ON 
REFLEX IRRITATIONS 
THROUGHOUT THE 
GENITOURINARY TRACT, 
RESULTING FROM CONTRACTION OF THE URETHRA,' 
AT OR NEAR THE MEATUS URINARIOUS, 
CONGENITAL Oil ACQIT/RED. 
By FRESSENDEN N. OTIS, M. D., 
Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, 
New York. 
READ BEFORE THE NEYV YORK ACADEMY OF MEDICINE, 
THURSDAY, FEBRUARY 19th, 1874. 
CHARLESTON, S. C. 
PRINTED BY H. P. COOKE & CO. 
52 BROAD STREET. 
1874. Art. III.— On Reflex Irritations throughout the G-enito- Urinary 
Tract, resulting from contraction of the urethra, at or near the 
Meatus Urinarious, congenital or acquired. By Fressenden N. 
Otis, M. D., Clinical Professor of G-enito-Urinary Diseases in the 
College of Physicians and Surgeons, New York.—Read before the 
New York Academy of Medicine, Thursday, February 19th, 1874. 
From the Charleston Medical Journal and Review, July, 1874* 
The influence of the irritation of peripheral nerves in producing 
centric disturbance in the spinal cord, which may thence be transmit- 
ted to distant parts of the animal economy, first claimed by Dr. 
Marshall Hall more than twenty years ago, has found corroboration 
in the testimony of every medical scientist since his time; and 
besides, so much clinical proof has been accumulated by the medical 
profession at large, in support of this proposition, that it is no longer 
a matter of discussion. Morbid reflex disturbances are now accepted 
as occupying an important place in the recital of human suffering. 
Varied and grave disturbances, influencing the entire nervous system, 
are often ascertained to be dependent upon as apparently insignficant 
a cause as a decayed tooth, an indigestion, a simple erosion upon the 
cervix uteri, ceasing at once on the cessation of the cause. Dr. D‘ 
Campbell Black, in his very interesting and valuable book on the 
Renal and Urinary organs, cites cases of retention of urine from 
reflex irritation, the result of an operation for haemorrhoids. Dr. 
Sayre, of New York, has published an account of several cases of 
incontinence, caused by contracted prepuce, which were at once and 
permanently relieved by circumcision. Trousseau has recorded simi- 
lar cases. I have seen several cases of this sort, besides one marked 
case of retention in an infant nine months old, which, after lasting four 
days, was completely relieved within an hour by slitting up the pre- 
puce. Seminal emissions are well known to occur as a result of phy- 
mosis, relief occurring promptly on ablation of the prepuce. 
Dittel relatSs a case where a man, 26 years of age, had a slight 
phymosis, and was the subject of incomplete erections, nocturnal 
emissions, frequent desire to urinate, and also of many hypochondriac 
symptoms, all of which were promptly and completely cured by re- 
moval of the prepuce. A similar case is related by Pitha. Schweig- 
ger-Seidel cites a case where the simple introduction of a catheter caused 
complete syncope, and yet no urethral disease was present. I have 
the record of a similar case, where complete unconsciousness instantly 
followed the introduction of a bulbous sound through the meatus 
urinarious. Every surgeon of much experience, has recognized the 
tendency to syncope in a considerable proportion of nervous patients 
on the first introduction of instruments through the meatus. 
Spasm of the bladder is noted by Dr. D. C. Black as occurring 
from sympathetic irritation, and to such a degree that complete 
closure of the uretral orifices results, producing retention of urine in 
the ureters and pelves of the kidney. Such a case, I believe, I have 
seen resulting in death from uremia, and caused by the rude introduc- 2 
Otis on Reflex Irritation of Genito- Urinary Tract. 
tion by the patient of a catheter through a narrow stricture at the 
posterior border of the fossa nivaeuiaris. Forcible and painful con- 
traction of the bladder followed immediately, with complete suppres- 
sion of urine. The patient died uremic 24 hours after. The bladder 
was found empty, (with the exception of a few drachms of grumous 
blood and mucous) closely contracted and free from disease. The 
ureters were normal, the kidney highly engorged with blood, but pre- 
senting no evidence of disease. The case was accepted as one of 
“ acute suppression ” at the time. The ureters are known to contract 
vigorously under the influence of the galvanic current. The above 
case, it now seems to me, was one of spasm of the ureters and bladder, 
reflected from the irritation at the end of the penis. A few days 
since, Dr. Brown Sequard related to me the following case: 
While in London during the past year, a gentleman was brought 
to him who presented all the rational signs of advanced central 
ramollisement. He had looked upon the case as quite hopeless, until 
noticing that the patient frequently applied his hand in an absent 
sort of way to his genital apparatus. The doctor requested permission 
to examine the part. An aggravated inflammatory phymosis, compli- 
cated with acute balanitis, was discovered. “ On making this dis- 
covery,’’ said Dr. Brown Sequard, “ I expressed to the medical gen- 
tlemen accompanying, and in charge of the patient, my belief that the 
apparent ramollisement might be due to reflex irritation, caused by 
this evidently chronic and severe irritation of the glans penis. I ad- 
vised complete division or ablation of the prepuce, and treatment of 
the balanitis as the best and only hope for the patient’s recovery from 
the brain trouble from which which he was suffering.” The opera- 
tion was performed, and the effect upon the mental and physical con- 
dition of the patient was almost immediate. “ So rapid was his re- 
covery,” said Dr. Brown Sequard, “ that within six weeks from the 
date of the operation he presented himself at my oflice, permanently 
well in every respect.” # 
Sir Henry Thompson (Stricture of the Urethra, London Edn, p. 
249) says: “ I have given complete relief to distressing symptoms of 
very long continuance, the cause of which was not suspected, by divid- 
ing an external meatus, which nevertheless admitted a No. 6 English 
catheter.” 
“■ I have met,” he further state*, “ with three marked examples of 
a similar kind, in which the very simple operation necessary was fol- 
lowed by complete disappearance of urinary difficulties, which had 
been long regarded as of an extremely obscure character.” He cites 
a single case: (page 253 op cit) “ T. T., aged 34, a gentleman whom 
I had visited at the request of his medical attendant, in the spring of 
1857, had been suffering from painful, prolonged and frequent mictu- 
rition for five years previous. He was compelled to pass water from 
three to five times every night, and- every two hours during the day; 
experienced severe pains in the back and loins, and general ill health. 
Urine was purulent, fetid, alkaline—results of habitual retention, Otis on Reflex Irritation of Genito- Urinary Tract. 
3 
and partial engorgement of the bladder. He had been treated for 
renal disease, without any good effect. On examination, I found a 
simple narrowing of the urethral orifice, and marks of previous ulcera- 
tion in a small cicatrice. “ I learned,” said he, “ that he had had a 
chancre seven years before, which involved a large portion of the 
meatus, after the healing of which his symptoms almost imperceptibly 
appeared. A probe only passed through the narrow opening. I 
divided the contraction so as to make a free opening. A number 10 
was passed easily into bladder, demonstrating that there was no other 
obstruction, and 12 ozs. of urine were drawn off, although he had 
passed water just before. The relief was almost instantaneous ; in a 
week it was complete. He has had perfect immunity from his urinary 
complaints ever since.” 
By the cases already cited, and many others scattered through the 
periodical literature of the past few years, it is sufficiently proved that 
hemiplegia may result from disease of the kidneys, without any 
coincident morbid change in the structure of the spinal cord, and 
that incontinence of urine, retention of urine, and involuntary seminal 
emissions, may, in the same manner, result from irritation of the 
extremity of the glans penis. The case of simulated central 
ramollisement related by Dr. Brown Sequara, occurring as a direct 
sequence of like irritation, indicates the wide range of sympathetic 
disturbances, which may be initiated by simple inflammatory action at 
this point. Now aside from the fact that the glans penis is known 
to be extraordinarily rich in sympathetic nerve cells, that it is the 
recognized initial point from which the physiological sexual excite- 
ment is transmitted throughout the male genitalia, clinical expe- 
rience abounds with evidences of the capacity and proneness of this 
especial region to produce reflex disturbances, often of a grave character, 
throughout the entire sympathetic nervous system. Notwithstanding 
these facts, I believe that the full significance of this locality, as a 
source of reflex irritation along the genito-urinary tract, has not yet 
been appreciated ; and further, I am convinced that many heretofore 
obscure difficulties and diseases of the genito-urinary organs, may be 
distinctly traced to the meatus nrinarious as the source of their initia- 
tion and continuance. In pursuance of this idea, prrmit me, gentle- 
men, to present for your consideration the following cases : 
Case 1.—A. Y., physician, aged 28, contracted first gonorrhoea, 
November 20th, 1873. Severe, lasted four weeks. Treatment by 
alkalies internally, application of cold and mild injections. Was under 
my care. I noticed on examination that his penis was large and the 
meatus small, and called patients attention to this fact, when he first 
presented for advice, and assured him if he did not have a fair reco- 
very it would be necessary to enlarge it. January 19th—Patient 
presents with gleety discharge, without known cause. Great irrita- 
tion at the neck of the bladder, and frequent desire to urinate. Is 
certain that his former disease was imperfectly cured, and that it has 
come forward from the deep urethra, to which it had extended in his 4 
Otis on Reflex Irritation of Gmiito- Urinary Tract. 
original clap. I remind him of his contracted meatus ; he is certain 
he needs deep injections, but submits to operation for enlargement of 
meatus. Cut it to 30 fr., after which 30 bulb passes throughout the 
cnnal with ease; to keep incision open until healing is complete. 
January 24—Patient reports immediate cessation of irritation in the 
perineal portion of the urethra on division of contraction ; discharge 
ceased within 48 hours, and he has had no trouble since. 
Case 2.—Sept. 10th, 1872. Mr. W., a Swede, silk weaver, was 
brought to me by his medical attendant, complaining of pain and 
general discomfort about the perineum, and especially of a nervous 
uneasiness in that region, which prevented him from pursuing his 
avocation. He could not sit still. Had had gonorrhoea several years 
previous. Had been treated for stricture by dilatation for several 
months, but without relief. Examination showed a narrow meatus ; 
No 21 f. Stricture at 2 b inches, defined by 18 f. A free division of 
meatus was made with Civiale’s bistouri cache and of the stricture 
with the dilating urethrotome, after which 27 f. passed readily 
through. To be kept open by daily introduction of sound until 
healed. September 20th—Patient reports entire cessation of irrita- 
tion and nervous feeling immediately following the operation, but this 
returned yesterday. Examination shows recontraction of meatus to 
20. Cut again freely. Nov. 16th—Patient again called with the 
statement that he had been able te work until the day previous, when 
the irritation had again returned, and he desired to be cut again. 
Examination showed a recontraotion at the meatus to 24. Cut again; 
introduced 30 f., which passed easily past the site of stricture at 
2b inches, and down to the bulbo membranous junction. The patient 
called two months after (January 20th), wishing to go to Philadel- 
phia, and had had no return of his trouble. No recontraction of 
meatus. 
Case 3—Mr. W., aged 27, had gonorrhoea in 1870, lasting one 
month, when a fresh exposure resulted in another attack, which lasted 
under a sharp fire of injeetions for six months longer. Since that 
time has always had a return of the discharge after connection. Has 
been under treatment for stricture by several physicians, but none 
succeeded in entering the bladder. His last medical attendant, after 
treating him for a couple of months, said that he had no instrument 
small enough to pass, and advised him to put himself under my care. 
Examination, April 16th, showed organ unusually well developed. 
Meatus contracted to 24 £., red, pouting and bathed in a muco-puru- 
lent discharge; 24 sound is arrested at 5 inches, only fine filiform 
will pass, and that is closely hugged. April 19th—Passed filiform 
with ease— followed with No 10, and then, with some effort, with No. 
16 f. After this the filiform was again closely hugged in the mem- 
branous portion. Divided the meatus freely and introduced No. 30 f. 
steel sound, which passed, literally by its own weight, down through 
into the bladder. Otis on Reflex Irritation of Genito- Urinary Tract. 
5 
Case 4.—Mr. J. W , aged 32, had gonorrhoea 10 years ago very 
severely. Lasted with pain and difficulty of micturition fully six 
months. After being apparently well for three years, a gleety dis- 
charge appeared, without new exposure. Masturbated daily from 14 
to 20 years, when he abandoned the habit. At 26 began to 
have nocturnal emissions, which growing gradually more frequent, 
since last two years have occurred almost nightly. He has had 
occasional sexual intercourse. Erections have been imperfect for 
last 18 months, ejaculation taking place before the erection was com- 
plete. He has suffered much from despondency and nervousness. 
Has had no treatment except for general health, which much of the 
time has been indifferent. Examination shows genitals well develop- 
ed and apparently normal, with the exception that while the circum- 
ference of the flaccid penis is three inches, the meatus is contracted 
to 22 f. The size of the urethra in a penis three inches in circum- 
ference is, as a rule, fully 30 f.* November 1st—Divided meatus 
thoroughly, and passed thirty-one bulbous sound readily through 
contraction. November 11th—Has had no emissions since date of 
operation. December 1st—Found himself getting so much better in 
spirits and feelings generally, that he ventured to marry on the 25th. 
Since that time has had no trouble of any sort. Considers himself a 
well man 
Case 5.—Mr. W., aged 25. Came under my care December 
1st, 1872. Contracted first gonorrhoea early in June, 1872. Was 
treated by the use of injections locally and alkalies internally until 
August 1st, during which time he had no freedom from the discharge, 
nor from acute suffering. About this time the vesical neck became 
involved, and he suffered much from frequent, painful micturition. 
Came then under the care of a skilled endoscopist, who discovered 
numerous spots of granulations in the course of the canal, extending 
quite into the prostatic portion; applications of a strong solution of 
nitrate of silver were made through the endoscope, which gave tem- 
porary relief; urination, still painful, every hour. By September 1st 
discharge decreased to a slight mucous, after the use of pencils of 
tannin and glycerine. A spell of damp weather brought back the 
purulent discharge, with a return of perineal pain and frequency of 
micturition. Tannin pencils again used, but after continuing for 
four weeks and no improvement, patient was put to bed and had hip 
baths every two hours, etc. After five weeks of treatment of various 
kinds, local and general, he came from his bed to me, December 1st, 
1872. On examination I found no difficulty in introducing No. 20 
f. bulbons sound, and discovered a firm cartilaginous stricture extend- 
ing from just within the meatus half an inch back. This I cut freely 
with Civiale. Immediately following the operation he expressed him- 
self as “ feeling like a new man.” In his written report of the case, 
■ * 3J inches indicates urethral calibre 32 f. 3£ indicates do. 34 f. 3f indi- 
cates do. 36 f. 4 inches indicates do. 38. 4£ indicates do. 40. 6 
Otis on Reflex Irritation of Genito-Urinary Tract. 
(he was a physician) he stated, “that in the division of the stric- 
ture the relief was wonderful, the discharge ceased within twenty- 
four hours, the perineal pain and frequency of micturition and the 
ardor urinse 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, and has continued on duty up to the present date, 
although he still suffers occasionally from prostatic pain. The pros- 
tate I found of double the normal dimensions on his first visit, and 
examination now shows it reduced fully one-third. 
*Case 8.—Mr. L., aged 46, regular and chaste in his habits until 
going to China, twenty years since, and following the customs of for- 
eigners in that country, he indulged excessively in sexual intercourse 
for several years. Had a single attack of gonorrhoea, from which he 
recovered completely in a few weeks. For the last few months has 
been troubled with involuntary emissions as frequently as once a week, 
and latterly in his attempts at sexual interoourse he has failed on 
account of the seminal discharge having occurred before the erection 
was complete. He feels quite certain that his genital apparatus is 
less in size than formerly. Examination shows penis of normal size, 
three inches in circumference and 3 inches in length. Some enlarge- 
ment of the left spermatic veins. Testes soft, full size, left largest. 
Meatus urinarius contracted to 22 f. On introduction of the bulbous 
sound through it, as it was quite unyielding, it required some slight 
pressure, and as it suddenly slipped into the fossa navicularis, a regu- 
lar spasmodic retraction of the penis occurred at intervals of three or 
four seconds, (retraction about i inch), and continuing during the half 
minute, that the instrument was retained and continuing with 
rythmic regularity for three or four minutes after its withdrawal. 
This result of the introduction of the sound was repeated several 
times at that sitting, the interval between the contractions gradually 
lengthening until an interval of five or six seconds occurred, when it 
ceased. These movements, so evidently of reflex origin, suggested tha 
dependence of his seminal troubles on the same cause. I therefore 
divided the meatus thoroughly, and introduced 31 sound without 
difficulty through the urethra. After the operation the introduction 
of the 31 bulb failed to excite the spasmodic contraction of the penis; 
nor in frequent subsequent experiments was I able to reproduce this 
phenomenon. An immediate improvement in the general condition 
of the patient occurred, his involuntary emissions ceased without other 
treatment, and six weeks after the operation he informed me that he 
had entirely recovered his sexual powers. 
Case 10.—Mr. H. F., aged 43, came under my care in March, 
1867, suffering from retention of urine, following a debauch. As no 
* Want of space compels us to omit the report of a number of Prof. Otis’ 
interesting cases; this will account for the irregularity of the numbering. Eds. Otis on Reflex Irritation of Genito- Urinary Tract. 
great amount of urine was present in the bladder, I gave him mur. 
tinct. ferri, advised a hot bath, and left him. On the following morn- 
ing he expressed himself free from any trouble, and declined an 
examination of the condition of his urethra. In December, ’71, he 
again presented, complaining of incontinence; he was also suffering 
from intermittent fever, which I suspected was due to his urinary 
trouble. Said he made his water freely, but could not hold it. I 
found some accumulation in the bladder. As the patient lived out of 
town, I made no examination, but advised him to make arrangements 
to come in town on the following day for treatment. He did not pre- 
sent again until November 30th, 1872, when he came with the state- 
ment that he had then lost all control of his urine; had had none for 
the past year. On the day previous, while riding, he noticed a swell- 
ing in the'perineum, and “ wished it looked after.” Examination 
revealed a firm elevation on the left of the raphe, one and a half inches 
in diameter at the base, and about an inch in elevation, extending 
from just behind the border of the anus to the junction of the scro- 
tum, with the perineum, solid, resilient and painless. No constitu- 
tional disturbance ; temperature 98£°. On examination of the ure- 
thra, expecting to find a deep, tight sti’icture, I was surprised to find 
myself able to pass No. 13f. catheter into the bladder, and to draw off a 
full pint of fetid urine, although he had just urinated. During the 
day the swelling increased,and interfered with the calibre of the 
urethra, so that I could only pass a No. 1 catheter into the bladder, 
and this with difficulty. Attaching this to Dieulafoy’s aspirator, I 
drew off a pint and a half of urine. This, on examination, was found 
to be free from any evidence of organic disease of the kidney. I then 
incised the tumor down through the superficial perineal fascia, and 
gave exit to a thin layer of pus, in quantity about a drachm. It was 
only on the 14th day after, (the swelling gradually subsiding,) that 
urine was found flowing through the wound. In the meantime the 
patient was suffering from cystitis. His bladder was washed out with a 
double channelled catheter, No. 20 f., which was passed without diffi- 
culty, although a perceptible grasping was recognized near the meatus. 
His bladder trouble increasing so that he made his water every hour, 
and this loaded with pus, I urged an operation on the stricture, 
which, from the easy passage of the catheter, I had not before con- 
sidered of much importance. Introducing bulbous sound No. 20 f., I 
could not detect any stricture; on its withdrawal it was arrested at a 
point half an inch from the meatus. Incising the stricture with the 
dilating urethrotome, which (No. 23 f.) I introduced with some diffi- 
culty, I then passed No. 28 sound, without obstruction, down into 
the bladder. On the following day I found that the frequency of 
evacuation of the urine had decreased from one hour to six between 
the acts; that the pus had diminished, and that much less urine 
flowed through the opening in the perineum. From that timo the 
patient continued to improve, his control of the flow of water was 
restored, the pus gradually disappeared, and within a week his 8 
Otis on Reflex Irritation of Genito- Urinary Tract. 
perineal incision had healed, and he left for his home apparently well, 
not having had any treatment whatever since the healing of the 
wound at the point of stricture. 
Case 12.—October 16th, 1873—T. W., 35. Had gonorrhoea fif- 
teen years ago; has had it several times since—the last time four 
years ago; coming on 48 hours from date of exposure. After the 
discharge had existed ten or twelve days, he states that he “ stopped 
it with a powerful quack injection/’ Three or four days subsequent 
to this, he began to suffer with a nervous pain in the testicles; scro- 
tum became tender and red, testicles moved up and down alternately 
much of the time, and the penis was greatly contracted. There was 
also pain in the groins, described as drawing and sickening, which 
extended down into his knees and the bottoms of his feet. (This contin- 
ued with varying severity, almost without cessation, up to Feb. 22d, 
when he came to New York for treatment, and fell into the hands of 
an endoscopist, who discovered numerous granular spots, deep in his 
urethra. Applications made at regular intervals, for about three 
months, without benefit. An application of carbolic acid to the scro- 
tum, gave some relief to his nervous feelings, but caused vesica- 
tion, and the relief was but temporary. About May 1st he sought the 
advice of a surgeon skilled in genito-urinary diseases. Slight stric- 
ture was discovered near the meatus, and several indurated points 
farther down. A 28 f. solid steel sound was introduced, and after-some 
repetition during one month, was given to the patient to be regularly 
used once in three days, until the trouble ceased. Went back to his 
home, some 800 miles distant, and pursued the plan laid out for him, 
but received no benefit. The motion of his testicles was almost con- 
stant, and the nervous feeling this induced drove him almost frantic ; 
compared with it, the pains in his groins, knees and feet were a posi- 
tive relief. He became very low-spirited and despondent. Early in 
October, when hi3 physician, who had accidentally met with an arti- 
cle in the second number of Hr. Brown-Sequard’s archives on “ Re- 
flex Irritations of the Genito-Ur inary apparatus resulting from stric- 
ture,” advised him to return to New York, and put himself under my 
care. Examination, discovered a penis of normal size, 3 inches in 
circumference, scrotum greatly relaxed and covered with exzematous 
scales, produced by the carbolic acid; testicles hanging very low. My 
attention was at once drawn by the patient to the rythmical contrac- 
tion of the cremaster muscles, through which a see-saw motion of the 
testicles was kept up, and which constituted his chief annoyance. A 30 
bulbous sound passed the meatus, and was arrested at half an inch, a 
point to which his greatest sensitiveness, during the passage of instru- 
ments, has always been referred. No. 28 passes through and detects 
another stricture at two inches, and still another at two and a half 
inches. Friday, October 17th.—On my invitation, the patient was 
examined by Dr. Coldham, of Toledo, Dr. J. De Forrest Woodruff 
and Dr. Frank Howe, especially in reference to the spasmodic action Otis on Reflex Irritation of Genito- Urinary Tract. 
9 
of the cremasters. This was very marked and constant, and contin- 
ued until the patient was placed under the influence of ether, by Dr. 
Howe. I then demonstrated the size and locality of the strictures 
before mentioned, and divided them in succession with the (my) large 
dilating urethrotome, after which I passed with ease a 30 steel sound 
through all, and into the bladder. As the patient emerged from the 
influence of ether, it was observed that there was no longer any of 
the spasmodic action of the cremasters. When he became conscious, 
he stated that he had already felt the cessation of his nervous feelings, 
more than for many months, and “ was certain that the right cord 
had been struck.” October 18th—Improvement continues ; no return 
of spasmodic motion. October 20th—Examination with 30 bulb, 
shows a slight narrowing at J inch from the external orifice. Cut this 
at once, and freely, with straight bistoury, and passed 31 f. The 
patient on the following day expressed his belief that a complete cure 
had been effected ; that since the final division of the meatus he had 
not had the slightest return of the abnormal sensations and pain 
with which he had, in some degree, constantly suffered for the pre- 
vious four years. Daily introduction of the bulb was kept up in this 
case until bleeding ceased, when the patient was dismissed, promising 
at once to inform me by letter if he had any return of his trouble. 
Case 14.—Mr. H. D., aged 51. Had been under my professional 
care for several years. Suffered from renal colic on two occasions— 
once in 1868, and again in 1871. Was not conscious of having pass- 
ed any stone through the urethra. Came to me in February, 1872, 
complaining of a sense of irritation at the glans penis, and a frequent 
desire to urinate. Careful examination failed to discover any calcu- 
lus, but the meatus was red and tender, and contracted to 20 f. This 
was at once freely divided. Size not noted. The relief from the 
irritation was immediate and complete. In May, 1873. Mr. D. called, 
stating that his old irritation had returned. Examination showed 
meatus contracted to 23. This was again divided, with relief equally 
prompt as on the first occasion, but in the subsequent treatment by 
daily introduction of a glass tube, size 30 f., an unnecessary degree of 
violence was used, setting up an inflammation, which extended back 
as far as the prostate, and threatened to culminate in an abscess of 
that organ. The inflammation was accompanied by a discharge, which 
did not differ from an ordinary gonorrhoea in the declining stage. 
After two months of treatment the discharge still continued, with 
more or less irritation of the vesical neck. Meatus recoutracted to 
24. Cut to 30. This operation was followed by immediate relief 
and cessation of discharge. Well up to date, January, 1874. 
Case 17.—Mr. X., aged 54. Seen in consultation with Dr. Ives, 
his family physician. Has a history of first gonorrhoea "twenty-eight 
years previous; severe, lasting two months. Second attack eight 
years ago; not severe, subsiding entirely on 10th or 12th day, under 
the use of injections of acetate of lead alone. Three years ago began 10 
OTIS on Reflex Irritation of Genito- Urinary Tract. 
to be troubled with frequent micturition during the and four or 
five times during the night, associated with pain extending from the 
end of penis to the neck of the bladder, also pain in testicles and 
perineum, and [extending down to the thighs. Water occasionally 
stopped and required to be drawn off with a fine catheter. Was 
taught to do this himself, and has often required relief in this way. 
About the first of August last, after using his catheter, he discovered 
a small bit of gravel in the eye of the instrument; since that time he 
has voided a large quantity of the same sort, with fine, whitish sand, 
mucous, pus and blood. Was under the care of a prominent surgeon 
at Brooklyn last summer, who, after careful examination, assured the 
patient that he had no stone in the bladder. Treated him at first by 
frequent washings out of the bladder; afterwards used the galvanic 
current, with one pole in the bladder, and one on the back. This 
was continued for six weeks, but no improvement was manifest, and 
as the patient was much debilitated, he was sent into the country to 
recruit. Since that time he has had no treatment, except the use of 
Lee’s lithontriptic pills, and the use of the catheter when required 
by attacks of retention of urine. Nqv. 24th, 1873.—Present condi- 
tion. Is in feeble, general health. Has an expression of great and 
constant pain, is very restless, and moans frequently, although evi- 
dently attempting control; skin pale and yellow; says his weight is 
130; weight formerly 160. Genital apparatus well developed; right 
testicle invaded inferiorly by a mass of fibrous feel, involving one- 
half of the body of that organ; left, much the same, but softer. 
Passes urine in my presence in a small, divided, uncertain stream. 
Urine of strong, stale odor, thick and muddy in appearance. Coagu- 
lum under heat, which is not dissolved by nitric acid. Cursory 
microscopic examination shows cells of pus and blood, epithelia from 
urethra, bladder, and pelvis of kidney, but no casts. Meatus urinari- 
ous apparently normal; 29 bulb sound, to the depth of 4 inch ; it is, 
however, abruptly arrested at this point, and only 20 f. will pass. 
This found no further obstruction in the deeper portion of the canal, 
but on return was firmly held at f inch—thus defining a stricture 
more than J of an inch in breadth. On the 26th, visiting the 
patient’s residence, he was found moaning and walking the floor, beg- 
ging to have the operation done at once, to relieve his pain. Assisted 
by I)r. Ives, the patient was anaesthetized. The stricture near the 
meatus was then thoroughly divided; No. 30 was passed through to 
one inch, where it was arrested ; 24 only would pass beyond, and was 
held on return at 1J inches. Introduced dilating urethrotome, turn- 
ed up to 30, and cut; then passed 30 f. down to two inches, where it 
Avas again arrested. 28 f. passed, and on withdrawal is held at 24 
inches. Keadjlisting the urethrotome, this band was also divided, 
when 31 steel sound was passed by its own weight, through the entire 
.urethra. Fergusson’s short beaked sound was then introduced into 
the bladder, and thorough search made for stone, but without success. 
Hemorrhage slight, ceasing entirely within fifteen minutes after ope- OTIS on Reflex Irritation of Genito- Urinary Tract. 
11 
ration. Dr. Ives remains in charge. Nov. 29th—Three days subse- 
quent to the operation Dr. Ives called, reporting that the patient had 
no pain of any kind following the operation, up to his visit of yester- 
day. Under the influence of 10 grains of quinine and l grain of 
morphine, he slept for six hours, and on waking, passed water with 
freedom—with slight smarting, but no pain after this ] the intervals 
between the acts of micturition averaged about 4 hours. Passed the 
steel sound 31 with ease; purulence of the urine greatly decreased. 
December 16th—Dr. Ives reports Mr. — as having suffered for a day 
or two past with pain in the penis; purulence in the urine has entirely 
disappeared. 30 steel sound drops through the urethra into the blad- 
der by its own weight. Suggests the possibility of slight recontrac- 
tion of the stricture at the meatus as cause of trouble. December 
23d—Mr. X. called with Dr. Ives. He reports, personally, that while 
he passed his water every half-hour with great straining and pain 
before the operation, that since, he has not been called to urinate often- 
er than once in three or four hours up to within a week, when it has 
been once in two hours. All the pains in the back and in the lower 
part of the abdomen, in the testicles, and extending down the thighs, 
passed of entirely within a few days after the operation. Within the 
last ten days he has had pain referred to the vicinity of the prostate 
when urinating, and the stream was fine and weak; could urinate 
only by straining. He had himself passed 30 sound the day previous. 
Examination of the prostate per rectum reveals no enlargement or 
tenderness. Pass 30 sound without difficulty into the bladder, except 
a little hugging near the meatus. 29 bulb is arrested at one-quarter 
inch, and is held on return at three-quarters. Passed a straight bisboury 
and out through the contraction, so that No. 34 bulb passed in and 
out without obstruction. To keep this well open until healing is 
complete. 
Case 18.—October 9th, 1873. I was called to see a gentleman 
aged 64, whose general health has always been good. He had lived 
generously but regularly. He stated that for the ten years previous 
he had occasion to urinate on an average every hour during the day, 
and through,the night even more frequently. For the previous six 
months he was confident that he had micturated every half hour, 
unless when some necessity prevented, and then suffered always from 
the delay. At no other time had he any pain. The frequency of 
micturition was simply an inconvenience. He had never had any 
gonorrhoeal trouble. Several years since he had consulted an eminent 
surgeon in regard to his urinary trouble, and was said to have stric- 
ture just beyond the middle of the penis. For this he was treated by 
the occasional introduction of bougies for a couple of months, at the 
end of which time, no benefit being apparent, he ceased bestowing 
any attention to the matter. About three months ago he began to 
notice a creamy sediment in the urine, which would cling to the floor 
of the pot de chambre. It was not, however, until about three weeks 
ago that he began to suffer actual pain, straining on passing his water. 12 
On* on Reflex Irritation of Genito-Urinary Tract* 
To this was soon added pain in the testicles, through the hypogas* 
trium. and also in the perineum end, extending down the inner aspect 
of the thighs to the knees. The stream of urine was subject to fre- 
quent sudden arrest, and the straining that followed was severely 
painful, and pain extended throughout the region previously men- 
tioned. The urine soon became of a deep reddish brown color, with 
occasional strings of blood and mucous, mixed with the copious 
creamy sediment, which was now persistently deposited. Notwith- 
standing all this, he continued to ride daily a distance of some three 
miles to his office. About a week since, finding the motion of his 
carriage greatly aggravating his pains, he consulted an eminent medi- 
cal personal friend of his, who informed him that he had a grave 
cystitis, and commended him to my care. I found him sitting upon 
a hot poultice, which had been prescribed for him by his wife’s medi- 
cal attendant (a homeopath), and besides this that he had been tak- 
ing frequent doses of a homeopathic preparation of belladonna. Pres- 
ent condition. Constitutional disturbance very slight; pulse 80, tem- 
perature 99f. Inspection of urine in the pot de chambre, which was 
about one-third filled, and had been standing for several hours, show- 
ed a deposit of mucus and pus, stained and streaked with blood, 
fully one and a half inch in depth. Examination per rectum showed 
the prostate to be even less than the normal size, and free from ten- 
derness. The introduction of Fergusson’s short beake sound (No. 20 
f.) into the bladder was effected with great gentleness, but with ease 
and without meeting with any abnormal impediment in its passage. 
The bladder wag then thoroughly explored for calculus, but with a 
negative result. Confident at first from the history and condition of 
the case that it would prove to be one of stone in the bladder, I had 
so far only cursorily examined the meatus urinarius. Fergusson’s 
sound, No. 20 f., had passed through it easily—22 f. and 23 f. bulbous 
sounds even now passed with ease, but 24 f. was held at one-third of 
an inch. After slight pressure for a few seconds it slipped suddenly 
through a ring of fibrous tissue and passed without obstruction down 
to the bulbo-membranous junction. The patient was then put upon 
the free use of Triticum repens and suppositories of belladonna and 
hyoseyamus every six hours. 
A subsequent microscopic examination of the urine showed pus 
and blood in abundance, some urethral and vesical epithelium, none 
from the ureters and pelves of the kidneys, no casts—albumen slight. 
On suggesting to the patient that division of the strictured meatus 
was likely to be a necessity before much relief would occur, he de- 
sired that his friend, Dr. J. Marion Sims should be called in consul- 
tation. 
On Tuesday, the 14th, after an exhaustive consideration of the 
case, Dr. Sims coincided with me as to the possibility—nay, in the 
absence of calculous and prostatic disease, of the probability that the 
well defined stricture at the meatus was the original cause of the cys- 
titis, and might be justly held responsible for its continuance. The Otis on Reflex Irritation of Genito- Urinary Tract. 
13 
operation was at once decided upon, and the patient placed under the 
influence of ether by Dr. Henry Sims. I then thoroughly divided 
the contraction, first by the use of Civiale’s bistouri cache, completing 
the division of some remaining elastic fibres with a straight bluut 
bistoury, until the opening admitted bulbous sound 31. This was 
then carried easily down to the membranous urethra, without dis- 
covering any further obstruction. The bladder was again thoroughly 
explored for calculous by both Dr. Sims and myself. It was found 
much contracted and thickened, but contained no stone. On the 
15th, the day following the operation, I ascertained that since the 
division of the contraction, our patient had not had the necessity of 
passing his water more than once in two hours, and that the pains in 
the testicles, the hypogastrium, the perineum, and down the thighs, 
which had previously been the chief suffering, had entirely 
disappeared. There was manifestly less blood in the urine. By the 
16th the pus had diminished half in quantity, the blood had entirely 
disappeared, and the interval between the acts of urination had 
increased to two hours and a half. From this date the only treat- 
ment to which the patient was subjected was the daily introduction 
into, and not beyond, the fossa navicularis, of a 31 bulbous sound, up 
to the 26th, by which time purulent sediment in the urine had entire- 
ly disappeared ; riding nor walking no longer gave him discomfort, 
and he had resumed his business. The interval between acts of uri- 
nation now vary from two to three hours. There is an occasional 
occurrence of spasm during the act, which causes the sudden stoppage 
of the stream, and the urine is voided slowly, and with but little more 
force than before the operation; but he is not conscious of any other 
abnormality remaining. He expresses himself as feeling and being in 
better condition than for years. A few days subsequent to this inter- 
view with the patient, he went abroad to remain during winter, and I 
have not since heard from him. 
Case 19.—Mr. A., aged 68. History of a first gonorrhoea at 21. 
Married at 27. Had seven children, and no trouble with genito-uri- 
nary apparatus until four years ago, when he contracted another gon- 
orrhoea. This, after a month, subsided into a gleet, and to this, 
in about three months after, an acute cystitis was added. The cystitis 
resisted every treatment, and has continued in a greater or less degree 
of severity up to the present time. About a year since he began to 
suffer with neuralgic pains in the groins and perineum, and a very 
uneasy sensation in his testicles, one of which became considerably 
enlarged. November 26, 1874—Penis only 2 inches in length, flacid; 
3] inches in circumference. Meatus 18 f., left testicle half the usual 
size, right testicle normal, but with a greatly enlarged and soft 
epididymis, almost entirely covering in the glandular structure and 
forming a swelling about it as large as a Madeira nut, and described 
as the seat of long standing and troublesome irritation. Some muco- 
purulent secretion from urethra. Has been treated for some time by 
use of soft bougies, with pain and no relief. Complains of pain in the 14 
Otis on Reflex Irritation of Genito-Urinary Tract. 
back and groins, extending down along inner aspect of thighs. Urinr- 
tion every half hour day and night. Freshly voided urine loaded 
with pus and mucus, alkaline reaction, strong urinous odor, no 
renal epithelium or casts; albumen slight. Is uneasy and restless 
in manner, and full of anxiety, quite like a confirmed hypochondriac. 
Examination with 18 f. bulbous sound detects a stricture at meatus, 
extending back for half an inch, after which it slips down the urethra 
without giving evidence of any further obstruction. December 22d. 
Saw the patient in consultation with Dr. Willard Parker. Division 
of the stricture at meatus agreed upon. Ether administered by Dr. 
Charles Turnbull. The stricture at the meatus was first divided— 
dense cicatricial tissue, extending for fully half an inch. Bulbous 
sound 32 f. was then passed to 2f inches, when it was arrested by a 
second stricture. 27 f. defined its calibre. The dilating urethrotome 
was then introduced, turned to 30 f. and made to cut. 31 f. solid steel 
sound then passed without obstruction through into the bladder. 
Relief to the neuralgic pains followed the operation almost immediate- 
ly. Within 48 hours the intervals between acts of micturition 
increased from half hour to four or five hours j pus in urine greatly 
decreased; irritation in scrotum ceased; swelling of epididymis 
gradually went down, and the patient made a complete recovery with- 
out other treatment, within four weeks. 
In the foregoing cases, presenting features more or less grave in 
their conditions and consequences, a point of significant interest is 
common to all, viz., an abnormal contraction at or near the meatus 
urinarious—the well determined sequel, in the majority of instances, 
of' antecedent inflammatory action. Abnormal spasmodic muscular 
action plays a prominent part in every case—spasm of the urethral 
walls, of the accelerator urinal muscle, of the cremasters, of the vesi- 
cal neck and of the seminal ducts. Spasm, as in case 10, so firm and 
persistent that the urethral walls finally gave way behind it; spasm 
that for months resisted the introduction of the smallest instrument, 
as in case 3d ; spasm so persistent that the bladder was not allowed 
to completely empty itself for years, as in cases 17, 18, 19, and thus 
producing the chronic catarrh, which finally became so grave an ele- 
ment in these Cases, and, as in case 12, where the testicles played at 
see-saw for nearly three years, and until the poor wretch who owned 
them was driven to the verge of suicide. Some one or several of 
these conditions appear as a persistent feature in each. Spasm, a well 
recognized result of irritation, is equally significant of debility. Most 
of the cases, if not all, were subjects of sexual excess. Irritation 
supervening upon nervous debility, spasm naturally results—not of 
necessity a painful irritation, which invites attention, by reflex distur- 
bance, at once to the point of trouble. 
Dr. Hanfield Jones, in his work on functional nervous disorders, 
says : “ It seems to be well ascertained that an unfelt irritation may 
give rise to very various morbid phenomena, affecting both the motor 
and sensory nervous organs. Dr, Brown-Sequard maintains that Otis on Reflex Irritation of Genito- Urinary Tract. 
15 
various forms of insanity, of vertigo, cliorea, hysteria, tetanus, etc., 
may be due to irritations starting from a centripetal nerve, and fre- 
quently slightly felt or unfelt, and that the suppression of these irri- 
tations may cure the patient. He cites the case where a married 
lady suffered for a considerable time with a uterine neuralgia, which 
ceased completely on the extraction of a tooth that had not caused 
any considerable annoyance. In the excellent little brochure on 
stricture by SamT L. Wilmot, London, page 9, we read; “ it is easy to 
conceive, however, with what ease morbid irritation in the urethra 
may elude detection, and which, though slight, may be capable of 
exciting perfect reflex action, particularly in systems of high nervous 
mobility—and where the slightest irritation exists within the urethra, 
the mere influence of the mind, derangement of the digestive organs, 
and various other remote causes, will lead to spasm.” What then in 
these cases of evident reflex nervous trouble is suggested as the cause 
of the irritation ? Division of a contracted meatus, as has been shown, 
relieves the reflex disturbances, and yet simple contraction of the 
meatus cannot be sufficient to produce such morbid nervous action as 
cited, for it is well known that congenital contractions at this point 
are frequent, and yet no irritation ensues. In congenital contractions, 
however, the muscular surroundings of the urethral orifice are in a 
normally supple condition, and able efficiently to play their part in 
completing the emptying of the urethra after micturition. Let th's 
delicate muscular structure become infiltrated with plastic material, 
and the complete discharge of the last drops of urine, through its 
action, is rendered impossible. A dribbling after the act is the neces- 
sary consequence; and this is also an unvarying feature in all the 
foregoing cases. It is this inevitable retention of a few drops of urine 
which I believe to be the starting point of the irritation. As time 
goes on, and the plastic exudation becomes organized; cicatricial tissue 
forming and necessarily condensing, a permanent contraction results, 
which adds to the muscular inefficiency, especially when it occurs in 
an orifice congenitally insufficient. It is this condition which pro- 
longs gonorrhoea, and is the most fruitful source of chronic urethral 
discharge following a gonorrhoea. That the retained urine causes the 
irritation I am led to believe still further, inasmuch as behind stric- 
tures at the meatus, granular spots of inflammation occur, sometimes 
extending throughout the urethra, and, on relief of the stricture, 
promptly disappear, without other treatment, as in the third case 
cited. I have seen many such. Local points of tenderness were 
present in almost, if not quite all, the cases of reflex urethral irrita- 
tion that I have met. Then, as the urethal orifice becomes perma- 
nently contracted and unyielding, a distinct and sudden arrest of the 
stream of urine repeatedly occurs during the forcible act of urination. 
Is it too much to believe that the force of this blow at the point of 
arrest will add to the irritation, and that the effect of its recoil should 
be felt back even to the vesical neck ? It seems to me that this may, 
aftei* long years of such constant irritating influence, prove an impor- 16 
Otis on Reflex Irritation of Genito- Urinary Tract. 
tant element in disturbing the harmonious action of the complex sen- 
sory, motor, and sympathetic nervous distribution in the deeper parts 
of the urethra. Considering the force and persistence of the spasm 
in certain cases, the idea of its tetanic nature has suggested itself, 
induced by pressure and irritation of the nerves of the glans in the 
cicatricial contraction. The treatment of the contractions by complete 
division, resulting in prompt and notable relief in all the cases, is 
equally suggestive of simple mechanical obstruction, urinary retention 
or cicatricial irritation. To be effectual, however, the division must 
be absolute and entire. It is not sufficient that the meatus be 
enlarged up to the normal. urethral calibre. The incision must reach 
down through all cicatricial tissue, and be so complete that the largest 
sized bulbous sound that can be passed through the opening, shall 
pass in and return without the slightest sense of resistance. If it is 
less than this, the contraction is absolutely certain to return within a 
few weeks, even within a few days, and often in spite of every possible 
effort to keep the parts dilated. Once, however, the strictured tissue 
is completely divided, it is only requisite that the edges of the 
wound be kept asunder by the daily introduction of a sound, until 
granulation is established throughout its extent. After this, not only 
will no recoutraction take place, but the fibrous material will, in time, 
become wholly absorbed. This important statement, applying virtual- 
ly to all strictures of the urethra wherever located, I do not make 
without the ability to prove it by the results of this plan as present- 
ing in many cases thus treated—in over 30 of which examination has 
been had at periods varying from two years and three months to six 
months from the date of operation. 
During the last month, I presented before the members of the 
New York Medical Journal and Library Association, a case where 
originally six urethral strictures were present, including one at the 
meatus of a size of 24 f. These strictures were operated upon in 
January, 1871, more than two years previous. Examination with 
the bulbous sound, No. 30, in the hands of a committee, consisting of 
Prof. Alfred Post, Dr. Miner, and Dr. J. De Forrest Woodruff, failed 
to detect the slightest stricture, either at the meatus or at any other 
point. And in order to demonstrate the complete return of the urethra 
to its normal resiliency, by gentle pressure I introduced, in the 
presence of the Journal Association, bulbous sound No. 34 millimeter 
in circumference through the meatus, and down to the bulbo-membra- 
nous junction.