O N REFLEX IRRITATIONS THROUGHOUT THE GEN ITO-URINARY TRACT, RESULTING FROM CONTRACTION OF THE URETHRA AT OR NEAR THE MEATUS URINARIUS, CONGENITAL OR ACQUIRED. BY FESSENDEN N. OTIS, M.D., CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. READ BEFORE THE NEW YORK ACADEMY OF MEDICINE. Thursday, February 19th, 1874. NEW YORK: MCDIVITT, CAMPBELL & CO., Ill NASSAU STREET. 1875. WORKS OUST (Metrics aafl Diseases ef Women ana Ciiilflrei, FOR SAFE BY McDIVITT, CAMPBELL & GO., Ill Nassau St., New York. HYSTEROLOGY : A TREATISE, DESCRIPTIVE AND CLINICAL, ON THE DISEASES AND THE DISPLACEMENTS OF THE UTERUS. By E. N. Chap- man, M.A.. M.D., late Professor of Obstetrics, Diseases of Women and Children, and Clinical Midwifery, in the Long Island College Hospital. In one octavo volume of over five hundred pages, finely illustrated with superior woodcuts. Price, $4.50. RESEARCHES IN OBSTETRICS. By J. 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Klois, M.D., Professor at the University of Vienna. Translated from the German by Joseph Kammerer, M.D., Physician to the German Hospital and Dispensary, N. Y., and Benjamin F. Dawson. M.D., Assistant to the Chair of Obstetrics in the College of Physicians and Surgeons, New York. Vol. I.—AFFECTIONS OF THE UTERUS. In one handsome octavo volume, bound in muslin Price, $5.50. HOW TO NURSE SICK CHILDREN : Intended especially as a help to the Nurses at the hospital for Sick Children ; but containing directions that may be found of service to all who have the charge of the young. By Charles West, M.D. In one 18mo volume, bound in muslin. Price, 50 rents. VESICO-VAGINAL FISTULAS, FROM PARTURITION AND OTHER CAUSES, WITH CASES OF RECTO-VAGINAL FISTULA. By Thomas Addis Emmet, M.D., Surgeon-in-Chief to the New York State Women’s Hospital. In one octavo volume, illustrated, bound in muslin. Price, $4.75. ESSAYS ON INFANT THERAPEUTICS. To which are added Observations on Ergot; History of the Origin of the Use of Mercury in Inflammatory Complaints ; with tlie Statistics of the Deaths from Poisoning in New York, in the years 1841-2-3. By John B. Beck, M.D. Third edition. One very neat duodecimo volume, muslin. Price $1.00. THE DISEASES OF WOMEN AND CHILDREN. By Gunning S. Bedford, A.M., M.D., Professor of Obstetrics, the Diseases of Women and Children, and Clinical Obstetrics, in the University of New York ; author of the “ Principles and Practice of Obstetrics.” Ninth Thousand, carefully revised and enlarged/ One volume, octavo, six hundred and seventy pages. Muslin, $4.00 ; leather, $5.00. PRINCIPLES AND PRACTICE OF OBSTETRICS. By Gunning S. Bed- ford, A.M.. M.D., formerly Professor of Obstetrics, the Diseases of Women and Chil- dren, and Clinical Obstetrics, in the University of New York; author of Clinical Lectures on the Diseases of Women and Children. Fourth edition, illustrated by four colored lithographic plates, and ninety-nine wood engravings. One superb octavo volume of over eight hundred pages. Eighth thousand, carefully revised and enlarged. Price, cloth, $5.50; sheep. $6.50. SENT BY MAIL, POST-PAID, ON RECEIPT OF PRICE. O N REFLEX IRRITATIONS THROUGHOUT THE GENITO-URINARY TRACT, RESULTING FROM CONTRACTION OF THE URETHRA AT OR NEAR THE MEATUS URINARIUS, CONGENITAL OR ACQUIRED. BY FESSENDEN N. OTIS, M.D., CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. > . / READ BEFORE THE NEW YORK ACADEMY OF MEDICINE, Thursday, February 19ih> 1874. NEW YORK: McDIVITT, CAMPBELL & CO., Ill NASSAU STREET. 1875. ON REFLEX IRRITATIONS THROUGHOUT THE GENTITO-TJRIRAR Y TRACT. Mr. President and Fellows of the Academy : The influence of the irritation of peripheral nerves in pro- ducing centric disturbance in the spinal cord, which may thence he transmitted to distant parts of the animal economy, (first claimed by Dr. Marshall Hall, more than twenty years ago), has found corroboration in the testimony of every medical scientist since his time ; and besides, so much clinical proof has been accumulated, by the medical profession at large, in support of this proposition, that it is no longer a matter for dis- cussion. Morbid reflex disturbances are now accepted as occu- pying an important place in the recital of human suffering. Varied and grave disturbances influencing the entire ner- vous system, are often ascertained to be dependent upon as ap- parently insignificant a cause as a decayed tooth, an indigestion, a simple erosion upon the cervix uteri, ceasing at once on the cessation of the cause. Dr. D. Campbell Black, of Glasgow, in his very interesting and valuable work on the renal and uri- nary organs, cites cases of retention of urine from reflex irrita- tion, the result of an operation for hcemorrhoids. Trousseau has recorded cases of incontinence of urine dependent solely upon the irritation caused by a preputial contraction. Dr. Sigismund Waterman, of New York, has shown me a case of this sort which was promptly relieved by division of the prepuce. I have seen other similar cases, and also one marked case of re- tention of urine in an infant nine months old, which, after lasting 4 ON REFLEX IRRITATIONS four days, was completely relieved within one hour by slitting up the prepuce. Seminal emissions are well known to occur as a result of phymosis, relief occurring promptly on ablation of the prepuce. Dittel relates a case where a man twenty-six years of age had a slight phymosis, and was the subject of incomplete erections, nocturnal emissions, frequent desire to urinate, and also of many hypochondriac symptoms, all of which were promptly and completely cured by removal of the prepuce. A similar case is related by Pitha. Sweigger-Seidel cites a case where the simple introduction of a catheter caused com- plete syncope, and yet no urethral disease was present. I have the record of a similar case where complete unconscious- ness instantly followed the introduction of a bulbous sound through the meatus urinarius. Every surgeon of much ex- perience has recognized the tendency to syncope in a considera- ble proportion of nervous patients, on the first introduction of instruments through the 'meatus. Spasm of the bladder is noted by Dr. D. C. Black as oc- curring from sympathetic irritation, and to such a degree that complete closure of the uretral orifices results, producing re- tention of urine in the ureters and pelves of the kidney. Such a case I believe I have seen resulting in death from uraemia, and caused by the rude introduction, by the patient, of a catheter, through a narrow stricture at the posterior border of the fossa navicularis ; forcible and painful contraction of the bladder followed immediately, with complete suppression of urine ; the patient died uraemic twenty-four hours after. The bladder was found empty (with the exception of a few drams of grumous blood and mucous), closely contracted and free from disease. The ureters were normal, the kidneys highly engorged with blood, but presenting no evidence of disease. The case was accepted as one of acute suppression at the time. The ureters are known to contract vigorously under the influence of the galvanic current. The above case,* it now seems to me, was •Reported to the N. Y. Pathological Society, March, 1872. THROUGHOUT THE GENTTO- URINARY TRACT. 5 one of spasm of the ureters and bladder, reflected from the irri- tation of the end of the penis. A few days since Dr. Brown-Sequard related to me the fol- lowing case : “ While in London, during the past year, a gentleman was brought to me who presented all the rational signs of advanced cerebral ramollissement. I had looked upon the case as quite a hopeless one, until noticing that the patient frequently applied his hand, in an absent sort of way, to his genital apparatus. Permission being accorded, examination of the parts revealed an aggravated inflammatory phymosis, compli- cated with acute balanitis. “ On making this discovery,” said Dr. Brown-Sequard, “I expressed to the medical gentleman accompanying and in charge of the patient, my belief of the possibility that the apparent ramollissement might be due to reflex irritation, caused by the evidently chronic and severe irritation of the glans penis. I advised complete division or ablation of the prepuce, and treatment of the balanitis, as the best and only hope for the patient’s recovery from the brain trouble from which he was suffering.” The operation was performed, and the effect upon the men- tal and physical condition of the patient was almost immedi- ate. “ So rapid was his recovery,” said Dr. Brown-Sequard, “ that within six weeks from the date of the operation he pre- sented himself at my office, perfectly well in every respect.” Dr. Sayre, of New York, in the Transactions of the Ameri- can Medical Association for 1870, has reported several inter- esting cases of partial paralysis of the lower extremities asso- ciated and evidently dependent upon adherent and contracted prepuce. One was of a boy five years of age, unable to walk without assistance or to stand erect—his knees being flexed at an angle of forty-five degrees. The operation of circumcision was performed on this lad by Dr. Sayre, and “from the very day of the operation the child began to improve,” and without other treatment made a rapid and complete recovery. In a second case, a lad of fourteen years had been under treatment for paralysis of his legs for several months without marked im- 6 ON REFLEX I BRIT A TIONS provement, when it was found that a contracted and adherent prepuce was present, causing great local irritation, dysuria, and painful erections. The preputial contraction was recog- nized as a possible important factor in causing the paralytic trouble. Circumcision was performed, resulting in complete recovery from the paralysis in six weeks. Sir Henry Thompson says* : “ I have given complete re- lief to distressing symptoms of very long continuance, the cause of which teas not suspected, by dividing an external meatus, which, nevertheless, admitted a No. 6 English catheter. 1 have met” (he farther states) “ with three marked examples of a similar kind, in which the very simple operation necessary, was followed by complete disappearance of urinary difficulties, which had been long regarded as of an extremely obscure char- acterHe cites a single case : “ J. J., aged thirty-four, a gentleman whom I had visited at the request of his medical attendant, in the Spring of 1857, had been suffering from painful, prolonged and frequent micturition for five years pre- vious. He was compelled to pass water from three to five times every night, and every two hours during the day ; experienced severe pains in the back and loins, and general ill health. Urine was purulent, foetid, alkaline; results of habitual retention and partial engorgement of the bladder. He had been treated for renal disease without any good effect. On examination I found a simple narrowing of the urethral orifice, and marks of pre- vious ulceration in a small cicatrix. 1 learned ” says he, “ that he had had chancre seven years before, which involved a large portion of the meatus, after the healing of which, his present symptoms almost imperceptibly appeared. A probe only passed through the narrow opening. I divided the contraction so as to make a free opening. A No. 10 catheter was passed easily into the bladder, demonstrating that there was no other obstruc- tion, and twelve ounces of urine were drawn off, although he had passed water just before. The relief was almost instantaneous, •Stricture of the Urethra, Second Ed., page 249. tPage 259, opp. cit. THROUGHOUT THE GENITO-URINARY TRACT. iii a week it was complete. He has had perfect immunity from his urinary complaints ever since.” By the cases already cited, and many others scattered through the periodical literature of the past few years, it is sufficiently proved that paresis, more or less pronounced, may result from irritations reflected through peripheral nerves, without any coincident morbid change in the structure of the spinal cord, and that incontinence of urine, retention of urine, suppression of urine, involuntary seminal emissions, may, in the same manner, result from irritation at the extremity of the 0f bulbous sound passed through to one inch—here it was abruptly arrested. 24f only would pass, and was held firmly on return at one and one-third inches. I THROUGHOUT THE GENITO- URINARY TRACT. 25 then introduced the dilating urethrotome, turned up to 30f and cut. 30f bull) was passed down to two inches, where it was again arrested. 28/ only will pass, and on withdrawal is held at two and one-fourth inches. Re-adjusting the urethrotome this hand was also divided, when 31/ steel sound was passed without force through the entire urethra. Ferguson’s short- beaked sound was then introduced into the bladder and thor- ough search made for stone, but without success. Hemorrhage slight, ceasing entirely within fifteen minutes after the oper- ation. Dr. Ives remains in charge. Nov. 29th, three days subsequent to the operation, Dr. Ives called, reporting that the patient had no pain of any kind fol- lowing the operation, up to his visit of yesterday. Under the influence of ten grains of quinine and a quarter grain of mor- phia he had slept for six hours, and on waking passed water with freedom, with slight smarting but no pain. After this the intervals between the acts of micturition averaged about four hours. Passed the steel sound 31 with ease. Purulence in the urine greatly decreased. Dec. 16th. Dr. Ives reports Mr. X. as having suffered for a day or two past with pain in the penis. Purulence in the urine has entirely disappeared. 30 steel sound drops through the urethra into the bladder by its own weight. The possi- bility of slight recontraction of the stricture at the meatus as cause of trouble was suggested. Dec. 23d, Mr. X. called with Dr. Ives. He reports, personally, that while he passed his water every half hour with great strain- ing and pain before the operation, that since then he has not been called to urinate oftener than once in three or four hours, up to within a week since, when it has been once in two hours. All the pains in the back and lower part of the abdomen, in the testicles and extending down the thighs, passed off entirely within a few days after the operation. During the last ten days he has had pain referred to in the vicinity of the prostate, when urinating, and the stream has been small and weak. Could void it only by straining. He had himself passed 30f steel sound the day previous. 26 ON REFLEX IJUU'J'A TIONS Examination of the prostate, per rectum, reveals no enlarge- ment or tenderness. 30f sound passes without difficulty into tin* bladder, except a little hugging near the meatus. 29/ bulb is arrested at J inch, and holds on return at 4. I introduced a straight bistoury, and cut through the contraction, so that No. 34/ bulb passed in and out without obstruction, to keep this well open until healing is complete. Case 17.—October 9th, 1873, 1 was called to see a gentleman aged sixty-four, whose general health had always been good ; he had lived generously, but regularly. He stated that for the ten years previous he had occasion to urinate on an average every hour during the day, and through the night even more frequent- ly ; for the previous six months he was confident that he had micturated every half hour, unless some necessity prevented, when he always suffered from the delay. At no other time had he any pain ; the frequency of micturition was simply an inconvenience. He stated that he had never had any gonor- rhoeal trouble. Several years previously he had consulted an eminent surgeon, in regard to his urinary trouble, and was said to have “ stricture just beyond the middle of the penis.” For this he was treated by the occasional introduction of bougies for a couple of months, at the end of which time no benefit being apparent, he ceased bestowing any attention to the matter. About three months ago, he began to notice a creamy sediment in the urine, which would cling to the floor of the pot de chambre. It was not, however, until about three weeks ago that he began to suffer actual pain, and straining on passing his water. To this was soon added pain in the testi- cles, through the hypogastrium, and also in the perineum, and extending down the inner aspect of the thighs to the knees. The stream of urine was subject to frequent sudden arrest, and the straining which followed was severely painful, and pain ex- tended throughout the regions previously mentioned. The urine soon became of a deep reddish brown color, with occa- sional strings of blood and mucous mixed with the copious creamy sediment, which was now persistently deposited. Not- withstanding all this, he continued to ride daily, a distance of THROUGHOUT THE GEN IT O- URINARY TRACT. 27 some three miles, to his office. About a week since, finding the motion of his carriage greatly aggravating his pains, he con- sulted an eminent medical personal friend of his, who informed him that he had a grave cystitis, and commended him to my care. I found him sitting upon a hop poultice, which had been prescribed for him by his wife’s medical attendant, (a homeo- path), and ascertained that he had been taking frequent doses of a homeopathic preparation of belladonna. Present condition : Constitutional disturbance very slight, pulse 80/, temperature 994. Inspection of urine in the pot de chambre, (which was about 3 filled, and had been standing for several hours, showed a deposit of mucous and pus, stained and streaked with blood, fully inches in depth. Examination per rectum determined the prostate to be of even less than the nor- mal size, and free from tenderness. The introduction of Ferguson’s short beaked sound (No. 20/), into the bladder, was effected with great gentleness, but with ease, and without meeting with any abnormal impedi- ment in its passage. The bladder was then thoroughly explored for calculus, but with a negative result. Confident, at first, from the history and condition of the case, that it would prove to be one of stone in the bladder, I had, thus far, only cursorily examined the meatus urinarius. Ferguson’s sound No. 20/’ had passed through it easily. 22/ and 23/ bulbous souud were now passed with ease, but 24/’ was held at 3 of an inch. After slight pressure for a few seconds it slipped suddenly through a ring of fibrous tissue, and passed, without obstruction, down to the bulbo membranous junction. The patient was then put upon a free use of infusion of triticum repens, and supposi- tories of belladonna and hyoscyamus every six hours. A subsequent microscopical examination of the urine showed pus and blood in abundance, some urethral and vesical epithe- leum, none from the ureters or pelves of the kidneys, no casts. Albumen slight ; specific gravity 10.20. On suggesting to the patient that division of the strictured meatus was likely to be a necessity before much relief would occur, he desired that his friend, Dr. J. Marion Sims, should be called in consultation. 28 ON REFLEX IRRITATIONS On Thursday, the 14th, after an exhaustive consideration of the case, Dr. Sims coincided with me as to the possibility, nay (in the absence of calculus and prostatic disease), of the prob- ability that the well-defined contraction at the meatus was the original cause of the cystitis, and might be justly held respon- sible for its continuance. The operation was at once decided upon, and the patient placed under the influence of ether by Dr. Harry Sims. 1 then thoroughly divided the contraction—first by the use of Civiale’s Bistoury Cache; completing the division of some remaining elastic fibres with a straight blunt bistoury, until the opening admitted bulbous sound 31. This was then carried easily down to the membranous urethra, without dis- covery of any farther obstruction. The bladder was again thoroughly explored for calculus by both Dr. Sims and myself. It was found to be much contracted and thickened, but con- tained no stone. On the 15th—the day following the operation—I ascertained that, since the division of the contraction, our patient had not had the necessity of passing his water more than once in two hours, and that the pains in the testicles, the hypogastrium, the perineum, and down the thighs, which had previously been his chief points of suffering, had entirely disappeared. There was manifestly less blood in the urine. By the 16th the pus had diminished one-half in quantity, the blood had entire- ly disappeared, and the intervals between the acts of urination had increased to two hours and a half. From this date the only treatment to which the patient was subjected was the daily introduction through the meatus, into and not beyond the fossae navicularis, of a No. 31 bulbous sound. By the 26th —twelve days from the date of operation—the purulent sedi- ment in the urine had entirely disappeared; riding or walking no longer gave him discomfort, and he had resumed his busi- ness. The intervals between acts of urination now vary from two to three hours. There is an occasional occurrence of spasm during the act, which causes the sudden stoppage of the stream, and the urine is voided slowly, and with but little more force than before the operation, but he is not conscious of THROUGHOUT THE GENITO-URINARY TRACT. 29 any other abnormality remaining. He expresses himself as feeling and being in better condition than for years. A few days subsequent to this interview with the patient, he went abroad, to remain during the winter, and I have not since heard from him. Case 19.—Aaron, aged sixty-eight. History of a first gonor- rhoea at twenty-one. Married at twenty-seven, had seven chil- dren, and no trouble with genito-urinary apparatus until four years ago, when he contracted another gonorrhoea. This, after a month, subsided into a gleet, and to this, in about three months after, catarrhal cystitis was added. The cystitis resisted every treatment, and has continued, in a greater or less degree of severity, up to the present time. About a year since he began to suffer with neuralgic pains in the groins and in the perineum, and he experienced a very uneasy sensation in his testicles, one of which became considerably enlarged. Nov. 26, 1874, penis only 2 inches in length, flaccid, 3* in cir- cumference. Meatus 18/. Left testicle half usual size, right nor- mal, but with a greatly enlarged and soft epididymis, almost entirely covering in the glandular structure, and forming a swelling above it as large as a madeira nut, and described as the seat of long standing and very troublesome irritation. Some muco-purulent secretion from urethra. Has been treat- ed for some time by use of soft bougies, with pain and no re- lief. Complains of pains in back and groins, extending down along inner aspect of thighs. Urination every half hour, day and night. Freshly voided urine loaded with pus and mucous. Reaction alkaline. Strong urinaceous odor. No renal epitlie- leum or casts. Albumen slight. Is uneasy and restless in manner, and full of anxiety—quite like a confirmed hypochon- driac. Examination with 18/ bulbous sound detects a stricture at the meatus, extending back for half an inch, after which it slips down the urethra without giving evidence of any farther obstruction. Dec. 22d. Saw the patient in consultation with Dr. Wil- lard Parker. Division of the stricture at meatus agreed upon. Ether administered by Dr. Chas. Turnbull. The stricture at ON REFLEX IRRITATIONS the meatus was first divided. Dense cicatricial tissue, extend- ing tor fully one-half inch. Bulbous sound 32/ was then passed to two and three-fourth inches, when it was arrested by a second stricture. 29/defined its calibre. The dilating ure- throtome was then introduced, turned to 34, and the stricture divided. 31 solid steel sound then passed without obstruction through into the bladder. Relief to the neuralgic pains fol- lowed the operation almost immediately. Within forty-eight hours the intervals between acts of micturition had increased from one-half hour to four or five hours. Purulence in urine greatly decreased. Irritation in the scrotum ceased, swelling of epididymus gradually went down, and the patient made a complete recovery, without other treatment within four weeks. In the foregoing cases, presenting features more or less grave in their conditions and consequences, a point of significant interest is common to all, viz., an abnormal contraction at or near the meatus urinarius ; the well determined sequel in the majority of instances of antecedent inflammatory action. Abnor- mal spasmodic muscular action plays a prominent part in every case. Spasm of the urethral walls ; of the accelerator urinal muscles ; of the cremasters ; of the vesical neck, and of the seminal ducts, etc. Spasm, as in Case 10, so firm and persist- ent that the urethral walls finally gave way behind it. Spasm that for months resisted the introduction of the smallest instru- ment, as in Case 3. Spasm so persistent that the bladder was not allowed to completely empty itself for years, (as in Cases 17, 18 and 19,) and thus producing the chronic catarrh, which finally became so grave an element in these cases. Spasm, as in Case 12, where the testicles played at see-saw for nearly three years, and until the poor wretch who owned them was driven to the verge of suicide. Some one or several of these conditions appear as a persistent feature in each. Spasm, a well recognized result of irritation is equally significant of debility. Most of the cases, if not all, were subjects of sexual excess ; irritation supervening upon nervous debility, spasm naturally results. Irritations which are known to give rise to reflex disturbance are not of necessity THROUGHOUT THE GEN I TO- URINARY TRACT. 31 painful irritations, or which by any special sensation invite attention at once to the source of trouble. Dr. Hanfield Jones (in his work on Functional Nervous Disorders, page 704), says : “It seems to he well ascertained that unfelt irri- tation may give rise to very various morbid phenomena, affecting both the motor and sensory nervous organs Dr. Brown-Sequard maintains that various forms of insanity, of vertigo, chorea, hysteria, tetanus, etc., may be due to irrita- tions, starting from a centripetal nerve, and frequently slightly felt or unfelt ; and that the suppression of these irritations may promptly cure the patient.” He cites a case where a married lady suffered for a considerable time with a uterine neuralgia, which ceased completely on the extraction of a tooth that had not caused any considerable annoyance. In the excellent little brochure on Stricture of the Urethra, by Samuel R. Wilmot, London, he says : “ It is easy to con- ceive with what ease morbid irritation in the urethra may elude detection, and which, though slight, may be capable of exciting perfect reflex action, particularly in systems of high nervous mobility, and, where the slightest irritation exists within the urethra, the mere influence of the mind, derange- ment of the digestive organs, and various other remote causes will lead to spasm.” What, then, in these cases of evident reflex nervous trouble, is suggested as the cause of the irritation ? Division of a contracted meatus, as has been shown, relieves the reflex disturbance ; and yet, simple contraction of the meatus cannot be sufficient to produce such morbid nervous actions as cited ; for it is well known that congenital contrac- tions at this point are frequent, and yet no irritation ensues. In congenital contractions, however, the muscular surround- ings of the urethral orifice are in a normally supple condition, and able efficiently to play their part in completely emptying the urethra after micturition. Let this delicate muscular structure become infiltrated with plastic material, and the complete discharge of the last drops of urine, through its action, is rendered impossible. A dribbling after the act is the necessary consequence, and this is also an unvarying ON REFLEX IBBITA TIONS feature in all the foregoing cases. It is this inevitable retention of a few drops of urine which I believe to he the starting-point of the irritation. As time goes on, and the resulting plastic exudation becomes organized, cicatricial tissue forming and necessarily condensing, a permanent contraction re- sults, which adds to the muscular inefficiency, especially when it occurs in an orifice congenitally insufficient. It is this con- dition which often prolongs a gonorrhoea, and is the most fruitful source of chronic urethral discharge following a gonor- rhoea. That the retained urine causes the irritation, I am led to believe still farther, inasmuch as behind structures at the meatus, granular spots of inflammation occur, sometimes ex- tending throughout the urethra, and on relief of the stricture, promptly disappear without other treatment, as in the third case cited. I have seen many such. Local points of tenderness were present in almost, if not quite all the cases of reflex ure- thral irritation that I have met. Then, as the urethral orifice becomes permanently contracted and unyielding, a distinct and sudden arrest of the stream of urine repeatedly occurs during the forcible acts of urination. Is it too much to believe that the force of this blow at the point of arrest will add to the irritation, and that the effect of its recoil should be felt, back, even to the vesical neck ? It seems to me that this may, after long years of such constant irritating influence, prove an important element in disturbing the harmonious action of the complex sensory, motor and sympathetic nerve distribution, in the deeper parts of the urethra. Considering the force and persistence of the spasm in certain cases, the idea of its tetanic nature has suggested itself: in- duced by pressure and irritation of the nerves of the glans, in the cicatricial contraction. The treatment of the contractions by complete division, resulting in prompt and notable relief in all the cases, is equally suggestive of simple mechanical obstruction, urinary retention, or cicatricial irritation. To be effectual, however, the division must be absolute and entire. It is not sufficient that the meatus be enlarged up to the nor- THROUGHOUT THE GENITO URINARY TRACT. 33 mal urethral calibre. The incision must reach down through all cicatricial tissue, and so completely that the largest sized bulbous sound which can be passed through the opening, shall pass in, and return, without the slightest sense of resist- ance. If it is le3s than this the contraction is absolutely certain to return, within a few weeks, often within a few days, in spite even of every possible effort to keep the parts dilated. Once, however, the stricture tissue is completely divided, it is then only requisite that the edges of the wound be kept asunder by the occasional introduction of a sound, un- til granulation is established throughout its extent. After this (if no new inflammatory action is set up), not only will no recontraction take place, but the old abnormal fibrous material will in time become wholly absorbed. This important statement, applying virtually to all strictures of the urethra, wherever located, I do not make without the ability to prove it by the results of this plan, as presenting in many cases thus treated, in over thirty of which, examination has been had at periods varying from two years and three months, to six months from the date of operation. During the last month I presented before the members of the New York Medical Journal and Li- brary Association, a case where originally six urethral strictures were present (including one at the meatus) of a size of 24/’. These strictures were operated on (completely divided) with the dilating urethrotome in January, 1871—more than two years previous. Examination with the bulbous sound No. 30f, in the hands of a committee (consisting of Prof. Alfred C. Post, Dr. James M. Miner, and Dr. J. DeForrest Woodruff) failed to detect the slightest stricture, either at the meatus or at any other point. In order to demonstrate the complete restoration of this urethra to its normal resilience, by gentle pressure, I introduced, in the presence of the members of the Journal Association, a bulbous sound 34 M. in circumference, through the meatus, and down to the bulbo-membranous junction. ON REFLEX IRRITA TIONS DISCUSSION. Prof. Alfred C. Post, after expressing his thanks for the very interesting and valuable paper presented by Dr. Otis, said there was a single point which had been made concerning which he had some personal knowledge, viz. : that one part of the body may he1 the seat of a painless affection, and yet cause distressing symptoms in some other part. Twenty years ago he suffered with a neuralgic affection for several days, when he discovered that a wisdom tooth was the offending cause. This removed, the pain was at once and entirely relieved. After- ward, on relating the case to a dentist, he remarked that it was nothing new, that Ik; had often met with similar cases. Dr. Post had also met with several of incontinence of urine in children, associated with phymosis, and which, treated by re- moval of the prepuce, resulted in cure without other remedial means. He had not met with the class of cases referred to in the paper just read, hut he considered them analogous to those above related by him. Dr. Richards had observed the association of varied reflex phenomena with stricture of the oesophagus and trachea, and could not but be struck by the coincidence in the character of the troubles, with those described by Dr. Otis. Prof. Detmold remarked that the facts presented by Prof. Otis were not surprising, if we stop a moment to consider that the sensitive point of all the tubes of the body is at the openings. Normally there was no sensation in the cavities. If there was stone in the bladder, the pain would be felt at the glans penis ; and besides, the most sensitive region of the human body— that with which the entire individual most thoroughly sympa- thizes—is that of the sexual organs. In connection with the feeling of wetness which is alluded to in some of Dr. Otis’ THROUGHOUT THE GENITO- URINARY TRACT. 35 cases, he had noticed that the feeling of cold was complained of by patients suffering from stricture and the resulting irrita- tion, and was rather surprised that it was not mentioned among t lie cases related by Dr. Otis. Dr. Otis remarked that he had not unfrequently met with cases suffering from seminal debility where the feeling of cold was complained of, but it was not present in any of the cases referred to. Dr. J. G. Adams would like to ask if Dr. Otis had any faith in dilatation for the relief of such cases as he had described. Dr. Otis replied that he had none. That complete division was the only remedy he had any confidence in. One of the most aggravated of the cases presented had been subjected to careful and persistent efforts at dilatation, the effect of which had only been to aggravate the troubles of the patient. He had, however, seen a number of cases where the difficulties had been temporarily relieved by a division which was not complete; these cases had occurred at his clinique, where the daily attendance necessary to prevent recontraction could not be secured. Dr. Detmold stated that a patient of Dr. Otis’, whose meatus had been divided for a slight stricture, had come to him for treatment, and that he was the subject of an intense and pain- ful orchitis ; that he had refused the case, and had sent him back to Dr. Otis’ cliniqne. He would like to know if this was the result of the operation, and if cutting stricture at this point had ever brought about troubles elsewhere. Dr. Otis said he would not attribute the orchitis to the in- cision ; that if not the result of extending urethral disease, it was probably caused by the introduction of a sound through the curved portion of the urethra ; that the simple division of stricture had never in his experience produced inflammatory trouble at any point, but that on several occasions the forcible attempts, by the patients, to keep the incision open, had re- sulted in inflammation of the glans, and in one instance had extended down the urethra, simulating an ordinary sub-acute urethritis, until it involved the prostate gland. It would have 36 ON REFLEX IRRITATIONS been remarked that several of the cases of reflex irritation re- ported were associated with an enlarged and sensitive epidi- dymis, and that these conditions, as in Prof. Parker’s case, were relieved by dividing the stricture at the meatus. Dr. Detmold remarked that in a certain proportion of strict- ures there was also enlarged epididymis; but in the case he had referred to it was not a chronic condition, but an acute inflam- matory swelling of the body of the testicle. If Dr. Otis ascribes this condition to the dilatation, does he believe that dilatation after or before cutting the stricture will bring about an orchi- tis ? It must have been the combination of the incision with the injudicious dilation, for he had never seen dilatation alone produce an orchitis. Dr. Otis had had quite a different experience, and considered that the simple passage of an instrument through the urethra, (sound bougie or catheter) was capable of producing such an accident, and this, too, when the introduction had been effected in the gentlest and most judicious manner. Dr. Otis referred to two cases published by him, he believed, in the Medical Record, in July, 1871, when the introduction of a soft bougie through a deep, but not very close stricture, was followed in both instances by an inflammation which could be distinctly traced, by the sensations of the patients, as it gradually ex- tended through the entire course of the vas deferens, termina- ting within forty-eight hours in an acute epididymitis. Professor Fordyce Barker spoke of several cases that had come under his observation, where disease of the orifice of the female urethra had simulated uterine disease, and that he could readily understand the possibility of such results as had been described by Dr. Otis as resulting from contraction of the male urethral orifice. Prof. A. Jacobi remarked that he had no experience in such cases as those described, but that he would say a word con- cerning some of the symptoms alluded to. First, that of the sensation of cold. He thought Dr. Detmold had stated that this symptom was associated with partial or complete impo- tence. In such cases we had the symptom of cold from partial THROUGHOUT THE GENITO-URINARY TRACT. or complete paralysis of the vaso-motor nerves, and that in the cases related by Dr. Otis this symptom was necessarily absent, as the cases he cited were all those of nerve excitation, and not paresis. Then the feeling of wetness spoken of. There was no moisture in reality. The function of the urethra was to allow urine to pass ; the brain identified this sensation with wetness. When the stomach is empty there is a feeling of hunger. When the mucous membrane is diseased, as in chronic catarrh, there is a feeling of hunger. In the same manner when we have trouble with the mucous membrane of the urethra we had the feeling of wetness. 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