from the 2 Discharge disappeared Recontraction at 27 35 4 Meat.- meatus. None £ in IS urethra. of deep stric- % 1 in 27 tures. 2 2 in T 32 Frequent and painful mictu rition. Four mos after 2i r Masturbation... £ in 2 in 21 21 abscess. operation. No recontraction. ) Gonorrhoea thret years previous. 3± in 21 i 38 Frequent micturition. Sense of foreign body just be awt. Cure within two weeks [Nine months af- 21 4 £ in 3( ter operation. No recontrac- 1 hind the meatus, causing great nervousness. Gleet tion. m STATISTICAL TABLES— Continued. FFSSENDEN N. OTIS. c t U o E is 31 i -C i- 1 C .2 . *. 8 o O V Guise and X & ~ = Accidents Results. g u Ji < Date of. o *© ► Xl jC Operation. after Operation. a 3 £ V C O fc M a o .5 g u £ 3 c £ 30 19 Gonorrhoea two 7 1 in 25 31 Frequent and painful mictu- Gleet i Chills _ _ Cure Five months af- ter operation. years previous. 24 in. 31 rition. Repeated urethral 5 in. 26 chills, caused by attempt- No recontrac- m. 22 ed dilatation. Gleet. tion. Perfect- 34 in. 31 lv well at date, 4 in. 31 January,1875. in. 27 31 19 Masturbation... 1 1 in. 26 32 Frequent and painful mic 2 turition. pain in perineum, turn of symptoms. Recon- glans penis, thighs, testi- traction discovered. Second cles, nervousness. operation. Partial return of 32 24 Gonorrhoea svmntoms four months after. 2 Meat. 29 31 Gleet I Immediate relief of spasmo 29 in. modic stric abscess. stricture, under other care ture at sev- Pros, abscess reported ten en inches. days after. 33 25 Gonorrhoea s i x 1 1 in. 22 32 Gleet for four years. Gleet 1 Cure Two mns. after operation. No recontraction. 34 29 years ago. Fre- quently since. Gonorrhoea s i x 5 1 n. 24 Gleet. Vesical tenesmus.. Cystitis, gleet, 1 Immediate relief of all symptoms connected with the urinary months previous 3 n. 25 p1 e u r i s y, 84 in. 24 with effus- organs. Tolerance of diu e* 3 5 n. 26 i o n. Ag- tics re-established. 44 in. 29 gravation of symptoms from diure- tics. 4_ # < 35 46 l in. 19]31 Frequent and painful mic \ uoiiorrnoea 1 turition. Pain in should- tious. times. Last operation about ders, knees, legs. Painful i month ago. Perfect relief erections. after each operation, until re- contraction occurred. 3G 38 Gonorrhoea s i x 0 in. 26 32 Painful micturition. Gleet. 1 Pure of troubles within a month. years previous. 2 in. 30 modic stric- Gleet, etc. ture. 37 ii Gonorrhoea s i x Meat. 24 30 Gleet. Unpleasant sensa- 1 f!nre of odeet and the nervous years previous. 1 in. 24 tion in testicles. trouble in testicles. 47 Gonorrhoea twelve years previous. 1 i in. 28 32 Frequent micturition. Irri- tation in deep urethra. 1 Cure. 32 passes with ease into the bladder after division of K e-e x a m i ueu O l two weeks af- Had been treated for the meatus. No re examiu- ter operation. deep stricture. ation after two weeks. No reeontrac- tiou. 39 22 34 Frequent and painful mic- 2 Dmhtherit- Cure of gleet and frequent mic- Three months five years previ- 1 in. 31 turition. Gleet. Weak- ic exuda- turation. alter opera- ous. 14 in. 31 ness. tion on tion recon- 2 in. 31 surf ace traction at 2 4 in. 31 of wound meatus. No at meatus trace of deep after first operation strictures. 40 28 Gonorrhoea seven years previous. 1 i in. 30 34 0 Cure of gleet for one month, when patient aquired a fresh gonorrhoea. 41 29 5 Meat.. 9 32 Freauent and painful mic- Gleet. Re ten- 1 Uretnraife- Recovery with thirty f. calibre. Recontrac ton 24 in. 9 turition. Gleet. Fre- tion of ver Haem- To continue use ol sound as slight after 34 in 9 quent attacks of retention urine. or rhage, recontraction at some point one month. 4| in. 9 of urine. causing had taken place. Further Memb. 8 retention operation deferred. port. and neces- sitating perinea] incision and aspira- tion of the 1 1 bladder. ONE HUNDRED CASES OF URETHRAL STRICTURE. STATISTICAL TABLES—Continued. FESSENDEN N. OTIS. ONE HUNDRED CASES OF URETHRAL STRICTURE. — 2 « “1 £ G a © G C3 o c u o g <£ 11 < Cause and date of. x w o © X 5 o £* U o CO c £ o X> 73 O Condition at date of Operation. g £ C3 _o 'E, a c5 © G. o i- o Si Accidents after Operation. Results. G* O G a c3 c3 © £ O h Si £ Q £ © — — — — _ . 42 39 Masturbation ] i in. 28 32 Frequent painful micturi- Frequent 1 Immediate relief of all reflex tion. Pain in thighs, seminal troubles. Cessation of semin- knees and legs. emissions. al emissions for one month. Return of trouble. No re-ex- 43 57 Follicular ulcera- tion. 3 From 32 Frequent and painful erec- Urethral fis- 2 amination. Cure. Immediate relief fol- Meat id tions. Very severe pains tula. Urin- lowing operation. Urinary IU 1 in. in thighs and feet. Ex- ary abscess abscess healed in ten days: 26 23 28 treme sensitiveness of over right Perfectly well four months 44 24 Masturbation 1 2£ in. 2i in. i in. 34 glans penis. Excessive sensitiveness of crus penis. Freq’ent sem i after operation. No re-examin- ation. Cure of sensitiveness of glans, and consequent relief of sem- glans. i n a 1 emis- sions. Pre- mature dis- charge o f iual trouble. . 45 32 Gonorrhoea s i x 1 Meat.. 23 31 Frequent micturition seminal fluid Retention of Cure. Perfectly well four months after operation. years previous. urine re- peatedly. S p asmodic stricture at in e m b ran ous portion. • cri i — '< 46 * 5 Meat.. i iu- 26 26 36 flloeit. __ Gleet - i Cure of "leet within two weeks.l Three weeks af- £1 UTULiui i nucd tin cc, Re-examination three weeks ter operation. and also two 2 in. 26 after operation. No recon- No recoutrac- months previous 2i in. 26 traction. tion. 47 28 Gonorrhoea s i x years previous. 7 1 in. Meat.. 1 in. 2 in. 30 22 22 30 32 Gleet, lasting six years d One and two and a half years a f t e r opera- 2J in. 30 tion. No re- in. 30 contraction. 4 in. 30 48 25 Gonorrhoea ten and also seven 5 in. | in. It in. 30 20 20 28 3 Hemorr’age controll’d Cure Seven months after opera- years previous. H in- 3 in. 20 27 by tube. tion. No re- contraction. 49 Gonorrhoea five years previous. 4 4 in. Meat.. 2t in. 2£ in. 27 23 26 30 32 4 Cure Three months after last op- eration. No 3 in. 31 re-contrac- tion. 50 Gonorrhoea twelve years previous. 1 Meat.. Gleet Gleet. Fre- quent erec- tions. Uri- 3 Cure of gleet. Sinuses healed. No re-examination. nary sinus near mea- tus. 51 62 Gonorrhoea forty- 9 Meat.. 28 ;33 Spasmodic 1 Immediate relief followed oper- Frequent micturition, fol- 1 one years pre- vious. 3 2 in Meat. 30 25 t 34 stricture at rn e m bran- ous portion dilated for twenty yrs Weekly semi- ation. Intervals between mic- turition, eight hours. One month after operation, reliel permanent. No recontraction. Relieved from frequent mictu- rition and priapism for aboui 52 72 Masturbation 2\ in 25 lowed by severe pain iu nal emis 3j in 25 back and soreness in ure sions. Pri three weeks. Return ot thra. apism. i trouble. No re-examination STATISTICAL TABLES.— Continued. FESSENDEN N. OTIS. ONK HUNDRED CASES OF URETHRAL STRICTURE. C3 h rG — £ £ t- S-. p p D U O Si* Cause and o h h ~ "o Condition at C3 «5 s date of to t j£ date of O O after Results. O © o o X Operation. ’0 Operation. c3 u* *r ce a C3 >4 1 M ■g a c O) S 8 © © tL 1 o | *4 S' c c3 g < l-l XT. S3 O O S3 « 53 J5 Gonorrhoea ten 6 in. 3 b’nds 2( 30(Gleet. Irritable bladder Gleet 2 Cure Re-examini n e d years previous. 4£ in. thirteen 2 b'nds 2' months after operation cure still per- 54 Gonorrhoea 8 Meat. 21 31 Gleet Gleet feet. Thirteen months after last ope- ration. N 0 r e - c 0 n trac- tion. 2J in. 21 21 in. 2t 2| in. 2< 3 in. 3C 3} inJ3C 4£ in. [24 5 in.24 (slight). C urva- ture ol penis du- ring erec- tion. 55 _ Gonorrhoea two 3 2f in. |29 |30 Gleet Gleet One year after last operation and also one and a half years pre- 3J in. |27 2* in.127 liage not vious. no re-contrac- v e r e . tion. C 0 ntrol- ed by 56 . Gonorrhoea five 1 f in. 24 30 Gleet Gleet tube. 2 Cure Half a year af- ter last oper- and two years previous. ation no gleet 1 A L- no re-contrac- tion. < Meat. |24 4 0 Gleet |G rleet ( 8 Iflure of (rleet. No re-contrac S ix months after 57 23 Gonorrhoea one 10 tion at any point after six last operation year previous. i in. 22 1 in. 31 u in. 22 lj in. 31 1} in. 40 2 in. 33 2£ in. 37 in. 37 4£ in. 37 • months. Contracted another gonorrhoea. i’reedom from symptoms fol- lowing each operation, and continuing from one to two no re-contrac- tion. 30 Pain and uneasiness in peri- neum and glans penis. Ireat nerv- . ousness. 58 30 Gonorrhoea 2 Meat. 21 2h in. 18 months. Six months after the operation no recontrac- 59 27 Gonorrhoea Meat... 24 30 Gleet. Profuse purulent discharge, caused by in- Gleet. Spas- modic stric- t u r e at - Cure, remaining complete one year after the operation. tercourse. tion. m e mbran- ous por- Gonorrhoea ten 1 Meat... 22 tion. Frequent 1 Cure of gleet within two weeks. Two months aft- er operation. 60 3‘ s e m i n a 1 e m i ssious. Married at the end of one years previous month. Re-examined two No recontrac- Masturbation. months after. No return ot tion. trouble. 30 Frequent micturition. Pain in penis. Gleet. Gleet. In- tense pain foil owing Cure. Relief of pain and fre- quent micturition. Cessation of discharge for three mouths, 6114 ) Gonorrhoea twelve years previous. 1 i in. 26 2 when it returned, and also emissions. the frequent micturition. Re- contraction found. Second operation followed by renewed relief, which continued foi six months when he contract- ed a fresh gonorrhoea. STATISTICAL TABLES—Continued. FESSENDEN N. OTIS. ONE HUNDRED CASES OK URETHRAL STRICTURE. © K © u. a © U © 2 X p c o e) o 3 £ C c2 a Vi o © Cause and £ 33 *E c Condition at date of ts © a. Accidents "a x> £ 3 < date of. c © o c © jO 'S O Ojie ration. c after Operation. -Results. a cS £ S S c3 9 3 cZ B o fei . o £ £ © © 62 45 Gonorrnoea twice. 1 Meat... 28 38 Irritability of bladder. Pain Spasmo die 2 Immediate relief. Recontraction after connection. stricture at after two months. Return of operation. No m e mbran- trouble. Second operation recontraction. ous portion followed by relief, which was permanent six months after 63 34 1 i in. 15 34 Pain in back, hypogastrium, Double hydro- 3 operation. Immediate relief of pains. Dis- appearance of hydrocele with- in a month. Two recontrac- groins, testicles, inner aspect of thighs and khees cele. Fre- quent sem- inal emis- tions with returuof Symptoms sions. Third operation followed by • relief, which continues one 64 50 Gonorrhoea twenty 1 4 in. 18 30 Irritability of bladder. Gleet Gleet 9 year after operation. Cure; return of symptoms five mouths after first operation. Two and a half years after live years pre- vious. for five years. 1 | second opera- tion, remains 65 31 Masturbation 4 Meat. 1 in. 30 38 Constant desire to urinate. Burning in penis. Pain No erections; l Diphther- Relief of pains. Patient still perfectly well 34 no venereal 1 itic ex ud- 3 in at meatus, in back hypo- desire for a t i o n . after operation. 34 in. 94 gastrium, right testicie fourmonths Acute and legs. urethritis t . • - < 66 41 i in.l 20 34 Frequent and painful mic- l! yj uonormoea nrsi stranguary. Pus in urine t w e nty-ni n el years previous.j 1J in. 20 turition. Stranguary. 3£ in. 20 Pam in perineum, above diminished. Frequent mic- Several attacks, since. Gonorrhoea twenty live years pre- vious. 4£ in. 15 pubes and in groins. turition persists. Still under treatment. 41 - i in two bands. 32 Frequent and painful mic- turition. Small stream. i Cure -- - Two months af- 61 ter operation, no recontrac- 51 Meat. 21 34 Micturition every hour Loss of sexual power. i Diphther- itic de- posit. Immediate relief of frequent micturition. Recurrence of erections. Patient still under tion. Gonorrhoea twenty years previous. 68 1 treatment. 69 2 3J in. 5£ in. til lil Frequent micturition. Pus in urine. Subpubic and perineal fis- 1 Relief of symptoms 52 Gonorrhoea tulae. Cure of symptoms. No re-ex- amination. 10 31 Gonnorrlioea four #> Meat. 30 Difficult micturition. Blood 9 35 times ; last at- tack three years previous. Gonorrhoea 2 in. deep. til 25 34 in urine. Urine in drops. Pain in back. Gonorrhoea acute for five Gonorrhoea.. 11 Immediate relief to acute 1 1 in. months. symptoms. Still under treat- ment. 12 32 Gonorrhoea seven years previous. 9 Meat. 3 in. 34 19 38 9 Relief of discharge. Slight re- Recontra c 11 o n ■ contraction after one month. after ono month. Several times 13 29 since. Gonorrhoea three months pre- 9 4 in. 2* in. 26 '29 30 ftWt. __ Gleet. Spas- modic strie- 3 Relief of spasmodic stricture Recontra c t i o n Slight discharge remains. at meatus. vious. ture. None of deep stricture. 14 28 Paraphimosis Oc- cidental. 4 14 in. 2i in 16 21 31 3 'Relief of symptoms Three months urine after opera- 2| in 21 21 1 Gleet. tion found contraction at 1 three inches. STATISTICAL TABLES.,—Continued. FESSENDEN N. OTIS. one' HUNDRED CASES OF URETHRAL STRICTURE. o cS s K 3 O <5 t- 00 3 O •*-» t- I g'| O rtJ fl ”1 3 O O C 0/ , bt o < 3 £ u Cause and * Date of. 'g 3 A is ~ cn ►3 Condition at Date of £ Operation. j5 U £ o cs c V a § o rj Accidents after 5 Operation. U - S 3 5 Results. 3 1 c3 01 »: £ Condition at date of I s'! £ £ 2 Accidents i i date of o “ £ Operation. a O after Results. | fc c *4 o o S C5 o Q c3 ■g 1 Operation. c3 a £ . s 5 g 1 1 bi s g M >-3 5 5 © O * 6 ft 8( >22 Gonorrhoea five 2 i in. 2 4 31 Occasional increased fre - Redun dent 1 Gleet ceased for six months Then he had a fresh gonorr licea, followed by gleet. Six months after operation re- contraction at years previous. 2£ in. 2 2J in. 2 1 quency of micturition. prepuce! C i rcumcis- ion. J f meatus. None of deeper 87 47 Gonorrhoea twenty 1 1 in. 25 33 Return of gleet after eacl venereal indulgence. Gleet 1 Cure. No return of trouble strictures. previous. six months, also one year 88 28 Gonorrhoea I2 Meat.. 24 31 Gleet for two years Gleet 1 alter operation. Cure of gleet. No return when 2 in 24 ■jin. 17 89 30 Gonorrhoea ten 1 34 Gleet Gleet.. . 3 Gonorrhoe- al rlieu- patient was seen last. Cessation of gleet for three months. Recontraction at Recontraction at years previous. 3 in. 17 Gonorrhoea twenty matism. three inches and return of discharge. Still under treat- ment. Complete relief. After division six months af- ter operation. 90 45 2 Meat.. 22 34 Several attacks of retention i of urine. Treated for deep S p asm. S t r icture. 1 P r o s tatic abscess. ! stricture. Trouble refer- ■ red to neck of bladder. Ret ention of urine. 1 passed into bladder. Passed out of observation one week ' 1 after operation. i .* X. * 91 Gonorrhoea twenty 2 Iranular 1 Pure. Immediate relief to fre- 4 t < 111. .. five years pre_ two ular urethra and great urethra. quent micturition. Urethral vious. bands. sensitiveness of urethra. trouble disappeared without further treatment. 92 34 Gonorrhoea ten years previous. 1 i in. 27 31 Frequent micturition. Sensei of fullness in urethra. 1 Pure of frequent micturition and abnormal sensations in urethia ... Highly spasmodic condi tion of urethra. 91? 47 Gonorrhoea twenty 7 Meat. 24 31 Frequent micturition. Two] tetention of 1 Chills Relief of all symptoms which rwo months af- years previous. 1 in. 22 attacks of retention of uriuo. continues. ter the opera. 3J in. 15 four bands, nembr portion tilifo’m urine. Small stream. Cure. Immediate relief of in- tion no recon- traction. Three months 94 10 1 Meat 12 Phymosis cir- cumcision. micturition. 1 continence. Return of incon- after last oper- tinence. Recontraction. Re- division of meatus. Perfect ation. relief of incontinence up to date. 95 50 Gonorrhoea twenty 2 * in. 27 32 Frequent micturition. Pain Immediate relief of symptoms, years previous. 2£ iu. 30 and tenderness in hypo- gastrium and back. Small stream. Dribbling. which continues up to date. Eight months af- 96 27 Masturbation 1 Meat. 30 38 Frequent micturition. Sense Frequent sem- 3 Cure. Remains perfectly well of wetness about glaus. inal enns- eight months after last opera- ter last opera- Dribbling. sions. tion. Recontraction with re- turn of symptoms twice. tion no recon- traction. 97 27 Gonorrhoea seven 2 i in. 20 31 Frequent and painful mictu- Postatic e n - 9 Cure. Relief of all symptoms Ten months af- ter last opera- years ago. Sev- eral attacks sub- 1 in 119 rition. Pain in penis, largement. for two months. Recontrac- perineum, rectum. Con- tion with return of symptoms tion, no recon- sequently. stant desire to defecate. , Second operation followed by relief, which after ten months remains perfect. traction. STATISTICAL TABLES.— Continued. 36 FESSENDEN N. OTIS. | Number of Case. <6 bb < Cause and date of. | Number of Strictures. Locality of Stricture. | Size of Stricture. Norm. Calib. of Urethra. Condition at date of Operation. Complications. | Number ot Operations. Accidents after Operation. Results. Re-examinations. 98 33 Gonorrhoea thir- 14 Meat.. 22 30 Gleet. Retention of urine. Gleet. Reten- 2 Chills after Complete relief of symptoms Reeon traction of teen years pre- 1 in. 19 Urine in drops. tion. intro due- External and internal opera- two strictures vious. 2 in 15 tion of in- tions combined. to 24. 3 in. 10 strum’ts. 3 to 1 4£in l 6 8 bandsj 44-to ) 64 in V 1 2bds ) 64 to j Hin [ i 3bds ) 99 30 Gonorrhoea 8 f in. 31 Gleet for two years Gleet 3 Curv ature Urn l 27 of penis half after op- 3bds f during e ration, no 3J in. 25 e reetion. re contraction, 2 in. 26 D i s ap- except at two 2| in. 26 peared points, be- 3 J to 4 after one tween three year. and four ins. 100 30 Gonorrhoea ten 2 Meat.. 30 Frequent and painful mictu- Gleet 2 Cure . One year and a years previous. 64 in. 17 rition. Gleet. half after last operation, no recontraction. Total number of operations, 203 STATISTICAL TABLES—Continued.