THE 
i 
SURGICAL IMPORTANCE 
OF 
STRICTURES 
OF 
LARGE CALIBRE. 
BY 
CLINICAL PROFESSOR OF GENITO-URINARY 
SURGERY 
IN THE UNIVERSITY OF PENNSYLVANIA ; 
SUR- 
GEON TO THE PHILADELPHIA AND 
GERMAN HOSPITALS. 
|. WILLIAM WHITE, M.D 
FROM THE 
Medical ajid Surgical Reporter, 
December 15, 1888. From the Medical and Surgical Reporter, 
December 15, 1888. 
THE SURGICAL IMPORTANCE OF 
STRICTURES OF LARGE 
CALIBRE.1 
BY J. WILLIAM WHITE, M.D., 
CLINICAL PROFESSOR OF GENITO-UR1NARY SURGERY 
IN THE UNIVERSITY OF PENNSYLVANIA ; SUR- 
GEON TO THE PHILADELPHIA AND 
GERMAN HOSPITALS. 
There is no necessity at the present day 
for an argument in favor of the existence of 
the slight contractions of the urethral canal 
known as strictures of large calibre. The 
work of Dr. Otis in this country, Mr. 
Teevan in England, MM. Guyon, Ter- 
rillon and others in France has shown con- 
clusively that such contractions may be of 
considerable importance; and the general 
phenomena associated with them now con- 
stitute a group familiar to every genito- 
urinary specialist. The patient will present 
himself with the following symptoms, often 
so slight that he is inclined to apologize for 
seeking professional advice, and sometimes 
elicited only by careful questioning. He 
will have noticed that in the mornings the 
XA translation of this article is published in the 
current (November) number of the Annales des 
Maladies des Organes CIni to- Urinary eg edited by 
M. Felix Guyon. 2 
lips of the meatus urinarius are glued 
together, and that on separating them a 
drop of whitish, opalescent fluid makes its 
appearance. Micturition will be found to 
be slightly more frequent than usual, and 
the patient will particularly describe a 
slight haste and urgency to begin the act, 
which in its actual performance is a little 
slow and somewhat imperfect. At the end 
of urination, unless he pays especial atten- 
tion to shaking and stripping the penis, 
there will be a dribbling of a certain amount 
of urine, varying from a few drops to a 
drachm or two. He will often complain of a 
dull aching sensation in the lumbar region and 
of a similar feeling in the hypogastrium, or 
occasionally of a neuralgic pain in one or both 
testicles. I have elsewhere explained 1 what 
seems to me the rationale of the develop- 
ment of these symptoms, and I reproduce a 
portion of that explanation here as a fitting 
introduction to a few cases which I desire 
to place on record. 
To account for the symptoms above men- 
tioned, and for their cause, there are certain 
general physical and physiological laws 
which should be recalled. Persistent irrita- 
tion, such as that which results from fre- 
quent or protracted attacks of gonorrhoea, 
causes at any given point in the body an 
increase in the fibrous tissue of that region, 
and the deposit or development of new 
tissue of a similar character. This is espe- 
1 International Encyclopaedia of Surgery, Vol. II. 3 
dally true of mucous and submucous sur* 
faces, and still more particularly of the 
Urethra, which, by its anatomical peculiari- 
ties, offers peculiar facilities for the pro- 
duction and organization of inflammatory 
products. Such a deposit, occurring in the 
submucous structures around the urethra, 
interferes to a greater or less extent with the 
lumen of that canal and thus constitutes a 
stricture. Once deposited, here as else- 
where throughout the body, this new tissue 
tends to contract more or less steadily and 
continuously. This is in consonance with 
a well-known pathological law; and the 
contraction is no more noticeable here than 
when it occurs in the intertubular spaces 
in interstitial nephritis, strangulates and 
destroys the parenchyma of the liver in cir- 
rhosis, produces induration and bronchi- 
ectasis in chronic pneumonia, limits the 
movements of inflamed joints, distorts or 
deforms after burns and scalds, or in any of 
the many possible directions exerts its power 
in the production of disease. We have, 
then, it must be admitted, in urethritis, a 
sufficient cause for the production of a con- 
dition which tends gradually to diminish 
the size of the urethra and to interfere with 
its dilatability. 
In studying the effect of this condition in 
producing the symptoms that have been 
detailed, certain other physiological laws 
must be taken into account. Habit is a 
powerful agent in facilitating and controlling 4 
the functions of animal life. Illustrations 
of this fact in other systems than the genito- 
urinary are frequent and familiar. But to 
take up the case in question, it is safe to say 
that in a healthy adult, a certain equilibrium 
has been established and maintained between 
the usual efforts and powers of the bladder 
as an expulsive organ, and a certain average 
amount of resistance which must be over- 
come before it can empty itself. At the 
age of twenty-one years, this adjustment of 
force depends upon a large number of pre- 
vious distinct acts of micturition. This 
balance between the force of expulsion and 
its work cannot with impunity be disturbed, 
and even a slight interference with the 
calibre of the urethra tends to produce such 
disturbance. 
Apart from the proclivity to muscular 
spasm in the neighborhood of and behind 
every stricture, this interference with the 
action of the bladder arises from the 
encroachment of the new deposit upon the 
urethral calibre. It is a law of hydrostatics 
that, if a current of liquid be passed along a 
tube, a certain degree of friction propor- 
tionate to the amount and velocity of the 
current and the size of the tube takes place 
between the walls of the latter and the 
liquid ; if the tube be narrowed at any one 
place, the friction is increased at that point, 
and, to avoid a diminution in velocity, the 
propulsive force behind the liquid must also 
be correspondingly increased. 5 
Still another point must be mentioned 
before I turn to the group of symptoms, the 
occurrence of which after so many cases of 
gonorrhoea I shall endeavor to explain. 
The act of micturition is one requiring for 
its perfectly normal performance: first, the 
relaxation of certain muscles to secure 
patency of the urinary channel; and, next, 
the thorough and complete contraction of 
those muscles to produce entire evacuation 
of the contents of the passage. The latter 
portion of this act is accomplished by the 
contraction of the circular muscular fibres 
which surround the urethra, and which, in a 
healthy condition, serve to bring and retain 
its walls in close apposition during the 
intervals of urination. The submucous 
deposit which increases the friction of the 
stream of urine at any point, also interferes 
with the accurate closure of the canal by 
those muscles whose action is impeded, and 
whose structure itself is in part often 
invaded, and as a consequence we have 
imperfect emptying of the urethra at the end 
of urination. Finally, if in addition we 
recall the intimate nervous connection of the 
urethra with all the viscera of the abdomen 
and pelvis, and with the walls of those cavi- 
ties, and the reciprocal relations that exist 
between them, we are in a position to sum 
up the relation of the pathological and sub- 
jective phenomena as follows: 
The increased friction and resistance 
resulting from even a slight fibrous peri- 6 
urethral deposit disturb the normal relations 
of the bladder, and, by rendering it irri- 
table, bring on one of the common symp- 
toms of stricture, frequent micturition. The 
imperfect closure of the tube, the muscular 
action of which at the point of deposit is 
materially interfered with, causes the equally 
imperfect expulsion of the last drops of 
urine, and produces another characteristic 
symptom—dribbling at the end of micturi- 
tion. The retention and decomposition of 
these last drops, together with the abnormal 
friction between the stream of urine and 
the urethral walls, gives rise to a subacute 
inflammation of the mucous membrane, 
accompanied with a catarrhal or muco-puru- 
lent discharge, constituting the condition of 
gleet; while pains in remote organs and sit- 
uations, notably in the lumbar and hypo- 
gastric regions, are developed by reflex irri- 
tation transmitted from the area of inflam- 
mation. 
This relation of causes and effects has 
been in the main accepted as correct by the 
profession for many years. Probably no one 
denies that in certain strictures in which 
the urethral calibre is markedly diminished, 
the connection between the pathological 
changes and the observed indications is 
about as has been stated. The differences 
of opinion which now exist are chiefly as to 
the amount of urethral contraction which is 
sufficient to produce noticeable effects. 
That every urethral coarctation following 7 
on urethritis must at some time have been a 
stricture of large calibre, is self-evident, but 
just when such a stricture becomes an active 
pathological factor, and is able in the man- 
ner indicated to give rise to symptoms, is an 
unsettled point. Indeed, it is not probable 
that it ever can be definitely determined. 
The idea that any particular fixed calibre 
represents the normal condition of the 
urethra has long ago been abandoned, the 
observed variations of that canal being such 
that no special dimensions can be assigned 
to it as representing the precise dividing 
line between health and disease. The old 
method of regarding the size of the meatus 
as an indication of the normal calibre of the 
canal behind it, is also unquestionably falla- 
cious, it having been conclusively shown 
that no more definite relation exists between 
them than between any other mucous canal 
and its corresponding outlet—the mouth 
and the oesophagus, for example, or the 
anus and the sigmoid flexure. That there 
is a certain correspondence between the 
size of the urethra and that of the flaccid 
penis, is true, the calibre of the one increas- 
ing with the circumference of the other, but 
that this ratio is present in any absolutely 
unvarying manner, has not yet been dem- 
onstrated. At the most, the size of the 
penis may be said to furnish a general 
indication of the urethral dimensions, but 
one which is approximate merely. On the 
other hand, it has been shown that there 8 
are usually certain normal variations even 
in the spongy portion, which is now claimed 
with much show of truth as the most com- 
mon seat of pathological contractions, and 
that it is impossible with any of the means 
at our command to distinguish between 
these natural irregularities and coarctations 
of equal calibre due to incipient stricture. 
An illustration of what I refer to is found 
in the following case : A muscular and appar- 
ently robust man, aged about 55 years, was 
admitted to my wards in the Philadelphia 
Hospital, suffering from a leg-ulcer. No 
urinary trouble was suspected until he was 
subjected to an examination for the purpose 
of verifying a theory to which I shall 
presently allude. He was then found to 
have a coarctation at the distance of four 
and a half inches from the meatus. There 
were no marked subjective symptoms what- 
ever : micturition was possibly a little too 
frequent, and was not quite complete, a 
slight dribbling following the flow of urine ; 
there were obscure lumbar and hypogastric 
pains, and occasional neuralgia of the glans 
penis; but these facts were only elicited 
after careful questioning. A No. 28 steel 
sound passed into the bladder without 
the slightest perceptible difficulty, but the 
patient complained of pain extending from 
the peno-scrotal junction to the perineum. 
An examination with a bulbous bougie, No. 
24, revealed a stricture situated in the 
spongy portion of the urethra at the point 9 
mentioned, about four and a half inches 
from the meatus ; No. 26 bulbous could be 
passed only with great trouble. 
Dilatation was commenced, but an attack 
of some intercurrent disease—pneumonia, I 
believe—caused the patient to be transferred 
by one of my internes to the medical ward, 
where he soon after died. At the autopsy I 
carefully removed the genito-urinary organs, 
on the appearance of which I have the fol- 
lowing notes : The penis was of average size, 
the pendulous portion measuring about four 
and three-quarters inches in length, and a 
little over three inches in circumference. 
(This would have fixed the normal calibre 
of the urethra, according to Dr. Otis’s 
standard, at about thirty-one millimetres.) 
Upon dividing it along the dorsum a band 
of fibrous structure was seen almost encir- 
cling the urethra four and a half inches from 
the meatus; extending from a point a little 
anterior to this back to the bulb of the cor- 
pus spongiosum and to the crura of the cor- 
pora cavernosa was an area of intense con- 
gestion, which persisted even after macer- 
ation of the specimen in chloral solution for 
two weeks, and was then plainly noticeable 
across the room at a class demonstration ; 
the bladder was dilated and hypertro- 
phied and the ureters slightly dilated; 
the kidneys were healthy; there was no 
enlargement of the prostate. Two small 
patches of ulceration existed on the floor of 
the membranous urethra, each measuring 10 
about two lines in diameter. A microscop- 
ical examination of the constricting band 
was made by Dr. Shakspeare, Pathologist 
to the Philadelphia Hospital, with the fol- 
lowing result: “ The section which I made 
of the stricture submitted for examination 
by Dr. White included the mucous and 
submucous tissue. Longitudinal sections 
were made after the specimen had been 
hardened in alcohol. These, after staining 
in carmine and mounting in dammar, exhib- 
ited under the microscope a great increase 
of the fibrous portions of the submucous 
tissue. Among the fibrous bundles were 
numerous typical, curly, elastic fibres. 
“It was also noticeable that the walls of 
the capillary vessels running toward the 
mucous surface were very thick and fibrous 
(sclerosed). The inflammatory processes 
were in the last stages, as was evidenced by 
the sparseness of cellular elements scattered 
throughout the fibrous portion ” 
This case is, in my opinion, one of a large 
class formerly often overlooked, and still 
neglected or misunderstood by those prac- 
titioners who adhere to the old methods of 
examination. 
As lately as 1875 Sir Henry Thompson 
said : “ When a young man consults you for 
certain troubles relative to which you desire 
to learn whether urethral obstruction be a 
cause or not, do not be tempted for an 
instant to adopt so unnecessary a course as 
the introduction of very large instruments 11 
or instruments with huge bulbs at the end 
of them; but simply take a flexible English 
gum-elastic bougie well curved toward the 
point, with a blunt end not larger as a rule 
than number ten or eleven of our scale, and 
pass it very gently and slowly into the 
bladder. If it goes easily—above all, if it is 
withdrawn without being held and slides out 
with perfect facility—take my word for it 
he has no stricture, and, quoad obstruction 
wants no use of instruments whatever.” He 
says elsewhere, however: “With the bulbous 
bougies (various sizes) you may determine 
the existence of any narrowing in any 
part of the urethra with great accuracy, 
and for many years I have never operated 
without employing them carefully before- 
hand.” I infer from the context of 
his lectures on the urinary organs, 
that he refers in this last remark rather to 
the locating of strictures already discovered 
than to their original detection. The value 
of the bougie a boule in the diagnosis of 
strictures is now so universally recognized 
that no argument in its favor seems neces- 
sary, but I desire en passant to call attention 
to one source of error which is associated 
with their use in the deep urethra and which 
is not infrequently overlooked. Years ago 
I published (The Philadelphia Medical 
dimes, May 26, 1877) a paper giving the 
results of some investigations into the relation 
between onanism and urethral stricture, 
which led me to examine a large number of 12 
persons with healthy urethrae. In these 
examinations I found that without exception 
at a distance varying from 5to inches 
from the meatus the bougie a boule was 
arrested during its withdrawal from the 
bladder, and that the obstacle which was 
there encountered gave to the hand of the 
surgeon the characteristic sensation so 
familiar to those who have used this instru- 
ment in cases of stricture. It was evident 
that this condition could not be an abnor- 
mal one and its explanation was sought and 
I believe found in the anatomy of the 
curved portion of the urethra. 
Any extended consideration of this would 
be inconsistent with the limits and purpose 
of this paper; but there are one or two 
points which seem to me worthy of special 
mention. Directly beneath the symphysis 
pubis the urethra perforates the posterior or 
visceral layer of the deep perineal fascia. 
A little in advance of this point is the 
anterior layer of the same fascia, continued 
round the under surface of the urethra, 
becoming lost upon the bulb and filling in 
the sub-pubic arch from in front. Between 
these two layers, which are often described 
as the triangular ligament, are found various 
vascular structures, important muscles, 
Cowper’s glands, and the membranous ure- 
thra. It is said that the anterior layer 
exerts the larger share in stopping the prog- 
ress of an instrument inward, owing to the 
fact that just in front of it is the freely 13 
movable and dilatable bulbous portion of 
the urethra, permitting considerable motion 
in the point of the sound, which is suddenly 
arrested at the commencement of the mem- 
branous urethra by this firm fibrous anterior 
layer. This is probably true; but it is 
capable of demonstration that the posterior 
layer, for analogous reasons, offers a similar 
opposition to the free withdrawal of a bulb- 
ous bougie. The prostatic urethra being at 
once more movable and more dilatable than 
the membranous portion, the bulb slips 
smoothly along it until the point is reached 
at which this layer of fascia closely 
embraces the posterior part of the mem- 
branous urethra and the outer surface of the 
prostate. 
Here for obvious reasons it is arrested, 
and it is at this moment that the deceptive 
sensation which may be considered indica- 
tive of the existence of organic stricture is 
communicated to the hand. 
A series of observations and dissections 
upon the cadaver confirmed me in this view, 
which was originally purely theoretical, and 
moreover eliminated the possibility of the 
resistance being due to a spasm of the com- 
pressor urethrae muscle which surrounds the 
canal at this point, arrest of the instrument 
occurring just as invariably after death as 
before. 
The possible progress of the case described 
above, to which we may now return, had it 
not been interrupted by acute disease and 14 
death, can be easily stated. In consequence 
of the imperfect emptying of the urinary 
tract, cystitis would sooner or later have 
resulted, and would probably have been 
regarded as the primary disease if the 
urethral coarctation had remained unrecog- 
nized. Pyelitis, or infiltration of urine, or 
both, would have followed, and would 
possibly have caused death by uraemic or 
pyaemic poisoning. It is of course admitted 
that the case is in many ways an unusual 
one. With the same amount of existing 
disease the subjective symptoms would 
ordinarily be much more marked, or the 
contraction giving rise to it would be of 
smaller calibre : actual ulceration is rare in 
these conditions, and an involvement of the 
urinary tract posterior to the bladder was 
hardly to be expected where there was so 
little obstacle to the stream of urine. The 
dilatation of the ureters in this case was prob- 
ably due to the increased frequency of 
urination and the periodical obstruction 
thereby produced in the flow of urine into 
the bladder; at least, that seems to me a 
possible explanation. The facts remain, 
however, that the conditions which were 
found were simply exaggerations of the 
pathological processes which beyond a 
doubt result from any infringement upon 
the normal calibre of the urethra. I may 
select a few cases from my private practice 
to illustrate the same point. 
Case /.—A man 30 years of age, a 15 
hotel-keeper in a neighboring city, applied 
to me some months ago on account of a 
troublesome gleet which had persisted for 
several years. It was of the most trifling 
character, came from the deep urethra, and 
was associated with the symptoms mentioned 
above: frequency of urination, dribbling, 
and slight hypogastric pain. He had, before 
coming to me, tried various methods of 
treatment, among them the use of steel 
sounds of a calibre of 26 and 28, which 
were as large as his meatus would admit and 
really seemed to distend the whole urethral 
canal. Thinking that the course had been 
insufficient in duration I recommended per- 
sistence in that method of treatment, order- 
ing a 29 instrument which caused consider- 
able pain at the end of the penis. He used 
this, with and without various injections 
and different methods of internal treatment, 
with no effect whatever. He became much 
discouraged and finally agreed to allow me 
to enlarge the meatus, a procedure which I 
had originally recommended but had not 
urged, as he was excessively nervous and as 
the aperture was of more than the average 
size. After doing this I ordered a No. 30 
steel sound, intending gradually to increase 
the size of the instrument, but from the first 
week during which that size was employed 
his symptoms absolutely disappeared and he 
has never had any return. 
I am of course aware that the result in 
this case may be attributed to the enlarge- 16 
ment of the meatus. Ever since Mr. Fur- 
neaux Jordan called attention to the possible 
results of a congenitally small urinary meatus 
in males and females and recorded cases of 
urethritis, prostatitis, cystitis, and epi- 
didymitis due to this cause, it has been 
recognized as an occasional source of this 
and other genito-urinary diseases. Supra- 
pubic pain, frequent micturition, lumbar 
pain, hsematuria, preternatural sexual excit- 
ability are all in my own experience dis- 
tinctly referable to contraction of the meatus 
and I must therefore admit that in the 
above case the enlargement of that opening 
may have been the active factor in pro- 
ducing a cure. As it would have naturally 
receive'd a No. 28 sound with ease and a 
No. 29 with the use of a little force, it seems 
hardly likely however that its incision had 
much to do with the subsequent result. 
Case II.—A gentleman aged 45 years, a 
widower, came to me on account of sexual 
disability characterized by imperfect erec- 
tions and premature ejaculations. He had 
never had any venereal disease and had been 
happily married for many years, having a 
large family of healthy children. After the 
death of his wife there was a prolonged 
period of continence, at the end of which, 
under the influence of urgent sexual desire, 
he attempted intercourse on several occasions 
with entire want of success. He had been 
carefully and intelligently treated by his 
family physician, a man of large experience, 17 
and had used, as there was hyperaesthesia of 
the deep urethra, a steel sound No. 30, 
which he had introduced for himself twice 
a week for a period of some months. In 
addition to this, much judicious treatment 
had been employed. A physical exami- 
nation gave absolutely negative results. The 
therapeutics of his case had been so com- 
prehensive that I scarcely knew what to 
recommend, but, pending an examination of 
his urine, directed him to get a No. 31 
sound and to insert it at the usual intervals, 
intending gradually to increase the size if 
the urethra would permit it. He disappeared 
for a few weeks from my office, at the end of 
which time he returned to report that he con- 
sidered himself entirely cured, having for the 
first time for years had sexual connection. 
His cure has proved to be permanent. 
Case III.—A gentleman aged 48 years, 
but remarkably youthful and vigorous for 
his age, came to me recently in great dis- 
tress, giving the following history: He 
had been the subject of one or two gonor- 
rhoeal attacks early in life and had subse- 
quently had a slight urethral contraction, 
for which he had been treated by gradual 
dilatation. He had been accustomed all 
his life to having regular and frequent sexual 
intercourse, but about a year previous to his 
visit to me had become engaged to a young 
and attractive woman for whom he had great 
respect, and had for that period been entirely 
continent. A month ago he told me he 18 
had been married, and to his dismay and 
mortification found that he was unable to 
perform the sexual act, erections being 
imperfect or fleeting, and ejaculation occurs 
ring prematurely. He had used his steel 
sound No. 28 without apparent benefit. No 
stricture or other abnormal condition of 
any kind was discoverable by the most care- 
ful examination, and, considering his years, 
he was apparently a model of physical 
health. I recommended the preliminary 
use of a No. 30, which went in with slight 
difficulty, and gave a cautious prognosis 
to prepare him for a somewhat extended 
course of treatment. To his and my own 
surprise and gratification, however, after a 
week or ten days the only distinct subjective 
symptom which he had had, a neuralgic 
pain in the right testicle, disappeared and 
shortly after he without difficulty established 
natural sexual relations with his wife! 
Case IV.—A gentleman aged 30 years, 
a merchant of large interests whose business 
required constant visits to a neighboring 
city, applied to me for treatment for a condi- 
tion of irritability which gave him great 
annoyance. He found that he was unable 
to retain his urine for more than two or 
three hours at the most, and on starting 
from his office for the water-closet, or more 
particularly on arising from his seat in a 
parlor-car to go to the urinal at the end of 
the car to empty his bladder, he would find 
great difficulty in controlling the desire, the 19 
urine sometimes escaping before he had 
time to unbutton his clothes. He had no 
other marked symptoms, but had been care- 
fully examined by different practitioners for 
vesical calculus, stricture, prostatic disease, 
etc. His urine showed nothing abnormal. 
He had been instructed in the use of the 
steel sound and was then employing a No. 
30, which certainly seemed to be a full size. 
I repeated the examination which had been 
made by my predecessors and found nothing 
to account for his trouble. As his visit to me 
came shortly after my experience with one of 
the cases recorded above, I advised him to get 
a No. 31 steel sound, although he felt quite 
sure that he would not be able to pass it, 
the 30 distending the urethra so completely. 
I thought it was worth the trial, however, 
although I was disposed to consider his case 
an example of the urethral erethism so fre- 
quently seen in railroad employes and to a 
less degree in commercial travelers, and 
resulting doubtless from spinal congestion 
consecutive to the continual jarring experi- 
enced in railroad journeyings. While I 
was yet undecided as to what further treat- 
ment I would recommend, he returned to 
report the almost complete disappearance of 
his symptoms following the first week’s 
employment of the larger-sized instrument. 
I have seen a number of similar but less 
striking examples of the same general truth, 
which it seems to me may fairly be expressed 
as follows: A difference in the size of 20 
urethral instruments employed for dilata- 
tion, so slight as to seem trifling and unim- 
portant. may result in exceptional instances 
in a therapeutical effect far beyond what 
would be ordinarily anticipated ; the prac- 
tical conclusion from which is that, other 
means having failed or definite indications 
for other treatment being absent, we should 
never stop short of full dilatation in dis- 
turbances of the genito-urinary functions, 
the treatment being harmless in itself 
and sometimes so unexpectedly beneficial. 
While there is nothing new about these 
observations, it has yet seemed to me that 
even with genito-urinary specialists who are 
thoroughly familiar with the modern views 
in regard to strictures of large calibre, and 
certainly with general surgeons who do not 
always accept these views as a guide in prac- 
tice, treatment is often defective on account 
of a failure to recognize that a slight differ- 
ence, even that of one millimetre, in the cir- 
cumference of the dilating instrument, may 
sometimes make considerable difference in 
the results obtained.