URETHROTOMY, 
EXTERNAL AND INTERNAL COMBINED, IN CASES OF 
MULTIPLE AND DIFFICULT STRICTURE; 
WITH REMARKS ON THE URETHRAL CALIBRE. 
BY 
FESSENDEN N. OTIS, M. D., 
CLINICAL PROFESSOR OF VENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND 
SURGEON'S. NEW YORK 
[REPRINTED FROM THE N. Y. MEDICAL JOURNAL, APRIL. 1874.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1874. TWELVE YEARS OF THE WORLD’S HISTORY! 
APPLETONS’ AMERICAN 
ANNUAL CYCLOPAEDIA 
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TW“ The Annual Cyclopaedia for 1873 will be published in May, 1874. URETHROTOMY, 
EXTERNAL AND INTERNAL COMBINED, IN CASES OF 
MULTIPLE AND DIFFICULT STRICTURE; 
WITH REMARKS ON THE URETHRAL CALIBRE. 
BY 
FESSENDEN N. OTIS, M. D., 
CLINICAL PROFESSOR OF VENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK. 
[.REPRINTED FROM THE N. 7. MEDIQAL JOURNAL, APRIL, 1874.] 
NEW YOKE: 
D. APPLETON AND COMPANY, 
6 49 & 661 BROADWAY. 
1874. URETHROTOMY, EXTERNAL AND INTERNAL 
COMBINED, IN CASES OF MULTIPLE AND 
DIFFICULT STRICTURE; WITH REMARKS ON 
THE URETHRAL CALIBRE. 
In the early part of the year 1872 two cases of urethral 
stricture presented in my service at the Strangers’ Hospital, 
which, from the fact that the first was the subject of impassa- 
ble stricture at the bulbo-membranous junction, and that the 
second was suffering from a long, close, perineal stricture, ad- 
mitting only the finest whalebone filiform bougie, and was 
further complicated by the presence of several perineal fistulse, 
were decided to be appropriate cases for the external or peri- 
neal incision. The method of operation employed differed 
in some respects from that usually performed. The practice 
approved by authorities in such cases is to cut down upon a 
sound or other instrument which has been introduced through 
or down to the point of stricture, and then from without to 
incise freely all stricture-tissue until an instrument, sound or 
catheter, of the supposed normal dimensions of the urethra, 
can *be readily passed through the urethra into the bladder. 
The modification of this procedure, in the cases above alluded 
to, consisted in making the external perineal incision in great 
measure subsidiary to the operation of internal urethrotomy. 
This plan was determined on for the first case with the idea 
of including in the same operation several strictures which 
were present in the straight portion of the urethra, as well as 
the impassable one for which the perineal incision was de- 
manded, and for the second, to avoid the necessity of laying 
open the scrotum in the division of the long stricture, which 
was found to pursue a tortuous course through a mass of in- 
durated tissue traversed by the perineal fistula. 4 
URETHROTOMY, EXTERNAL AND INTERNAL. 
Tlie preliminary steps in this modified operation were 
taken as if the ordinary perineal section had been contem- 
plated. An incision was then made down upon the anterior 
face of the stricture, aiming to enter the urethra by as small 
an opening as possible, and through this opening, as a new 
point of departure, the endeavor was made, in the first case, 
to introduce a fine, soft, filiform guide through the posterior 
stricture. Succeeding in this, the staff of Maisonneuve was 
entered at the meatus and passed down through and past the 
perineal incision and into the bladder; blades of the instru- 
ment, Nos. 2 and 3, were then slid down the staff in succes- 
tion, cutting on the superior wall of the canal and dividing 
all remaining strictures. A large silver catheter was then 
passed into the bladder. In the second case the same plan 
was pursued, with like result, as far as the stricture posterior 
to the incision was concerned, and a large bougie was passed 
from the incision into the bladder: but there still remained 
the long and close stricture anterior to the perineal opening. 
A filiform guide was then passed from the meatus urinarius 
through the stricture and out of the perineal incision ; the 
staff of the instrument of M. Maisonneuve was then screwed 
upon it and also passed through the urethra and out of the 
incision ; this was followed by the blades Nos. 2 and 3 in suc- 
cession ; after which a full-sized catheter was passed through 
the entire urethra into the bladder. 
The result of these operations proved highly satisfactory 
in both the cases alluded to, detailed accounts of which were 
published in the New ITorh Medical Recorded April 15,1873. 
Among the advantages which it seemed to me might be 
legitimately claimed for this modified perineal section, were 
—1. That it methodically included in the same operation all 
points of stricture in the presenting urethra, with only a 
limited division of the external urethral walls, and yet one 
sufficiently extensive for the free discharge of urine and of the 
fluids resulting from the operation. 2. That all divided strict- 
ures, anterior to the perineal opening, were protected from 
contact with the urinary secretion after operation; thus ob- 
taining the advantages of each operation, viz., external sec- 
tion and internal urethrotomy, and at the same time lessening 
the disadvantages if not the dangers of each as separately per- URETHROTOMY, EXTERNAL AND INTERNAL. 
5 
formed. With the view of illustrating still further the value 
of the procedure above described, and in order to call your 
attention to some important imperfections in the modes of 
procedure ordinarily pursued in the treatment of urethral strict- 
ure, I beg leave to present the following case: 
On the 31st day of July last, Mr. W. C. H., merchant, aged 
thirty-three years, presented at my office, with the history of 
a gonorrhoea thirteen years previous. This was severe in its 
accession, and, through the aid of strong injections, continued 
in a higlily-inflammatory stage for fully one month. It was 
supplemented by a free, almost painless muco-purulent dis- 
charge, which, in spite of a variety of treatment, internal and 
by injections, continued, in a greater or less degree, through 
all the succeeding twelve years and up to the present time. 
He had his first trouble in urination seven years ago, after ex- 
cess in wine and sexual indulgence. This resulted in an at- 
tack of retention of urine, which was relieved, only after 
several hours’ effort on the part of the surgeon, by the intro- 
duction of a flexible filiform catheter. From that time he had 
frequently been obliged to resort to the introduction of the 
catheter, but had never since suffered from retention. For the 
last two or three years he had been troubled with occasional 
attacks of intermittent (urethral ?) fever, but was not aware 
that he had ever been exposed to any malarial influences. 
Ile passed his water guttatim, but says that, occasionally, 
he passes it in a fine, short jet, and that his condition in this 
respect has not varied materially for the last five years. 
Examination showed the external genito-urinary apparatus 
fully developed; penis in flaccid condition, three inches in 
length, and three inches in circumference ; from this I estima- 
ted the normal calibre of the urethra to be No. 30 f. Bulbous 
sounds detected stricture at the meatus, extending one-third 
of an inch, measured by No. 22 f.; one at one inch, No. 19 f.; 
one at two inches, No. 15 f.; one at three inches, No. 10 f.; 
six distinct bands from three inches to four and a half, de- 
fined by No. 8 f.; beyond four and a half inches, No. 1 fili- 
form passes to six and a quarter inches; m. whalebone, 
closely hugged, is finally arrested at seven and a quarter inches. 
Examination of the urine shows freedom from albumen, an 
occasional pus-globule, a few epithelial scales from the ure- 6 
URETHROTOMY, EXTERNAL AND INTERNAL. 
thra and bladder ; none from the ureters or pelvis of kidney. 
Ho casts. The foregoing measurement of stricture and condi- 
tion of urine were rehearsed from time to time without the 
appreciation of any marked changes, and with no further prog- 
ress toward entering the bladder up to Hovember 4, 1873. 
On this date an operation was decided upon. Present Dr. 
George A. Peters, Dr. George W. Ives, the patient’s family 
attendant, and Dr. J. De Forrest Woodruff. 
Diagram showing locality of the fourteen strictures in the case of W. C. H. 
As the initial step in the anticipated operative proced- 
ure, ten grains of quinine and one-quarter grain of mor- 
phine were administered. The patient was then placed under 
the influence of ether, and the calibre and location of each of 
the strictures were verified (as compared with the measure- 
ments already given) by the use of bulbous sounds and bulbous 
filiform bougies. It was then decided that the modified peri- 
neal section was indicated as affording promise of most rap- 
idly and certainly restoring the urethra to its normal calibre. 
Ho. whalebone filiform bougie was passed down to six 
and a quarter inches, beyond which it ‘could not be persuaded. 
With this as a guide (which was skillfully managed by Dr. 
Peters), I made an incision from a point just behind the scro- 
tum to within an inch of the anus, cutting carefully down in 
line with the centre of the sub-pubic arch, until I came squarely URETHROTOMY, EXTERNAL AND INTERNAL. 
upon the whalebone guide. At this point in the operation 
the knife was laid aside, and with No. 1 silver-grooved probe, 
entering the urethra through the incision from before back- 
ward, I passed it readily into the bladder. I then introduced 
the staff of the urethrotome of M. Maisonneuve alongside 
the probe into the bladder. A slight pressure accomplished 
this, when the probe was withdrawn, and the largest blade of 
M. Maisonneuve (capacity 22 f.) was passed, distinctly ar- 
rested at three points on its course, and, on withdrawal, a 20 f. 
catheter was introduced. dSTo urine flowed, although the end 
of the instrument was felt to be free in the bladder. This 
was withdrawn and found to be obstructed by a clot, but con- 
tained urine. No. 24 was substituted, with precisely the 
same result. It was then concluded that the curved catheter 
passed up above the line of urine present. No. 24 straight 
catheter was then substituted, and the clear urine flowed 
freely through it. The straight catheter having been closely 
embraced on entering, indicated some persistence of stricture. 
I then introduced a straight, probe-pointed bistoury along it, 
and incised dense cicatricial tissue for fully an inch; with- 
drew the catheter and passed No. 31 f. steel sound through 
the external incision back into the bladder. 
The next step in the operation, after thoroughly incising 
the stricture at the meatus, was the passage of the m. fili- 
form whalebone guide through the urethra, from the meatus 
down to and out of the perineal opening, then sliding down 
upon it the stafi of a Maisonneuve (which was perforated at 
the extremity for this purpose),1 it finally emerged from the 
perineal incision. The smaller blade of the urethrotome was 
then driven slowly down the staff, arrested abruptly at each 
stricture, and requiring all the force which could be used 
without bending the shaft of the knife, before its passage 
through the spongy portion of the urethra could be effected. 
This was followed by a blade of the second size, with much 
the same results. A passage of the third and largest blade 
was then attempted, but this, after passing with great diffi- 
culty, arrested at each of the strictures, up to three inches, was 
here arrested; and after a thorough trial, in which I was 
1 The filiform traversing the entire length of the staff. 8 
URETHROTOMY, EXTERNAL AND INTERNAL. 
efficiently supported by Drs. Peters and Woodruff, it was 
found impossible, on account of the density of the opposing 
strictures, to divide them with this instrument. The staff of 
Yoillemier’s divulsor was then introduced through the strict- 
ures and out of the perineal opening, and rapid divulsion 
made with the largest shaft (No. 30 f.). On examining the 
results of this last procedure, it was found that 28 f. bulbous 
sound was arrested at two inches. No. 26 passed, and defined 
the posterior face of the stricture at two and 
a half inches; the same instrument was ar- 
rested again at four inches, finding slight 
resistance for half an inch, then passed free- 
ly down to the perineal incision. The (my) 
small dilating urethrotome was then intro- 
duced through the posterior stricture, turned 
up to 30 f., and the narrow blade of the in- 
strument drawn through it. This urethro- 
tome was then adjusted to the anterior strict- 
ure, which was in like manner incised from 
four inches to four and a half (viz., about 
one-half inch). No. 31 steel sound was then 
easily passed down through the entire ure- 
thra into the bladder; thus evidencing—as 
much as the introduction of an ordinary 
steel sound can do—complete division of all 
the strictures. 
The patient rallied quickly from the ef- 
fects of the ether, having been under its in- 
fluence just one hour and three-quarters. 
The haemorrhage occurring during the op- 
eration was slight, only two superficial ves- 
sels requiring ligature. At the end of a half- 
hour there was not the least oozing from 
either the wound in the perinaeum or from 
the meatus; there was no complaint of pain 
subsequent to the anaesthesia ; and, as I was 
leaving him, he emphatically expressed him- 
self as feeling “ bully” 
From the date of the operation, November 4th, until the 
10th, the patient, who was seen daily by either Dr. Ives or 
Dilating Urethrotome. URETHROTOMY, EXTERNAL AND INTERNAL. 
9 
myself, had not the least untoward symptom. He had an 
average pulse of 76, and temperature not above 98f°. His 
urine, over which he had complete control, was passed en- 
tirely through the perineal opening for the first three days, 
after which a small portion found its wray through the an- 
terior section of the canal. A conical steel sound, Ho. 24 f., 
was now (six days after the operation) passed through the ex- 
tent of the urethra, and followed easily by Hos. 25 and 26 f. 
A slight gush of blood followed Ho. 26 f., but stopped in a 
few moments. On the 12th passed Hos. 28 and 30 f.; patient, 
as on the previous occasion, doing well; says he has not had 
an ache or a pain since the performance of the operation. 
Haemorrhage occurred on the next day, following the act of 
micturition; this was evidently from about the middle of the 
spongy portion. Hr. Ives was called; eight or ten ounces of 
blood were lost before it was completely arrested. 
14zlh.—Tenth day after operation. Wound in perinseum 
closing healthily ; passes water about equally through it and 
through the urethra anterior to it; feels well, eats well; walks 
about his room, or sits in his arm-chair, with equal comfort. Ho 
further instrumental procedure was had until two weeks sub- 
sequently (viz., December 28th), when he called at my office, 
saying that he felt quite well in every respect, that his stream 
was full size, and that only a few drops came through the 
perineal opening; he had gained several pounds in weight, 
and was looking in good condition. Examination of the 
urethra detects a recontraction of the stricture at one and a 
half to two inches from the meatus, 17 f.; rest of canal ap- 
parently clear. Ordered ten grains of quinine. 
December 4th.—Pass 17 f. easily, then 19 f., which was 
closely hugged. 
6th.—Find the stricture at from one and a half to two 
inches composed of two firm bands close together; introduce 
small dilating urethrotome; expanded it to Ho. 28 f. with 
difficulty, on account of the great density of the strictures; 
draw the blade of the urethrotome through them from be- 
hind forward, and pass 26 f. conical sound readily down into 
the bladder. Ho. 26 f. bulb passes down to the membranous 
urethra and returns, without giving any positive evidence of 
further recontraction at any point. Patient took ten grains 10 
URETHROTOMY, EXTERNAL AND INTERNAL. 
quinine and then started for home, three miles distant, in the 
cars, with directions to keep quiet for the remainder of the 
day. 
Two days subsequently (viz., December 8th) patient reports 
that there had been no haemorrhage, no disturbance nor dis- 
comfort whatever following the operation, except slight smart- 
ing on urination ; pass 25 and 26 f. conical sound with ease. 
9th.—Patient calls to say that he had a smart chill, fol- 
lowed by fever and sweats, coming on about five hours after 
the introduction of the sound yesterday. Ordered five grains 
quinine to be taken three times a day. 
12th.—Patient reports himself in good condition, having 
had no further trouble ; a few drops of urine still exude from 
the perineal opening during micturition, but he passed per 
urethram a full and comfortable stream; 28 f. passes readily 
through the entire urethra. 
Ibth.—Perineal incision completely closed ; discharge quite 
gone; patient makes a full and satisfactory stream ; repeat 
passage of 28 f. 
22d.—Pass 28 f.; 29 f. attempted, but finds resistance from 
three inches increasing to four and a half; smart bleeding fol- 
lowed the withdrawal of 29 f. Ordered ten grains of quinine. 
29th.—Patient reports that, on the morning following the 
passage of 28 f. and the partial passage of 29 f. at his last 
visit, he had a succession of severe chills, and bleeding with 
stoppage of water about half the length of the penis, after 
each urination ; finally a clot w'as expelled, and he had no 
further trouble. To-day a very sensible contraction is found 
at three inches, which permits only the passage of 23 f. 
January 8th.—Examination with bulbous sound No. 24 
finds a recontraction at one and a half inch ; one at two and 
an one-eighth, which arrests it; 17 f. only will pass, and is 
held on return at three inches. After which 23 f. conical 
sound is passed through the urethra without force, and fol- 
lowed with ease by 24 f. 
13th, 14th.—Defined recontraction at two and a half to 
two and three-quarter inches ; pass 24 f. and 25 f. with ease; 
from this date up to the present no examination has been 
made, and the patient, who appreciates the fact that there are 
features of rare interest and value to our profession in his case, UKETHROTOMY, EXTERNAL AND INTERNAL. 
11 
lias kindly consented to submit himself to an examination of 
his present condition in your presence.1 
It will be worth our while to pass in review some of the 
most salient points in this case, several of which seem to me 
to possess a rare interest and value. 
First in order seems to be the occurrence of an extraordi- 
nary number of distinct strictures in the same urethra. One 
at the meatus, defined by bulbous sound Ho. 22 f.; one at one 
inch from the meatus, defined by bulbous sound Ho. 19 f.; one 
at two inches from the meatus, defined by bulbous sound Ho. 
15 f.; one at three inches from the meatus, defined by bulbous 
sound Ho. 10 f.; six distinctly-recognized bands from three to 
four and one-lialf inches, Ho. 8 f. ; one apparently extending 
from four and one-half to six and one-quarter inches, permit- 
ting the passage of only Ho. 1 f. to six and one-quarter inches, 
and from this to seven and one-half inches, hugging one third 
closely; three bands distinctly arresting the blade of the urethro- 
tome when passing from the perineal urethral opening back- 
ward through the membranous portion of the canal: this 
makes in the aggregate fourteen strictures, distinctly defined 
and recognized by each of the gentlemen present and assisting 
in the original operation. 
In order to appreciate the rarity of this point in regard 
1 In order to facilitate the examination and to relieve the patient from 
the annoyance of repeated explorations, a committee, consisting of Prof. 
Alfred 0. Post, Dr. James M. Minor, and Dr. L. De Forrest Woodruff, was 
appointed by the President of the Association to examine the case’of Mr. 
, presented by Dr. Otis. Mo. 17 f. bulbous sound was first carefully 
introduced by Prof. Post in passing it down the urethra; this was dis- 
tinctly arrested at the points of stricture, at two and one-half and two and 
three-quarters, before mentioned, and also as distinctly defined on with- 
drawal of the instrument. The result was likewise confirmed by the re- 
maining members of the committee. Di*. Otis then introduced, in full view 
of the Society and without force, No. 24 f. conical steel sound through the 
strictures and into the bladder, the patient asserting that not the least pain 
was occasioned by this procedure. The removal of No. 24 f. was imme- 
diately followed by No. 25 f. with the same ease and freedom from dis- 
comfort. The attention of the Society was then called by Dr. Otis to the 
interesting and important fact here demonstrated, that, while the bulbous 
sound No. 17 f. defined the strictures distinctly, No. 25 f. steel sound failed 
to give any evidence of their presence. 12 
URETHROTOMY, EXTERNAL AND INTERNAL. 
to multiple strictures, I will quote from a late edition of Sir 
Henry Thompson’s work,1 concerning the number of strictures 
found in a single urethra: “ Occasionally,” he remarks, “ sev- 
eral separate strictures may be observed in the same subject. 
John Hunter records an instance wffiere he met with six strict- 
ures in one urethra : Lallemand mentions one with seven. 
Colot saw one with eight. Ducamp says there are rarely more 
than two, but that he has seen four or five. Boyer thought 
that three could exist together. A case is reported by Leroy 
D’Etiolles in which he found eleven ; “ but,” Sir Henry further 
remarks,“ it is necessary to state that this number rests only on 
the evidence afforded by the passage of an exploratory bulbous 
bougie (that is, a small gum-elastic sound with an olive-shaped 
extremity two or three sizes larger than the stem) on the per- 
son of a living patient. . . . The strictures,” Sir Henry says, 
“ to use the author’s words, ‘ were for the most part in the 
spongy portion, about two and one-quarter lines distant from 
each other]—“ a condition,” says Sir Henry, u which would 
perhaps be better described as a series of irregidar contrac- 
tions than by any statement of the exact number of the strict- 
ures. Rokitansky speaks of four, and does not record a higher 
number as having come under his own personal observation.” 
. . . “ My own researches,” he further states, “ have not led 
me to recognize numerous independent strictures in one ure- 
thra. Three or at most four distinct contractions I have seen, 
but such instances are very rare.” 
With the exception of M. Leroy D’Etiolles, Sir Henry 
Thompson does not inform us as to the methods of exploration 
in use by the various authorities he quotes—which, it seems to 
me, must greatly atfect the value of their observations; and, in 
regard to the method of M. Leroy D’Etiolles, he casts an impu- 
tation of inaccuracy upon it by Stating that the evidence of 
the existence of eleven strictures in a single urethra, which he 
claims to have demonstrated, rests only upon the evidence 
afforded by the bulbous sound; and, as if this were not suffi- 
cient to discredit the possibility of eleven strictures coinci- 
dently existing in the same urethra, he says, even if they 
were defined l>y the bulbous sound, that they were not strict- 
1 “ Strictures of the Urethra,” London, 1869, p. 68. TTRETIIEOTOMY, EXTERNAL AND INTERNAL. 
13 
ures at all, in his opinion, but simply “ a series of irregular 
contractions” of the urethral calibre. John Hunter’s state- 
ment that he met with six is accepted—even Colot’s, who 
claimed to have seen eight / but M. Leroy D’Etiolles, who 
claims eleven, is not accepted as having recognized strictures, 
but has been deceived by irregular urethral contractions. 
Why, it may be pertinently asked, with his acknowl- 
edged skill and great experience, has Sir Henry Thompson 
only been able to find four strictures in a single urethra, and 
is evidently slow to accept the occurrence of a greater num- 
ber in the practice of other surgeons ? A satisfactory expla- 
nation may be found on page 147 of Sir Henry’s work on 
Strictures of the Urethra, where he gives directions for the 
exploration of the urethra with the view of ascertaining the 
presence or the absence of stricture. “ In order to effect this 
object,” he says, “ a flexible bougie of medium size, that is, 
from Ho. 7 to 9 of the English scale (16 to 18 French), is to 
be used, while as to form, it should be rather slightly curved, 
and blunt, not conical at the point” . . . “ Whatever the pa- 
tient may say,” he further remarks, “ this rule is always to be 
adhered to. If a small instrument is employed, it might pass 
through the stricture without giving any sign of its existence, 
and so fail to detect it; but, if a No. 8 bougie (16 French) 
passes easily into the bladder, we may be satisfied that no 
stricture or at most a very slight contraction only exists” 
“ This bougie,” he goes on to remark, “ may be graduated 
in inches, for the purpose of noting at what distance from the 
external meatus obstruction is found.” Accepting this to 
be the best method of ascertaining the locality and calibre of 
the urethral strictures (which I am very far from doing), I 
am only surprised that even Sir Henry was able to demon- 
strate the existence of four distinct strictures in a single ure- 
thra ; and, if the same method was pursued by Hunter, Colot, 
Ducamp, and others, I am sure the number they claim was 
found in post-mortem examination; fori do not hesitate to 
say that, with a straight or curved bougie, with simply a 
blunt end, such as advised by Sir Henry, no living surgeon 
could demonstrate the existence of more than three or four 
strictures in any one urethra ; and I will say, furthermore, 14 
URETHROTOMY, EXTERNAL AXD INTERNAL. 
that such a method is unreliable and imperfect for the diag- 
nosis of even a single stricture. Sir Benjamin Bell, who in- 
vented the ball-probe, was aware of this fact, and M. Leroj 
D’Etiolles, who modified this invaluable instrument—resulting 
in the flexible, olive-pointed bulbous bougie—was, through its 
use, enabled on the living subject to demonstrate the presence 
of eleven distinct strictures in the same urethra. Sir Henry 
Thompson distinctly states that, if a No. 8 E. bougie (21 
French) passes easily into the bladder, we may be satisfied that 
no stricture, or at most a very slight contraction, exists. This 
teaching it seems to me of the utmost importance to combat 
as erroneous, and leading to disastrous errors in the diagnosis 
and treatment of urethral stricture. I am the more strongly 
impelled to take this position from the perusal of a recent 
brochure on strictures of the urethra by Dr. T. B. Curtis, and 
to whom, for this paper, the Civiale prize of two thousand 
francs was awarded during the past year. Dr. Curtis, the 
honored pupil of M. Guy on, of Hospital Keeker, and of M. 
Voillemier, may be safely accepted as mirroring truthfully the 
views of the French school of urethral surgery at the present 
time. In this paper he remarks, in regard to the treatment 
of strictures by dilatation, page 46 : “ The treatment shall be 
considered terminated when you shall have made to enter 
without effort No. 21. You will thus have restored to the 
canal the calibre of 7 millimetres (diameter), which represents 
the normal calibre of the canal of the urethra, which is more 
than sufficient for the purposes of micturition; ” and with 
infinite naivete he goes on to say: “ But the mission of the 
conscientious surgeon is not yet terminated. Although he may 
have the right to send his patient away as cured, he ought 
not only to have restored the strictured urethra to a calibre 
which can suffice for the passage of urine ; it is still his duty 
to put his patient in a position to give himself the consecutive 
treatment, without which all strictures, by whatever manner 
treated, will relapse almost infallibly.’51 We have here laid 
down, on the authority of both the English and the French 
schools, the exact capacity of the human male urethra. Sir 
Henry Thompson, representing the English urethral interest, 
1 The Italics are my own.—F. N. 0. URETHROTOMY, EXTERNAL AND INTERNAL. 
15 
states it to be No. 8 English, which is equivalent to No. 17 of 
the French scale. No stricture can be permitted in any 
urethra where the No. 8 English bougie finds easy passage. 
Dr. Curtis, as the laureate interne of the Hospital Necker, 
and the successful competitor for the two thousand francs prize 
of Civiale, in 1873, may well be accepted as representing the 
present status of urethral science in France; and he states, 
under the aegis of his distinguished masters, that the normal 
calibre of the human male urethra is equal to 7 millimetres 
in diameter; that, when a presenting urethra, the previous 
subject of strictures, more or less numerous or pronounced, 
shall have been brought by various kinds of dilatation, or di- 
vulsion, or incision, or what not, up to a calibre of 7 milli- 
metres in diameter, “ the conscientious surgeon ” has a right 
to dismiss him as cured. How is it, then, with the poor unfor- 
tunates, who cannot conform their urethrae to the procrustean 
bed of the French and English schools, who find themselves 
in possession of urethrae, the calibre of which extends to the 
size of 8, 10, or 12 millimetres in diameter instead of 7; or 20, 
22, and 24, of the English scale, instead of 8 or 9 ? Evidently 
the difference between the established normal standard and 
the figures just named (if they were within the range of possi- 
bility) might be occupied by stricture-tissue, which, although 
it might not be recognized by the No. 8 blunt-ended bougie, 
might nevertheless exist, and would inevitably be detected by 
a bulbous sound of a calibre corresponding with the size of 
this apparently extraordinary canal—extraordinary, if we are 
■willing to admit the size of the meatus to be a sure indica- 
tion of urethral calibre, without noting variations caused by 
congenital and pathological narrowings. A careful exam- 
ination of several hundred urethrae, within the past twelve 
years, by means of the metallic bidbous sound (which I pre- 
sented to the profession in 1861), has demonstrated to me that, 
while I have seen occasional extremes, varying from 20 to 40, 
the average calibre of the male urethra is not less than 30 of 
the French scale, or 18 of the English scale; and that the 
great majority of strictures which are sources of grave an- 
noyance, and call imperatively for treatment, are above what 
is set down by the French and English schools as worthy of 16 
URETHROTOMY, EXTERNAL AND INTERNAL. 
consideration. Within the past two years I have, in more 
than one hundred cases, recognized distinct bands of strict- 
ure in urethrae, where the English bougie of No. 8 and even 
the French of No. 21 could be readily passed down through 
them into the bladder without giving the least evidence of con- 
traction at any point; and I have frequently demonstrated 
this fact not only in my clinique at the College of Physicians 
and Surgeons, but to a large number of my professional friends 
in my private practice. 
On the 30th of December last I invited Dr. Bumstead, the 
distinguished author of “Bumstead on Yenereal Diseases,” to 
see a patient, fifty years of age, at my ofiice, with a view of 
examining the calibre of his urethra. The flaccid organ was 
three inches in length from the meatus to the pubis, and three 
and a half inches in circumference midway of the organ. In 
Dr. Bumstead’s presence I introduced into and through a nor- 
mal meatus a metallic bulbous sound 32 millimetres in cir- 
cumference, and then passed it down without the least force 
to the bulbo-membranous junction. Dr. Bumstead withdrew 
it, and pronounced the normal calibre of the urethra equal to 
32 millimetres in circumference. I then introduced, in the 
same manner, bulbous sound No. 34 ; this also was introduced 
and withdrawn by Dr. Bumstead, with a similar result. The 
normal calibre of this particular organ was thus shown to be 
34 millimetres. 
On Saturday evening, January 10,1874,1 invited .Dr. Gur- 
don Buck and Prof. Tliomas M. Markoe to examine with me 
the urethra of a patient, twenty-four years of age, who had 
never been the subject of gradual dilatation, but who had been 
operated on by me with the (my) dilating urethrotome for three 
strictures in the straight portion of the canal. The meatus, 
which was originally contracted to 24 f., had been incised two 
months previously. The length of the flaccid organ was four 
inches; the circumference, midway of its length, was four 
inches. In the presence of these distinguished surgeons I in- 
troduced No. 36 f. bulbous sound down to the bulbo-membra- 
nous junction. This procedure was repeated by Drs. Markoe 
and Buck in turn, and the urethra was recognized by them as 
possessing the normal calibre of 36 millimetres in circumfer- URETHROTOMY, EXTERNAL AXD IXTERXAL. 
17 
ence. Previously to this trial I had announced the presence 
of an abnormal contraction at one and a half inch from the 
meatus, which was detected by the Ho. 36 bulb on the morn- 
ing of the same day. Heitlier Dr. Buck, Dr. Markoe, nor 
myself, was able to distinguish this alleged contraction. Tak- 
ing the ground that the introduction of the sound in the 
morning had made the contraction less salient, I took the 
bulbous sound next in size, which (through a mistake on the 
part of Tiemann & Co.) had been made of a circumference of 
40 f. instead of 37 f. I pressed it gently against the orifice for 
a minute, when it entered and passed readily down to one and 
a half inch, when it was arrested firmly by the contraction 
before alluded to. Dr. F. D. Sturges and Dr. J. Deforest 
Woodruff had verified with me the passage of Ho. 34 f. bul- 
bous sound in the same case a few days previous. 
Do you ask, of what value is the recognition of urethrae 
of such enormous calibre as those just cited? Simply, I an- 
swer, to demonstrate the absurdity of fixing, upon the dictum 
of any man or school, a standard calibre for the human male 
urethra / to show the necessity of making every urethra a law 
unto itself, and to enable the surgeon to judge of the greater 
or less degree of contraction, in any given urethra, by the nor- 
mal ccdibre of that individual urethra, as ascertained by in- 
terior measurement. In the case presented to you to-night, 
is it for a moment supposed that his fourteen strictures, ranging 
from Ho. 22 f. to one-half of a millimetre in circumference, 
and extending from his meatus to the prostatic portion of the 
urethra, came without indication or warning, until the passage 
of urine was interfered with ? 
From liis original gonorrhoea, contracted more than twelve 
years ago, np to the time of his first trouble of micturition, five 
years ago, he was scarcely free from a chronic urethral dis- 
charge, and any surgeon, previous to that time, and subsequent 
to the inflammatory condition which initiated the trouble, with 
proper instrumental means, and sufficient intelligence, could 
have demonstrated the presence of stricture, and by a suitable 
treatment could have arrested the contractile urethral disease 
in its inception. His gleet was treated by internal remedies 
and injections: as w’ell have attempted to remove a ligature URETHROTOMY, EXTERNAL AND INTERNAL. 
tied around his penis, by internal remedies and injections, as 
to essay the cure of an internal cord, the result of inflamma- 
tory deposit in the urethral walls. Chronic urethral discharge, 
commonly called gleet, is the signal which Nature hangs out to 
notify the intelligent surgeon that an obstruction to the nor- 
mal working of the muscular apparatus of the urethra has oc- 
curred ; that plastic material, laid down in the antecedent 
inflammatory condition, has begun to contract the normal 
urethral calibre, whether it be 20 or 40 millimetres in circum- 
ference, and that nothing short of a complete restoration of 
the normal calibre of the canal will afford a permanent cure. 
Sandal-oil may stop it for a time; injections of innumerable 
variety may, any one of them, temporarily remove it; but a 
little vinous or venereal excess will reproduce it, and thus the 
case goes on ; getting, as many such cases will affirm, a new 
clap for every woman they look at, until finally an attack 
of retention of urine calls attention to the fact that the pa- 
tient has strictured urethra. 
One of the chief stumbling-blocks in the way of the sur- 
geon in recognizing urethral stricture is the contracted mea- 
tus. Authorities concur; as a rule, in asserting that the mea- 
tus is the narrowest portion of the urethral canal, and yet 
this is usually accepted as a test of its calibre. This opening 
is subject to great natural variations, in organs of about the 
same general proportions. The well-developed penis, in a 
dozen cases, may vary in regard to the size of the congenital 
meatus, from the calibre of Ho. 8 or 9 millimetres in circum- 
ference, to 32 f. or 3d f. It is important to recognize the fact 
that the meatus bears, necessarily, no proportion to the actual 
size of the urethra. If symptoms of stricture are present, such 
as persistent urethral discharge, etc., or if any chronic irrita- 
tion of the genito-urinary apparatus present, the meatus should 
be freely incised, and a thorough examination of the canal with 
the bulbous sounds should be made. 
The normal meatus urinarius is well represented by Ilenle,1 
who has been more minute and definite in his anatomical re- 
searches in regard to it than any anatomical authority with 
which I am familiar. Thus, as the accompanying plate rep- 
1 “Ilandbuch der systematiscken Anatomie des Mensclien,” von Dr. J. 
Henle, p. 417. TIEETIIEOTOMY, EXTERNAL AND INTERNAL. 
19 
resents, there is no abrupt enlargement alter passing the ex- 
ternal border, such as is seen in the usual representations ot 
the urethra, and in his descrip- 
tion he is entirely at variance 
with those who claim that a 
sort of sphincter is found at 
the meatus. There are no cir- 
cular muscular fibres entering 
into its composition—simply 
horizontal muscular fasciculi, 
or plates, as he terms them, 
which surround the opening, and are continuous with the 
muscular structure of the urethra. Vertical sections of the 
penis from the junction of the glans with the body of the 
penis show a nearly uniform calibre throughout the fossa 
navicularis, to its external boundary at the meatus, the open- 
ing of which is of corresponding calibre. This may be ac- 
cepted as the normal condition of these parts, and any varia- 
tions from such uniformity may be considered aberrations 
from the normal condition. These are, as a rule, of no prac- 
tical importance, unless the tissue composing them has been 
invaded by infiammatory action ; in which case the muscular 
layer being disabled, to greater or less extent, by the infiltra- 
tion of plastic material, its office of aiding in the complete 
emptying the urethra of urine being interfered with, its re- 
tention and subsequent decomposition may prove an added 
source of irritation. 
In order to gain a definite knowledge of the calibre of the 
urethral canal, in cases with or without contraction of the 
meatus, I have devised an instrument which I term the 
urethra-metre, or dilating bulbous sound, which I now present. 
It consists of a small, straight canula, size Ho. 8 f., ter- 
minating in a series of short metallic arms, hinged upon the 
canula, and upon each other. At the distal extremity where 
they unite, a fine rod, running through the canula, is inserted. 
This rod (which is worked by a stationary screw at the handle 
of the instrument), when retracted, expands the arms into a 
bulb-like shape, 10 millimetres in circumference when closed, 
and capable of expansion up to 40 millimetres. A thin rubber 
stall (Fig. C\ drawn over the end of the closed instrument, 
Vertical Section of the Anterior Portion 
of the Penis. 20 
UEETIIEOTOMY, EXTEENAL AND INTEENAL, 
protects tlie urethra from injury, and prevents the 
access of the urethral secretions to the interior of 
the instrument. When introduced into the ure- 
thra and expanded up to a point which is recog- 
nized by the patient as filling it completely—and 
yet is easily moved hack and forth—the index at 
the handle will then show the normal circumfei- 
ence of the urethra under examination. In with- 
drawing the instrument, contractions at any point 
may he exactly measured and any want of corre- 
spondence between the calibre of the canal and 
the external orifice he readily appreciated. Among 
the advantages to he claimed for this instrument 
are : 1. Its capacity to measure the size of the ure- 
thra and to ascertain the locality and size of any 
strictures present, without reference to the size of 
the meatus. 2. It enables the surgeon to complete 
the examination of several presenting strictures by 
a single introduction of the instrument, and by 
reduction of its size avoid the irritation which usu- 
ally attends the withdrawal of the ordinary bougie 
or bulbous sound. 
Returning to the case of aggravated multiple 
stricture above related, it will have been observed 
that, notwithstanding the easy passage of a Ho. 31 
solid steel sound, through the entire urethra, after 
the operation, there was an immediate tendency 
to recontraction; that within a comparatively 
short period, the presence of stricture was again 
definitely recognized. I do not call your attention 
to this important fact on account of its novelty, 
for every surgeon of experience has too frequently observed 
it; and every writer on stricture has recorded it in terms the 
most emphatic; some even going so far as to state, as does 
Mr. Wade1 (quotiug the illustrious Dupuytren), that, “what- 
ever care may be taken in the dilatation of strictures, the dila- 
tation is but temporary in the greatest number of persons, and 
the contraction has ahoays a tendency to return.” Sir Benja- 
min Brodie says {op. cit.): “ After a patient lias conceived 
urethra-metre. 
1 Wade on “Stricture of tlie Urethra,” London, 1860, p. 352. URETHROTOMY, EXTERNAL AND INTERNAL. 
21 
himself to be cured and every symptom of the disease vanished, 
it is not an uncommon thing for him to suffer a relapse, and 
in all probability a relapse of far greater danger than the pre- 
vious attack. . . . From what,” he asks, “ does this arise ? 
From his not continuing,” says Sir Benjamin, “ at regular 
intervals, to pass an instrument (sound) notwithstanding the 
disease should seem to have disappeared. To pass it once 
in two or three -weeks is enough, but it must never be thrown 
aside as useless, during the lifetime of the patient, if he de- 
sires to be freed from his troublesome affection.” 
Dr. T. B. Curtis, in his prize Essay previously quoted as 
representing the views of the leading French surgeons, says, 
page 46, “ All strictures, by whatever manner treated, and in 
appearance cured, will relapse almost infallibly.” 
It is, however, an accepted fact that a certain hut very 
limited proportion of strictures are permanently cured by each 
of the various methods—dilatation, division, divulsion. We 
may again ask, with Sir Benjamin Brodie, from what does 
this arise ? The answer is, simply, that, to prevent the return 
of stricture after operation, the stricture must first have been 
thoroughly sundered at some point — that those strictures 
which have been permanently cured (and in this number I do 
not include those facetiously termed cured, where the patient 
is obliged to use or have used a sound every two weeks for 
the balance of his life, but those that never reappear after 
operation) have been so sundered, either by rupture through 
dilatation more or less rapid, by divulsion, or division. The 
reason why the treatment of stricture after the usual meth- 
ods is imperfect—that there is always a tendency of the 
stricture to return—arises from the fact that, as in the case 
cited, the strictures were not completely sundered at any point 
—that they were distended, not completely divided. All ure- 
thral strictures are composed of elastic tissue, and any opera- 
tive procedure that falls short of complete division of the con- 
stricting band can never produce more than temporary results. 
As long as Ho. 8 of the English and Ho. 21 of the French 
scales are accepted as representing the normal calibre of the 
human male urethra, and as long as curative treatment ceases 
when this calibre has been reached, there will never be, radical, 
permanent cure of urethral stricture. Sooner or later, how- URETHROTOMY, EXTERNAL AND INTERNAL. 
ever, it is certain to be accepted that urethrae vary in size in 
different individuals just as widely as any other constituent 
portions of the human body, and that, consequently, stricture 
of the urethra is a relative term ; that, while Yo. 8 bougie 
English or Yo. 21 French wTill determine the presence or ab- 
sence of stricture in a urethra of corresponding calibre, it 
fails to recognize stricture in urethrae of larger size and which 
has been positively demonstrated in certain cases to reach as 
hi oil as 36 or even 40 millimetres in circumference; and 
that, complete division of stricture, of whatever calibre, hav- 
ing been accomplished, recontraction may be prevented, and 
that, thus, strictured urethrae can, by appropriate treatment, 
be with certainty restored to their normal dimensions, without 
fear of subsequent recontraction. 
This I do not assert unadvisedly or rashly, as the records 
of more than fifty cases, occurring in my own experience, will 
demonstrate. Several of these cases, in which five and six 
strictures were present two years ago, and then thoroughly 
divided, have been carefully examined by me, within the last 
month, and can be shown to-day, free from the slightest evi- 
dence of recontraction. This goes far to prove that com- 
plete division of stricture, with appropriate after-treatment, 
will give complete immunity from recontraction. The re- 
sults of operations with the dilating urethrotome, presented 
by me to the profession at a meeting of the blew York 
Medical Journal Association more than a year ago, have 
remained permanent; that is to say, that the strictures op- 
erated on, having been thoroughly divided, were afterward 
completely absorbed. These results were subsequently pub- 
lished in the Yew York Medical Journal of March, 1S73. 
One of the cases (Case III.) there reported, presenting origi- 
nally five distinct strictures, including one at the meatus— 
defined by 24 f.—was operated on in January, 1872, and the 
completeness of the operation was demonstrated by the 
passage of a 30 f. bulbous sound through the urethra, and was 
withdrawn without giving evidence of the slightest obstruc- 
tion at any point. This was one of four cases (comprising 
operations on eighteen bands of stricture) critically examined 
in February, 1873, by a committee of surgeons composed of 
Dr. Henry B. Sands, Dr. J. W. S. Gouley, Dr. Robert F. IJEETHEOTOMY, EXTEEXAL AXD IXTEBXAL. 
Weir, Dr. Thomas T. Sabine, and Dr. Frederick D. Sturgis, 
of Hew York, and Dr. Frederic D. Lente, of Cold Spring, 
H. Y., with the 30 f. bulbous sound at first, and subsequently 
with 31 f., without being able to detect any contraction, at any 
point, in any one of the presenting urethrae. I am able to 
afford this Society further proof of the absolute absorption of 
the above-mentioned strictures, by presenting this case (Ho. 
III.) to you for a reexamination to-night, more than two years 
subsequent to the operation, in which five distinct strictures 
were completely divided. In the case of multiple stricture 
presented, it will be remembered that while 25 f. solid steel 
sound was easily passed through the urethra without detecting 
any stricture, Ho. 18 f. bulbous sound was arrested at the 
stricture-points. I propose, therefore, in order to put the 
crucial test to this case, to examine the urethra with Ho. 30 
bulbous sound. This, you now observe, passes readily and 
easily through the urethra, and is withdrawn without the 
slightest retention at any point.. 
I now pass the case over to your committee for the verifi- 
cation of my examination. (Drs. Post, Minor, and Woodruff, 
having confirmed fully the absence of stricture by introduction 
and withdrawal of the bulbous sound Ho. 30, and so reported 
to the Association, Dr. Otis resumed.) In order to show more 
fully the complete absorption of the stricture-tissue in this 
case, I now take a larger bulb than has at any time been used. 
The urethra, when free from stricture, is very distensible, and 
hence, by a little pressure, will admit an instrument above the 
normal calibre. Thus, as you see, this larger bulb, pressed 
firmly, not violently, against the meatus, now enters and passes 
without perceptible difficulty through the urethra. The size 
of this bulb is 34 millimetres in circumference. 
In closing this somewhat desultory paper, I would like to 
he distinctly understood as claiming, that stricture, as ordina- 
rily met with, is absolutely within the reach of curative 
measures; that, if completely divided, and this division 
maintained by suitable means until healing of the parts has 
occurred, no recontraction can ever take place; that dila- 
tation, temporary or permanent, is never more than a pallia- 
tive measure, unless carried to a point sufficient to completely 
rupture the stricture; that the division of stricture is not 
more hazardous, to say the least, than permanent dilatation— URETHROTOMY, EXTERNAL AND INTERNAL. 
that is, by introduction of dilating instruments, which are 
required to remain in situ for hours or days—or than rapid 
dilatation, which requires instruments of increasing sizes to be 
introduced at one sitting ; and I may venture to say scarcely 
more likely to produce trouble than temporary or transient 
dilatation, as usually practised by surgeons, which is simply to 
pass a sound or bougie gently through the urethra, and to be 
immediately withdrawn ; the same to be reintroduced, at in- 
tervals of two or three days or weeks, for the rest of the 
natural life of the unfortunate patient. I will here call your 
attention to a point in the history of Mr. W. C. II., whose 
numerous strictures have been presented to you this evening, 
which, in relation to the foregoing resume, it seems to me is 
very instructive; viz., that his urethral chills, occurring on 
two occasions during the progress of tlie case, each time fol- 
lowed the easy and gentle introduction of a No. 29 f. steel 
sound; while the division of stricture was not followed, in 
either instance, by any such untoward result. This gives me 
an opportunity to state that, in nearly two hundred operations 
with the dilating urethrotome,1 performed by me on urethral 
strictures, chiefly in the straight portion of the urethral canal, 
within the past two years; beyond four troublesome but not 
serious cases of after-hsemorrhage, I have met with scarcely 
an untoward result. Slight chills have occurred in but six 
cases, and these were all associated with operations upon 
strictures in the curved portion of the canal. 
Among the inferences to be drawn from the foregoing 
cases and remarks are, first, that stricture may be present be- 
fore difficulty in urinating occurs; second, that it is always 
present when gleet is present—that gleet, as a rule, means 
stricture / third, that dilatation of strictures is, at best, but 
a temporary expedient; valuable in close stricture, where 
urination is interfered with, and the stricture is too close for 
the introduction of instruments for completely dividing it; 
but that dilatation is not only without permanent value, except 
in such cases, but that it is pernicious, inasmuch as, while it 
is never curative, it takes the place of curative measures; 
fourth, that nothing short of complete division of strictures 
can ever result in radical cure. 
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