ON 
SOME IMPORTANT POINTS IN THE TREATMENT 
OF 
DEEP URETHRAL STRICTURE 
(Read before the Medical Society of the State of New York, February 1,1887) 
BY 
F. i\. OTIS, M. IF 
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, NEW YORK 
Reprinted from The New York Medical Journal for February 19, 1887 
NEWYORK 
D. APPLETON AND COMPANY 
1887 ON 
SOME IMPORTANT POINTS IN THE TREATMENT 
OF 
DEEP URETHRAL STRICTURE 
(Read before the Medical Society of the State of New York, February 1, 1887) 
BY 
CLINICAL PROFESSOR OF GBNITO-URINARY DISEASES IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, NEW YORK 
F. N. OTIS, M. D. 
Reprinted from The New York Medical Journal for February 19, 1887 
NEWYORK 
D. APPLETON AND COMPANY 
18 8 7 ON SOME IMPORTANT POINTS 
IN THE 
TREATMENT OF DEEP URETHRAL STRICTURE. 
In regard to the locality of urethral strictures, it may be 
broadly stated that they are important in proportion to their 
distance from the external urethral orifice; and, again, that 
strictures at any point anterior to the bulbous region are, to 
a great extent, free from the chief difficulties and dangers 
which may attach to strictures located in the deeper portions 
of the urethra. It is fortunate, therefore, that we find by 
far the greater proportion of urethral strictures situated in 
the penile portion of the canal—a fact which is reasonably 
explained and corroborated by the well-known greater fre- 
quency, severity, and persistence of inflammations in this 
locality. 
Careful examination by means of the urethrometer and 
the bulbous sound, in more than one thousand cases which I 
have examined criticall}7, has shown that less than 10 per 
cent, were found at a point beyond four inches from the 
urethral orifice. Through similar examinations by means of 
the urethrometer and the bulbous sound in any case of strict- 
ures, their presence as well as their exact locality may be 
readily demonstrated, and thus the distinction between cases 
of much or little importance may be absolutely determined. 
Notwithstanding this, it is still a common practice to make SOME IMPORTANT POINTS IN THE 
4 
the diagnosis of strictures through symptoms alone, and to 
treat them by dilatation—not infrequently by division, with- 
out any knowledge of their exact location. For instance, a 
man comes to the surgeon complaining of a persistent gleet: 
the presence of stricture at some point in the urethra is natu- 
rally inferred ; a flexible bougie or steel sound of the size of 
the urethral orifice is introduced, and, if it can be made to 
traverse the entire canal and passed well into the bladder, the 
first step in the treatment of stricture by dilatation is success- 
fully initiated, and then a course of dilatation is carried out, 
without the least practical reference to the exact locality of 
the stricture. The stricture for which this procedure is initi- 
ated may be, and often is, confined to the anterior urethral 
orifice or its near vicinity, and yet the dilating instrument is 
carried not only through the entire penile urethra, which is 
usually very tolerant of unnecessary interference, but through 
the membranous and prostatic portions of the canal, where 
alone the greatest dangers of gradual dilatation reside. 
In cases practically identical with those above referred to, 
where the strictures were of large caliber and in the penile 
urethra alone, I have known the passage of the flexible bougie 
or sound to produce epididymitis in many instances, in two 
cases going on to orchitis and abscess, with complete loss of 
the testicle in each; in other cases urethral fever, in several 
with suppression of urine; acute prostatitis often, with pros- 
tatic abscess in two cases, one of which was in a surgeon of 
some distinction, and where the stricture was within one inch 
of the external urethral orifice. In other cases acute cystitis 
has resulted. All the above-mentioned accidents would have 
been avoided had the exact locality of the stricture been de- 
termined previously to the inauguration of the treatment, 
and this confined to the immediate locality of the stricture. 
Again, in cases where difficulty in urination constitutes 
the chief symptom of stricture, and only small flexible instru- 
ments can be passed, the same mode of procedure is not un- 
commonly practiced—the surgeon recognizing, perhaps, that 
the obstruction to the passage is in the deeper urethra, but 
overlooking entirely the presence of anterior contractions of 
greater or less caliber which are potent to produce spasmodic TREATMENT OF DEEP URETHRAL STRICTURE. 
5 
contractions of the membranous portion of the canal, which 
may perfectly simulate close organic stricture at this point. 
' It is especially true of strictures of small caliber in the 
deeper portion of the urethra—say at from a quarter to one 
and a half inches anterior to the bulho-membranous junction 
—that, in using the small flexible bougie, the instrument, 
after passing the above-mentioned strictures, is again arrested 
at a deeper point, and yet is finally made to pass on into the 
bladder, though often closely hugged. 
It is in just such cases as this, and they are not infrequent, 
that the surgeon, satisfied that there is a close, deep organic 
stricture heyond the bulb, resorts to the urethrotome of Maison- 
neuve, or possibly performs an external perineal urethrotomy, 
on a diagnosis based upon information afforded by the small 
flexible or filiform bougie alone. It is, however, of the great- 
est importance that the error should not be made of mistaking 
for an organic stricture of the deeper urethra a spasmodic 
stricture caused by an organic stricture in the bulbous urethra. 
It is in just such cases as that above described that the pre- 
liminary and careful use of the bougie-d-boule, or the bulbous 
sound, becomes imperative, as it will not infrequently put an 
entirely different aspect upon the difficulty by revealing the 
presence of one or more linear strictures immediately anterior 
to the bulbo-membranous junction, on the removal of which, 
a full-sized sound may be made with ease to pass into the 
bladder. Permit me to cite a case in illustration. 
Mr. W., aged forty, came to ray office in November last, suffering 
with a retention of urine of a few hours’ duration. He had a history 
of gonorrhoea fifteen years previously, followed by gleet, and, for a 
period of some ten years, was treated by injections and by dilatation 
for supposed stricture from time to time, but never had complete 
relief from bis discharge. Finally, becoming discouraged, be dis- 
carded the use of the"sound entirely, and contented himself with the 
occasional use of a mild astringent injection. Being a man of regu- 
lar and temperate habits, except from the slight gleet he experienced 
no trouble of consequence until some two years ago, when he had a 
retention of urine. 
Prolonged and urgent attempts to pass a catheter failed, and he 
was finally relieved by the hot bath. Much blood was lost in the 6 
SOME IMPORTANT POINTS IN THE 
attempts at catheterization, and, as a metallic catheter was passed 
down near to the bladder, it is probable that one or more false pas- 
sages were made. Although he voided his urine habitually in a 
small and interrupted stream, he had no farther retention for a year 
and a half, when he had a repetition of his former experience. Re- 
peated attempts at catheterization again failed, and he was again 
relieved by hot-water applications. Again a period of comparative 
freedom from usual trouble, until the morning of his visit to me. 
He had accomplished his urination with no more than his usual dif- 
ficulty on rising, but on attempting the act a few hours later he was 
unable to pass more than a few drops. No complaint of pain, only 
of anxiety lest his former experiences in catheterization should re- 
quire repetition. On examination, I found a penis of three inches 
and a quarter in circumference; length of pendulous portion, four 
inches and a half. The urethrometer was introduced to five inches, 
where it was easily expanded to 32 F., demonstrating on its with- 
drawal two narrowings of four millimetres at three inches and two 
inches and a half, and a meatus of 27 F. No. 27 solid sound was 
arrested at five inches. I then began a systematic examination with 
the metallic bulbous sounds. After careful and patient trial with 
sizes diminishing by one millimetre each, No. 6, the bulb of which 
represented six millimetres in circumference, slipped through a nar- 
row ring of stricture and passed on, hitching over two or three little 
folds within the next half inch, into a sort of pouch or dilatation. I 
then enlarged the linear stricture with successive bulbs easily up to 
8 F., and attempted to pass a catheter of this size, and, failing also 
in this, smaller sizes were patiently tried, besides various filiforms, 
but all were resisted at about six inches. I then started the Croton 
faucet, with directions that the patient should make no effort to 
urinate unless he had the desire, and left him for half an hour, 
thinking, later, to try the introduction under ether, if necessary. 
On my return he had voided eight ounces of fairly clear urine, and 
remarked that he had not made so large a stream in the last five 
years. On the following day he called and reported sustained im- 
provement. I then passed No. 9 bulb easily just to the pocket be- 
yond. He complained of severe smarting when urinating soon 
after; this, however, soon passed off, and as he left he remarked 
that he did not think he had ever passed a larger stream in his life. 
A few hours after he started for a neighboring city. He was obliged 
to stop en route during the night, on account of another attack of 
retention. Here catheterism was attempted and failed, and the TREATMENT OF DEEP URETHRAL STRICTURE. 
7 
bladder was aspirated, about eight ounces of urine only being with- 
drawn, On arriving at his destination, on the following morning, 
another retention occurred, accompanied by fever and great suffer- 
ing. This time the surgeon who was called, on hearing the history 
of the case, declined to attempt catheterism, but passed a trocar at 
once into the bladder through the rectum, and drew off over a pint 
of urine. The cannula was retained in situ for four days, when, a 
few hours after its removal, he passed his urine per viam naturalem 
with great ease. lie returned to New York the next day, accom- 
panied by his surgeon, from whom, in conjunction with the patient, 
the foregoing account was received. The patient expressed himself 
as considerably enfeebled, but as performing his urinary functions 
better than for many years. The day following the patient was 
etherized. 
The stricture at five inches was readily defined with Nos, 9 and 
10 bulbs. No. 10 flexible bougie was resisted at the bulbo-mem- 
branous junction. The staff of a Maisouneuve was then introduced 
six inches, and a blade, cutting to 28 F., was passed to and not be- 
yond five inches and a half. After division of the meatus to 32 F., 
my dilating urethrotome was introduced to six inches only, and 
turned up to 32, and the stricture at five inches to five inches and a 
half divided, also the contractions anterior, alluded to in the first 
examination. A No. 32 steel sound was then passed easily and 
without force well into the bladder. There was no haemorrhage, 
only the oozing of a few drachms of blood, during the night follow- 
ing the operation. There was no constitutional reaction. The urine 
was drawn for five days subsequently, in order to guard against the 
occurrence of urethral fever. The patient had been much debilitated 
by his retentions and the means used to relieve them; his recovery 
was on that account considerably delayed, but he was out on the 
tenth day. The only special treatment which he received, besides 
that above referred to, was the introduction of a 32 F. solid steel 
sound every other day, until the complete healing of the wounds of 
operation, when he left the city apparently well. 
It lias been in mj experience to meet with several cases 
practically identical with the one just cited, where close or- 
ganic stricture in the bulbous urethra presented all the char- 
acteristics of true stricture of the membranous portion, and 
where operative measures, rigidly confined to the urethra an- 
terior to the bulbo-membranous junction, have sufficed to re- 8 
SOME IMPORTANT POINTS IN THE 
move all evidences of stricture heyond that point. The cases 
of urythrismus, or chronic spasmodic stricture, previously 
reported by me during a discussion of that subject in the 
“Hospital Gazette,” June 28, 1879, and subsequently, were 
shown to be due to the presence of strictures of large caliber 
in the penile urethra. Strictures which have been demon- 
strated by means of the bulbous instruments in the immediate 
vicinity of the bulb were formerly accepted by me as deep 
organic strictures, and operated on either by external ure- 
throtomy, or by the use of the urethrotome of Maisonneuve, 
as I do not consider the amount of cutting sometimes neces- 
sary to completely divide the stricture by dilating urethroto- 
my justifiable in the deep urethra, or beyond a point where 
any resulting haemorrhage can be readily controlled by exter- 
nal pressure. It is, however, possible that many cases which 
present the usual evidence of deep organic stricture may, 
through careful exploration with small bulbous instruments, 
be relegated to the much less important class of strictures an- 
terior to the bulb. 
It will sometimes occur that strictures may be traversed 
by filiform instruments, and can be located by very delicate 
bulbous instruments, but where the caliber of the stricture 
is too small to admit the smallest guide bougie of the ure- 
throtome of Maisonneuve. In such cases, where immediate 
operation has become necessary, the only resource is an inter- 
nal urethrotomy. For aid under such conditions, I have had 
constructed, and have frequently used with much satisfaction, 
a miniature Maisonneuve, of scarcely more than half the size 
of the ordinary instrument, carrying a blade of not more than 
three or four millimetres’ breadth. This, with due care, may 
readily pass a stricture where no other cutting instrument 
can, and subsequently the ordinary - sized urethrotome of 
Maisonneuve may be readily entered. 
This little instrument in my hands has, in repeated in- 
stances, saved the patient an external urethrotomy, when 
without it such an operation would have been unavoidable. 
Some time since, a patient presented at my clinique at the 
College of Physicians and Surgeons, who was reported to be 
the subject of an impermeable stricture. On careful explora- TREATMENT OF DEEP URETHRAL STRICTURE. 
9 
tion, several strictures of large caliber were found in the 
penile urethra, and one at about five inches, which was de- 
fined by No. 6 bulbous sound, two millimetres less in size 
than the shaft of the ordinary urethrotome of Maisonneuve. 
The miniature instrument was introduced, and the deep strict- 
ure divided so that the ordinary instrument was easily made 
to follow. With the latter, room sufficient for the introduc- 
tion of my dilating urethrotome was secured, the deeper as 
w*ell as the anterior strictures were fully divided, and, with 
no cutting beyond five inches and a half, a steel sound, 
thirty-two millimetres in circumference, was passed easily 
into the bladder. 
I do not fail to appreciate the fact that such cases as I 
have recited are quite exceptional. I believe they would 
be found to be much less so, if the means of diagnosis which 
I have described and advised were more generally adopted. 
Permanence of results after operations on deep strictures 
depends, as in the case of anterior strictures, upon complete- 
ness of division. Complete sundering at some point is essen- 
tial to radical cure. 
This I first publicly maintained in 1873, as the result of 
careful re-examinations, several at least a year after opera- 
tion. In 1881 I was able to report over a hundred well- 
authenticated cases where the cure had remained perfect from 
two to twelve years after division, and the experience of the 
subsequent years has still further confirmed the proofs of the 
statement that complete division of urethral stricture, as a 
rule to which there are but few exceptions, means radical 
cure. Division of all anterior strictures is, has been proved 
to be, essential to the cure of deep strictures. Sir Henry 
Thompson, in his latest teaching on the treatment of stricture, 
students’ edition of 1884, says: “I am convinced, therefore, 
of the necessity of complete division of all the obstructing tis- 
sue, not only in relation to future results, but to the present 
well-doing of the patient, and thus have an additional support 
for the value of my maxim, ‘lf you cut one, cut all.’ ” And 
again, on page 10, “If you cut at all, cut all”; that is, he 
further says, all the points in the urethra in which the pres- 
ence of obstructing deposit is to be demonstrated. 10 
THE TREATMENT OF DEEP URETHRAL STRICTURE. 
“ Such,” says Sir H. Thompson, “ is the unhesitating con- 
viction which a very considerable experience of internal ure- 
throtomy has forced upon me.” 
Again he says, page 12: “ I have no hesitation now in 
advising internal urethrotomy whenever organic stricture, 
single or multiple, near or distant from the meatus, shows 
signs of not yielding readily to dilatation. No delay is, in 
these circumstances, of any value as regards the stricture 
itself. Division must be made sooner or later, if the organs 
behind it are to be preserved from injury ; the sooner, there- 
fore, other conditions being favorable, the urethra is rendered 
freely patent, the better it will be for the subject of it.” 
The reason why the results of division of deep strictures 
by perineal section are often but temporary, is because most 
commonly the anterior strictures-are not also divided. With- 
out this, the full size of the urethra in the perineal portion can 
not be kept up until the healing of the perineal incision ; hence 
re-contraction sooner or later is inevitable.