" Reprinted from the New York Medical Record of April io, 1897." STRICTURE OF THE URETHRA IN MALE CHILDREN. BY L. BOLTON BANGS, M. D., CONSULTING SURGEON TO ST. LUKE'S, THE CITY, AND THE M, E. HOSPITALS ; VISITING GENITO-URINARY SURGEON TO ST. MARK'S HOSPITAL ; FORMERLY PROFESSOR OF GENITO-URINARY DISEASES IN THE NEW YORK POST- GRADUATE MEDICAL SCHOOL AND HOSPITAL! " Reprinted from the New York Medical Record of April 10, 1897." STRICTURE OF THE URETHRA IN MALE CHILDREN. BY L. BOLTON BANGS, M. D., CONSULTING SURGEON TO ST. LUKE'S, THE CITY, AND THE M. E. HOSPITALS ; VISITING GENITO-URINARY SURGEON TO ST. MARK'S HOSPITAL ; FORMERLY PROFESSOR OF GENITO-URINARY DISEASES IN THE NEW YORK POST- GRADUATE MEDICAL SCHOOL AND HOSPITAL. BURLINGTON FREE PRESS, 1897- STRICTURE OF THE URETHRA IN MALE CHILDREN.* By L. Bolton Bangs, M. D., CONSULTING SURGEON TO ST. LUKE'S, THE CITY, AND THE M. E. HOSPITALS; VISITING GENITO- URINARY SURGEON TO ST. MARK'S HOSPITAL ; FORMERLY PROFESSOR OF GENITO-URINARY DISEASES IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. The subject of stricture of the urethra in male children is not a new one, for reports of cases have appeared from time to time in the journals and brief mention of the lesion will be found in some of the text-books devoted to surgery and to paediatrics. The majority of the cases reported have been congenital malformations, either at or near the meatus; others have been described as agglutination of the urethra occurring before birth; and others, again, have been due to traumatism. But the subject of acquired stricture as a result of a post natal pathological process (other than trauma) has not received deserved attention, for I am led to believe that cases of enuresis and of dysuria in children may be due to this unsuspected cause. In order to be clearly understood, I beg leave (to quote from my paper on Stricture of the Urethra and its Treatment ") to define stricture as any unnatural narrowing of the urethra in any part of its whole length. At various times attempts have been made to demon- strate the normal urethra as a " closed valvular chink with certain natural or physiological widenings and narrowings in different parts of it." It seems to me that the canal should be looked upon as a living organ, supplied with muscles and nerves for the physiological purposes of carrying away from the body the urine and, after puber- ty, of ejecting the seminal fluid. Anything in the canal, therefore, that will interfere with the proper performance of these duties or * Read February 11, 1897, before the paediatric section of the New York Academy of Medicine. 4 that irritates the nerve relations, disturbs the harmonious action of the organ and must be regarded as pathological and unnatural. Whether it be a deformity resulting from imperfect pre-natal devel- opment, or the result of post-natal disease, it occupies the same place in relation to the natural condition of the organ. It is, then, manifest that to arrive at a clear conception of an obstructed urethra its normal state must be appreciated, and, therefore, each urethra must be studied by itself. Observation has shown that these prin- ciples may be applied to the urethra of the child as well as to that of the adult. Many of the symptoms in the latter take place in the boy, but with additional features which make the treatment difficult, and, on the other hand, with favorable features, due to the fact that the softer tissues of the child are more amenable to radical cure than those of the adult. In order that this paper may not extend beyond the limits proper do such an occasion, and in order to define your discussion, it will be •devoted chiefly to a consideration of acquired stricture. But, in view of the importance of the subject of traumatic stricture, permit me to call your attention to the fact that there are cases on record of children, from two years of age and upward, who, having suffered traumatisms of the urethra either by blows upon the perineum or by lacerations of the urethra by impacted calculus, have presented later in life symptoms of extreme gravity. Therefore it has seemed to me that the time for treatment of such cases was immediately after the injury, and that, if possible, physiological rest should be obtained for the tissues of the urethra by perineal incision and drainage. In a paper entitled " A Plea for External Urethrotomy in Minor Traumatisms of the Urethra, " I called attention to the necessity for a perinal urethrotomy as soon after the injury as possible, and the abstinence from the passage of sounds and catheters. By perineal drainage nearly absolute rest is assured to the muscles of the perin- eum, the function of the urethra in most of its length is abrogated, inflammatory complications are prevented by irrigations, and physi- ological rest for the whole region is almost as nearly obtained as is the case when a splint is applied to a broken leg. The passing of sounds and catheters through a lacerated urethra interferes with the normal process of repair, irritates the locality of the lesion, and in- 5 duces an amount of cicatricial deposit which subsequently becomes a source of misery and often of danger to the life of the patient. Even in the youngest subject and in apparently minor traumatisms, I coun- sel such a procedure, but the anterior portions of the urethra must not be overlooked at the time of the operation. It is sometimes remarkable with what rapidity evidences of severe and intractable stricture follow an injury upon the perineum of a child, if it is not properly treated. Retention of urine is, of course, often reported immediately; but within a short time after the "apparent cure of the stricture by soundings,'' incontinence, the formation of fistulae, and distressingly frequent urination make their appearance. Not long since I was called to see in consultation a lad of four- teen, who, a year before, had fallen astride a fence, and who had complete retention of urine immediately after the injury. He had been operated upon through the perineum at the time by a local physician, who made the error of not including the anterior edge of the damaged area in the incision. The urethra at the latter point, say half an inch behind the perineo-scrotal junction, had remained strictured; the stricture rapidly narrowed, and from the time of the operation no urine had passed, excepting through the perineal sinus. After some difficulty and in two operations I succeeded in reaching the bladder and in restoring the continuity of the urethra. In regard to the subject of acquired stricture, it should be ob- served, first, that the etiology of these cases is often very obscure. In some we are able to obtain a positive and direct history of gon- orrhoeal infection; in others, vague statements from parents point to> some "inflammation'' of the parts; while in many no catarrhal or blennorrhagic antecedent condition can be ascertained. From the observation of certain cases of stricture in yonng adults, I have been led to form the opinion that many of these obscure cases will be found to be due to an extension into the urethra of a balano-posthitis. This opinion, I will admit, is not based upon conclusive evidence, but I have had under my care young adults with the subjective and objective signs of stricture of the urethra who gave a long history of dysuria and of memories from childhood of inflammations about the prepuce, but of no disease acquired from nurse or others. 6 Of course, it is easy to cast a cynical doubt upon the statements •of these individuals and suspect their chastity, but, being interested in the subject and having had some experience in regard to stricture of the urethra in boys, I have been led to make the closest possible investigation with an unbiased mind and with the determination to arrive at a just conclusion. I have therefore been compelled to be- lieve their statements and to attribute their strictures to a non-vene- real source in childhood. It is interesting to find, from the recorded literature upon this subject, the ages at which boys have given evidence of stricture. Permit me to quote briefly a few cases, with reference especially to the age of the child and also to the etiology : Dr. Poynter reports a case of a boy, three years old, who was infected with gonorrhoea by a vicious girl (colored) nurse, sixteen years of age. Two years later the child had stricture, which was treated with dilators.1 My colleague, Dr. Abbe,2 reported a case of four strictures of the urethra (three in the penile and one in the membranous portion), re- quiring external and internal urethrotomy, in a boy three years of age, who had previously been under my care for gonorrhoea acquired from a vicious girl. In this case the gonococci were perfectly dis- tinct, and I treated the boy with weak bichloride irrigations. Six months later, my tour of duty having ended, he came into the ser- vice of Dr. Abbe for the relief of retention of urine, which required the operation as stated. Dr. McMunn reports a case in a child, aged five years, who had had at two years of age a thick, yellow, urethral discharge, lasting ten months. Close questioning failed to elicit a positive cause of the urethritis, but the mother said that the child's nurse had suffered from a yellow discharge at the time. She was sure there was no traumatism. The urethritis was, of course, the cause of the stricture, for symptoms of the affection had existed for three years. There was extreme difficulty in micturition, and the urine was constantly dribbling away. A No. 4 millimetre bougie was firmly obstructed and held at the commencement of the deep urethra. The meatus 'New York Medical Record, November 14, 1885. 2New York Medical Journal' December 20, 1890. 7 was ample and the urethra not sensitive. The stricture was very rebellious to dilatation, but, as treatment progressed, a conditional cure was arrived at by means of tapering metal instruments.1 In Northrup's American edition of Ashby and Wright's " Dis- eases of Children " is reported a case of a boy, four years of age, who had always been well previously, who complained of pain in the penis and hypogastrium, and who had dysuria and a discharge from the urethra. The edges of the meatus were glued together and acted like a valve to cause retention of urine. The meatus was in- cised, the child catheterized and relieved. No opinion was expressed as to the cause of the discharge in this case. Another boy of five years of age, with a history of discharge for three years, supposed to be gonorrhoea though no microscopic exam- ination is mentioned, is also reported by the same authors. Both cases are looked upon by the reporters as congenital meatus stenosis, but in view of the presence of urethral discharge, especially of long duration, it would have been well to examine the remainder of the urethra. No mention is made of this procedure. A boy of six years of age, together with an eight-year-old broth- er, were reported by a Dr. Himowich2 as cases of probable gon- orrhoea. This was stated to be the cause of failure of treatment of " the strictures," no measurements of which are given. Fleming, in a very interesting article on this subject, reports two cases of impermeable stricture in boys of three and five years respectively, with signs of extravasation into the penis and scrotum. He could give no cause, but suggested that the stricture might have been due to a minute angular calculus which had escaped detection. He reports another case of a child, seven years of age; who for two years had had uneasiness in micturition, a tense, turgid penis, and suffered great agony. There was no haematuria. He gives no cause for. this case, but concludes, after a very interesting consideration of all the facts, that it was " strumous." 'British Medical Journal, 1894. '2Medical Record, November 25, 1893. 3Dublin Hospital Gazette, 1855, ii, pp. 67-69. 8 Among other cases of doubtful cause, King 1 reports one of a child who had suffered from early infancy from stricture of the ure- thra, and who was cured by operation. The case of a boy of seventeen is reported,2 who had had gon- orrhoea at eleven years of age and again at that time, and who had a stricture in the bulbous urethra of No. 18 Charr. It is interesting to note in this connection that this same author, S. Rona, reports six- teen cases of urethritis, mostly specific, in boys between fifteen months and thirteen and one-half years, but he makes no mention of stricture in these cases. The case of a boy of eleven, with stricture of the urethra of doubtful etiology, is reported by Bokai.3 This child had a bad ure- thritis a year before, followed by symptoms of general syphilis. The child was brought to the physician for the latter disease, and Bokai therefore considered the cause of the stricture undetermined. Another case in a boy of eleven years, cause not stated, but ap- parently gonorrhoeal, no particulars being given, is reported by E. Desnos.4 Another case of doubtful cause is reported by Gartner-5 A boy, six years of age, with a stricture of the urethra (location and meas- urements not given). The dysuria was relieved temporarily by drugs and, relapsing, was treated by catheter. There were hemor- rhage and complete retention. External urethrotomy was per- formed, and the boy recovered with cystitis. Masturbation has been given as a cause of organic stricture of the urethra. S. W. Gross, in his "Disorders of the Male Sexual Organs " (fourth edition, edited by Sturgis in 1890), mentions a num- ber of cases, notably that of a boy of thirteen years, an epileptic, with a stricture of No. 17 F., at six and one-half inches from the meatus. Dr. J. W. Thompson 6 mentions the case of a boy of fourteen years with an organic stricture, in his opinion due to masturbation. 'Monthly Journal of the Medical Sciences, London, 1853. 2Archiv fur Dermatologic und Syphilis, 1893, H. i. and ii. 3Gerhardt's " Kinderkrankheiten," 4 Band, 3 Abtheilung, S. 186. 4Annales des Maladies des Organes Genito-Urinaires, 1891. 5Med. Corr.-Blatt der Wurtemberg. Aerzte, 1892, p. 132. 6Louisville Medical News for 1897, No. vii., p. 137. 9 In Daniels' Texas Medical Journal for March, 1887, a case is re- ported of a boy, ten years of age, with a history of " spraying " and a small stream since birth. Cystitis was present, and he had three strictures, one posteriorly. The strictures were incised and dilated. This may have been a congenital case, but I agree with Dr. J. William White,1 who thinks that the history is insufficient and doubts the congenital origin of this affection. To these cases, derived from a careful search of the literature, for which I am indebted to Dr. Berkeley, I wish to add two in' my own experience. I beg leave to report them with some detail, be- cause they may serve as a contribution to the literature of this sub- ject and add to our knowledge of the treatment of the lesion. Case I.-A boy, three years and five months old, was brought to me by his father with the following history: He had had none of the usual diseases of children, but, on the contrary, had always been strong and healthy and without serious illness until the present one. When about two years of age, he had an attack of diarrhoea, after which he developed a constant pain in the region of the bladder, and on attempting to pass urine it was found that he could pass only a drachm or two in spurts. At first there was no frequency of urina- tion, but as time went on the attempts at urination were repeated frequently, the number of times in the twenty-four hours being in- definite. The efforts to urinate were accompanied by great pain. He would be taken up at night, crying with the desire to urinate, and when placed on the urinal he would sit and strain until a small quan- tity of urine was discharged. This would be repeated several times during the night. About once in two weeks there would be an ex- acerbation of these symptoms, during which the amount of mucus and pus in the urine would be increased. During the paroxysms of pain he would cry and seize the glans penis, which suggested vesical calculus, for which he was examined, with negative result. When brought to me, the child had a robust, hearty, and vigor- ous appearance in spite of his sufferings. His urine was opaque, ex- tremely alkaline, and putrid. Its specific gravity was 1.020, and it contained about two per cent, of albumin. The sediment was a mass of translucent mucus, many broken-down pus cells, and many small 'Keating's " Encyclopaedia of Diseases of Children. 10 triple-phosphate crystals and bacteria. The symptoms of stone seemed so positive that it was decided that an appointment should be made to anaesthetize him and examine him carefully. In the mean time the condition of the bladder was to be improved by irriga- tion, etc. This was done by his father, a medical man, a No. 14 F. silver catheter being used. To his surprise, he found that the child's bladder would hold twenty ounces of the irrigating fluid. As may be imagined, the washing was undertaken with great difficulty, the child crying and resisting. Finally, on account of swelling of the penis, the washing was discontinued, and, blood appearing in the urine, the child was brought to me for operation. He was placed under ether narcosis and a careful exploration of the bladder for stone was made. No calculus could be detected, but the bladder was found to be of large capacity for his age, extending quite up to the child's umbilicus. It was evidently in a condition of overdistention and atony, manual pressure being required to empty it. It seemed to me, therefore, that some obstruction to urination, probably in the urethra, had been operating for an indefinite period to produce this change in the muscular wall of the bladder. Accord- ingly I explored the urethra, and found a stricture of No. 14 F. just within the meatus. This was incised, and, on inserting the next size bougie a boule, viz., No. 15 F., it was distinctly obstructed by two stricture bands, one one and one-fourth inch and the other two inches from the meatus. They were not tough or fibrous in struc- ture, but apparently soft and yielding, so I thought it well to test the question of their cure by dilatation. The meatus was still further divided to No. 20 F., and the bladder was emptied and irrigated. No untoward symptoms arose, and the father was instructed to con- tinue the emptying of the bladder by means of the catheter and to leave the dilatation to me. The latter was persevered in by the passage of soft instruments upto No. 20 F., and the condition of the child gradually improved, the blood disappearing immediately after the relief of the overdistention of the bladder. The latter gradually regained its power, the frequent and painful urination ceased, and the urine assumed a more natural condition. I have not seen the child in two years, but recently I received a letter from his father, who says : "It is with pleasure that I can report him normal as to 11 urination. He does not have the least trouble, so far as we know. There is absolutely no pain. He urinates on an average four times daily, and almost never gets up at night for the purpose. He is developing, we believe, evenly in all directions." The etiology of the strictures in this case is evidently obscure. I could obtain no history of urethral discharge, but on closely ques- tioning the mother I learned that in his early infancy he had some form of " skin eruption " and some irritation of the prepuce, which was very redundant. The latter had been "dilated" from time to time by means of pocket forceps, for at the time he seemed to have some dysuria. How much importance to give to these symptoms I am in doubt, but in view of the statement in regard to the foreskin it is possible that he had a balano-posthitis which subsequently in- fected the urethra. Although this is problematical, the conclusion seems warranted that, as he was apparently a perfectly healthy child from birth up to the onset of the painful urination, it was a case of acquired urethral stricture and not due to any condition before birth. The blood in his urine just prior to the operation was an interesting feature. At first it was dark in color, was intimately mixed with the urine, and there were no clots. Subsequently it became bright and clotted, and sometimes merely tinging the urine. At the time of the operation I injected eight ounces of clear boric-acid solution into the bladder, and after manipulating the right kidney and ureter with- drew twelve ounces of a bloody effluent. The same procedure on the left side produced only the amount which had been injected. I drew the conclusion that there had been a dilatation of the right ure- ter and pelvis, but this may be only speculation and I have no posi- tive explanation of the symptom. At all events, the blood suddenly ceased when the bladder was relieved. Case II.-The second case was that of an intelligent lad of fif- teen, who gave me the following history, supplemented by state- ments from his father : For some years (the time could not be definitely stated) the boy had had considerable trouble in urinating ; that is, his urine when passed would scald him, and whenever he " caught cold " the act of urination was accompanied by pain. When thirteen years of age he had an attack of complete retention of urine, to relieve which he was given ether and a catheter was passed. It 12 was necessary to repeat this operation, aided by an anaesthetic, each day for a week. In the second week it was done every third day. As he had a long foreskin, this was considered the cause of the re- tention, and he was circumcised. After that he was etherized and catheterized " a couple of times," then was given some internal med- ication, and finally got so that he could urinate with but little pain. Following the catheterizations he had a discharge from his urethra, which was described as greenish-white and which stained his cloth- ing yellow. This discharge persisted for nearly a year and a half, when a doctor prescribed an injection for him which was used twice a week, with the result that the discharge ceased and he found himself able to urinate with more comfort. Still, if he had what he called " a cold," he immediately had a return of the difficult and painful urination. At times he had had a thin watery discharge from the urethra. To quote from the record made at the time : "At present he has no frequency of urination. According to his statement, he urin- ates but ' three times ' during the day, usually once during the night, and sometimes he will go for a period of three weeks without any nocturnal urination. On examination the urinary organs appear to be normal. The discharge described in his history is not now pres- ent. He urinates in my presence in a fine, dribbling stream with straining, and evidently it requires considerable effort to empty the bladder. Examination of the urethra shows a stricture of No. io F. a short distance within the meatus. The locality is excessively sen- sitive and further examination is impossible. It is therefore deemed advisable to put him under an anaesthetic, explore the urethra thor- oughly, and do whatever is determined by the examination." Accordingly, after antiseptic preparation, he was anaesthetized, the meatus and the first stricture were divided to No. 26 F.. and then three distinct, tough, fibrous bands of No. 12 F. were found between the meatus and a point two and three-fourths inches from the latter. The remainder of the urethra was normal. These bands were divided by the Maissonneuve urethrotome, followed by the dilating urethro- tome, until a No. 26 F. bougie a boule passed smoothly and easily. On the following day, under primary ether narcosis, a No. 26 F. bougie was passed, and subsequently the sound was passed once in 13 four or five days. Two weeks later he was sent home to his doctor in the country, with directions to pass the sound once a week until all bleeding ceased, but not to pass any instrument if the urethra was irritated or inflamed by its use. A recent inquiry in regard to this patient, of the medical friend who sent him to me, elicits the information that the boy has remained perfectly well, urinates with- out trouble, and thus far has shown no evidence of recontraction. Again I am compelled to admit the doubtfulness of the etiology. It is true there is no history of infection by nurse or others, and no history of balano-posthitis could be obtained; but as these strictures were firm and fibrous, such as follow urethritis in adults, it seems to me that the etiological factor must have been forgotten and that in all probability it related to the prepuce. The only urethral discharge referred to in the history was probably due to infection from the re- peated catheterizations. No examination of it was made, and I was unable to make any because there was none present when he came to me; moreover, speedy relief was imperative, and therefore the oper- ation was at once undertaken. You will observe the difference in the severity of the symptoms in these two children. The younger child, although his urethra was not so much strictured relatively as was that of the older boy, had the most violent symptoms and suffered far more, and yet regained with remarkable rapidity the tone of his bladder. You will observe also the contrast in the treatment. In one case, the strictures being soft and yielding, a good result was arrived at by intermittent dilata- tion; while in the other it seemed to me better judgment to apply the principles of internal urethrotomy to secure, if possible, a radical and permanent cure. What the permanent results will be in these cases I am unable to say, but it is my intention to keep them under observation and to obtain from time to time re-examinations of the urethra. At present they are both beyond my reach, and I am able to report only the statements as to their general well-being. 29 East 44TH St.