SUBCUTANEOUS DIVISION ~ 
OK 
URETHRAL STRICTURE. 
BY 
CLAUDIUS H. MASTIN, M.D., LL.D. Univ. of Penna., 
MOBILE, ALABAMA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY I, 1886. 
PHILADELPHIA: 
WILLIAM J. DORNAN, PRINTER. 
1886. SUBCUTANEOUS DIVISION 
OF 
URETHRAL STRICTURE. 
\JBY 
CLAUDIUS H. MASTIN, M.D., LL.D. Univ. of Penna., 
MOBILE, ALABAMA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY I, 1886. 
PHILADELPHIA: 
WILLIAM J. DORNAN, PRINTER. 
1886. SUBCUTANEOUS 
DIVISION OF URETHRAL STRICTURE. 
I have selected as the subject which I shall have the honor 
to bring before the Association at this session, “Subcutaneous 
Urethrotomy in Close Organic Stricture of the Urethra.” I do 
this for the reason that it has seemed to me better to discuss a 
question concerning which I have had a large personal expe- 
rience, rather than to recite the observations of others, however 
interesting and important the latter might prove. 
I fancy, at least, that the views I have to offer are not without 
importance, and I am convinced that they will not prove so 
familiar to you as many other topics which I might have 
selected. I shall, therefore, introduce to your notice, in the 
simplest and briefest manner, a running history of external 
operations upon the constricted male urethra, and then describe 
the operation which I have been induced to devise and adopt as 
the one which, to my mind, offers the best possible results in 
those cases of impassable stricture of the urethral canal which 
will not yield to the milder methods of dilatation, in one form 
or another, or to the operation of internal urethrotomy. 
Organic urethral stricture becomes sometimes so difficult and 
so obstinate an affection to treat that we are forced to resort to 
other than the usual methods for its relief. Such being the case, 
is not surprising to find that, from the earliest times, danger- 
ous and difficult operations have been introduced for its cure, or 
rather for its immediate relief: among which are incisions made 
from the outside, through the integument and urethral wall, 
dividing all the diseased structures, and leaving the parts gradu- 4 
MASTIN, 
ally to reunite. Such operations may all be embraced in the 
one general term “ External Urethrotomy.” 
As far back as we have any recorded history of surgery, we 
find the ancient surgeons, like ourselves, encountering difficulties 
in the treatment of urethral stricture, and oftentimes unable to 
gain an entrance into the bladder through the natural channel. 
Hence, they were forced to resort to the use of the knife, by 
which incisions were made into and through the urethral walls. 
Celsus was evidently familiar with such an operation, for in 
Book VII., Chapter XXVI. of his writings, we find this passage: 
“ In suppression of urine, if the urethra is stopped by a stone, the 
prepuce must be drawn out as much as possible, and, the glans being 
covered, it must be tied by a thread ; then, on one side, a longitudinal 
incision must be made into the penis, and after this the prepuce is let 
go; for by this means the sound part of the skin covers the incision in 
the penis, and the urine will be discharged in the natural way.” 
It is certainly very evident that he intended to speak of reten- 
tion, and not suppression of urine, and that the incision was 
made in the urethra and not into the body of the penis. A 
natural inference to be drawn from this quotation is that, if 
Celsus advised opening the urethra to get rid of an impacted 
stone which was obstructing the flow of urine, he evidently 
would have advised a similar operation in a case of retention 
caused by any other obstruction, as, for example, stricture of the 
canal. Still later than the time of Celsus, we read in the writings 
of Rhazes in the tenth century, a clear description of such an 
operation having been done for obstruction of the urethra. 
Again, Avicenna, who wrote in the eleventh century, mentions 
puncture of the urethra through the perineum for the relief of 
retention of urine. These operations appear to have been in- 
tended solely to give exit to retained urine, but with no intention 
or proposed plan of curing the disease which caused or produced 
the obstruction; the object of the ancients being more the relief 
of the immediate symptoms than an endeavor to eradicate the 
disease. 
The first reliable mention of an operation of which we have URETHRAL STRICTURE. 
5 
any positive knowledge, which was performed for the cure of 
stricture, and not entirely for the relief of retention, is the one 
recorded by Richard Wiseman, in his work entitled The III Con- 
sequences of Gonorrhoea. Here he speaks of having witnessed, 
in the year 1652, an operation done by Mr. Edward Molins, 
“which,” says Wiseman, “consisted of an incision into the ure- 
thra near the neck of the bladder, for retention of urine; that 
the knife did not readily divide it, for it was as hard as a gristle ; 
the urethra being opened, the urine gushed out, and the wound 
remained fistulous.” In this operation, if we fully understand 
Wiseman’s description, the incision was made into the urethra 
posterior to the obstruction, and subsequently the incision was 
carried through the coarctation to its anterior face, a very similar 
operation to the “ boutonniere,” a proceeding of which we shall 
have occasion to speak more at length in the course of this 
paper. 
Again, in the latter part of the same century, we find Soligen 
performing similar operations, once at Livourne, and again at 
the Hague. Then we hear of an operation, which was desig- 
nated “la boutonniere,” being done in 1687 by Francois Tolet, 
for the relief of retention, but not for the cure of stricture; and 
he tells us that it was an operation much in vogue “by men of 
great skill and reputation,” and employed by them only in cases 
of great emergency. 
Then, Frangois Colot follows him, operating in 1690 for the 
cure of impassable stricture complicated with perineal and scrotal 
fistulae. From that date onward we find, scattered here and 
there through the early literature of the profession, only refer- 
ences to the subject, until the year 1730, when Ledran operated 
upon “a case of organic impassable stricture;” this operation he 
did at two sittings,” and after the following manner: The first 
day, the perineum was opened down to the urethra, and on the 
succeeding day he opened into the canal upon the anterior face 
of the stricture, through which, after gradual dilatation for five 
days, he passed a bougie on into the bladder; when this had 
been accomplished, he “ slit up the urethra as far as the neck of 
the bladder.” Gradual dilatation was then resorted to, by which 6 
MASTIN, 
the entire length of the urethra was stretched open, and the 
patient is said to have gotten well. 
About the same date, J. L. Petit, on numerous occasions, 
appears to have performed similar operations for retention of 
urine, and in some cases he divided the stricture at the same 
time, with the evident intention of curing the obstruction. Petit 
relates a case where he performed the operation for the cure of 
a stricture through which it was impossible to pass an instru- 
ment, although there was no retention of urine, and no fistulae 
through which urine could find its way. He cut through the 
urethra at the face of the stricture, upon a grooved sound intro- 
duced down the canal to the seat of obstruction, after which he 
forced a trocar through the obstruction and into the bladder, 
following the supposed course of the urethra. He then slit up 
with a bistoury the strictured portion, tied in a catheter, and left 
the wound to heal by granulation, which it did in about a month 
or longer time, and the patient is reported as having been en- 
tirely cured. This was probably the first case in which a “sonde 
& demeure,” or retained catheter, was ever used. Petit subse- 
quently resorted to a similar operation in a number of cases, and 
states that, whenever he has performed “la boutonniere” (as he 
termed it) for retention of urine, his patients always “ regained 
the freedom of the canal when he comprehended the obstacle 
itself in the incision.” But he is very careful to remark that 
“the boutonniere is to be shunned whenever the introduction of 
a sound is practicable.” 
In 1750, twenty years after the operations of Ledran, Mr. 
Sharp, of England, described an operation very similar to his, 
“ by cutting in perineo if possible upon a staff,” and recom- 
mended its performance;1 but, in 1782, we find him condemn- 
ing it in no measured terms, and advocating in its stead the 
suprapubic operation for relief of retained urine, as one less to 
be feared, and less serious in its results.2 Only six years after 
this date—i. e., in 1788—John Hunter comes to the front, and 
1 “ A Critical Inquiry,” London, 1850. 
2 A Treatise on the Operations of Surgery, etc., by Samuel Sharpe, F.R.S., etc. 
Tenth edition. London, 1782. Chapter xv. pages 77, 78. URETHRAL STRICTURE. 
7 
not only advises but urges the operation as the proper one for 
the cure of strictures complicated with perineal fistulae; he 
himself having performed, in 1783, an operation in which he cut 
upon a staff introduced down to the stricture, and exposed the 
face of the obstruction, which was subsequently dilated so that 
the staff was with difficulty passed on into the bladder. This 
was neither new nor original with Hunter, for in the year 1738 
both Astruc and Daran had described the operation as done by 
Hunter, and again in 1748 called the attention of surgeons to 
the method ; but they both opposed and advised against its 
performance. In 1786 both Chopart and Desault performed the 
operation in various ways, but the mortality proved so great, 
and they denounced it in such violent terms, that very few 
surgeons could be found who were willing to attempt it. 
Desault writes: 
“ The operation known under the name of ‘ la boutonniere,’ though 
apparently better adapted to the nature of the disease, is, almost 
always, either useless or dangerous. It is useless if the surgeon has 
been able to pass a grooved director for the purpose of operating, 
because in such a case he might just as well introduce a hollow sound. 
It is dangerous if the surgeon has no director to guide him, for then 
he makes his incisions at hazard, may miss the canal, and divide parts, 
the lesion of which is followed by more or less serious accidents.” 
Chopart having had no success with the operation, became 
bitter in his denunciations of the procedure; and the failures, 
together with the great mortality attending it, about the close 
of the last century, threw it into such disrepute, that very few 
surgeons could be induced to perform it. Mr. Sharp, of Eng- 
land, then condemned it, and very soon it fell into disuse in 
France, and was not again practised in England until about the 
year 1807, at which time Sir Charles Bell called attention to it 
as an operation peculiarly adapted to, and required in those 
cases of aggravated stricture of the urethra complicated by 
perineal fistulae; still the operation did not receive favor in 
England, and we hear little or nothing more of it until the year 
1817, when it was revived and introduced into America by the 8 
MASTIN, 
late Dr. Alexander H. Stevens, of New York, who then operated 
successfully upon a case of stricture by this method after all 
other means of relief had failed. Then Dr. Jameson, of Balti- 
more, began to operate in 1820, and by the end of the year 
1823 he had performed ten operations without a single death. 
This remarkable success with a hitherto unsuccessful operation 
naturally directed the attention of American surgeons to the 
method, and it was not long before it became popular in New 
York and other Eastern cities. Dr. D. S. Rogers, of New 
York, also began the operation in 1823, and very soon laid 
before the profession the report of twelve operations, all suc- 
cessful. By the year 1843 Warren, of Boston, March, of 
Albany, Hoffmann, Post, Watson, and Buck, of New York, 
with many other American surgeons, had, by large numbers of 
successful cases, all done without the use of a conductor, so 
fully established the propriety of the operation, that it at once 
became an accepted operation on this side of the Atlantic. 
Carefully examining the reports of these cases, we find they 
were all performed after the method of the “ old boutonniere; ” 
that is to say, without a conductor, which goes to prove they 
were cases impassable to instruments. So, before we investigate 
the subject further, it may not be out of place to show what is 
meant by that term, and then analyze the methods which come 
under that general description. 
This operation has been performed in so many ways that we 
are at a loss to understand the exact idea which the old authors 
wished to convey when they used the term “ la boutonniere.” 
The most explicit description which we have been able to find, 
is the one given by Desault in his treatise upon the diseases of 
the urinary organs; this is, to my mind, most clearly evident 
that the operation was performed in three ways : First% upon a 
conducting staff which was passed through the stricture and on 
into the bladder, upon the groove of which conductor the in- 
cision was made. Secondly, where a staff was passed down the 
urethra until it reached the anterior face of the stricture, and 
the urethra opened upon the point of the staff, after which the 
stricture, together with the integuments, were all laid open by URETHRAL STRICTURE. 
9 
the knife upon a director which was introduced through the 
stricture from its distal opening. Thirdly, a staff was passed 
down to the stricture, and the urethra opened in the membranous 
portion posterior to the obstruction, through which opening a 
grooved director was passed from the posterior face of the ob- 
struction forward through the stricture until it came in contact, 
or nearly so, with the end of the staff as it rested upon the 
anterior face of the coarctation; then a knife was pushed along 
the groove of the director from behind forward, and the entire 
stricture, together with wall of urethra and integuments, all 
ripped open : this last method is the one usual with French 
surgeons. This completes a running epitome of the operation 
from its early history, to the year 1849, when Mr. Syme, of 
Edinburgh, called the attention of the profession to “ A New 
Operation for the Cure of Urethral Stricture: ” a method which 
he had devised, and which consisted in passing a special staff 
through the stricture, then opening the urethra behind the co- 
arctation upon the small grooved director attached to the staff; 
in this groove he passed a sharp, narrow-bladed knife forward 
through stricture, integuments, and all, laying the urethra freely 
open. It is, however, scarcely necessary to consume time by 
a long description of the method of the Scotch surgeon, or a 
detail of his cases, for I presume all are perfectly familiar 
with it. 
It may not be uninteresting, however, to show what were the 
conclusions which he proposed to draw from his method ; and 
it will serve my purpose better if I quote his own language on 
this point—they are as follows : 
“ 1st. That there is no stricture truly impermeable, and that, with 
time and care in every case, an instrument may be passed through it, 
and serve as a guide for the knife. 
“ 2d. That all strictures which cannot be remedied by simple dila- 
tation, admit of effectual relief only through a free division of the con- 
tracted part of the canal. 
“ 3d- That this object can be obtained with certainty and safety 
only by an external incision in a line corresponding with the raphd 
of the perineum upon a grooved director passed through the stricture. 10 
MASTIN, 
“ 4th. That the only after-treatment required is the introduction of 
a catheter during forty-eight hours, with the subsequent use of a full- 
sized bougie at distant intervals. 
“5th. That the operation, if properly per formed, is free from any 
risk whatever of hemorrhage, extravasation of urine, or fistulous 
opening.” 
I shall examine these conclusions and see how far they may 
be fully received; whether or not, in the first place, the pro- 
ceeding is entitled to be considered “a new operation;” how 
far, if in any particular, it differs from one of the varieties of 
“la boutonniere;” and, more important than all, whether it is 
free from danger. That it is not a new operation has been 
clearly proved by the description of the boutonniere by Desault. 
In his first division, he shows that the staff was passed through 
the stricture and the coarctation cut upon the groove of the 
same ; in his third division, that the urethra was opened pos- 
terior to the contraction, just as Mr. Syme described it, a director 
passed from behind forward, and the stricture cut from its pos- 
terior to its anterior boundary. The director of Desault was 
passed from behind, whilst that of Mr. Syme was introduced 
from the front; this is the non-essential difference in the two 
operations, one of no consequence, since the stricture, integu- 
ments and all, were laid open and left to granulate after both 
operations. 
Mr. Syme has assumed the non-existence of impermeable 
stricture, and says: 
“There is nothing of more consequence in the treatment of stricture 
than the knowledge of the fact that this alleged impermeability has no 
real existence except in those cases where the urethra has been divided 
by violence and allowed to cicatrize with obliteration pf the passage 
beyond the opening at the seat of injury. It is obvious, indeed, that 
if the urine is permitted to pass, no matter how small a stream, or 
even by drops, there must be room for the introduction of the instru- 
ment, if it be sufficiently small and properly guided. 
Even this assertion is not new, since Mr. Liston had, in 1835, 
enunciated the same opinion, as shown by this language— 
“there are no strictures impassable that I have ever seen, for URETHRAL STRICTURE. 
11 
where any water comes away, you can, by patience and perse- 
verance, get a catheter through sooner or later.” Still these 
assertions have not been proved, since we find in Mr. Syme’s 
own work two instances in which he acknowledges that he was 
unable to pass his special staff, and consequently he was forced 
to open the urethra anterior to the stricture and then cut through 
the same, as in Desault’s description of his second division of 
la boutonniere. Mr. Liston also has been repeatedly foiled in 
his attempts to introduce a catheter through an ordinary stric- 
ture, and was obliged to have recourse to an operation of tapping 
the bladder both above the pubis and also through the rectum. 
Yet Mr. Syme asserts that he has never been called upon to 
perform his operation for impermeable stricture, and simply 
because he had never met such a case. He makes permeability 
an indispensable prerequisite to the performance of external 
division, and does so upon the ground of the “ danger, uncer- 
tainty', anddifficidty" which, he asserts, must attend all operations 
done in the perineum in search of the urethra, without a guide. 
His own assertions are conclusive evidence that there are im- 
permeable strictures, even if we had no better authority; but 
upon this point the united experience of almost all surgeons 
goes to show and to prove that there are cases of stricture 
oftentimes met with which are impassable to instruments yet 
not absolutely impermeable to urine. 
2. His second conclusion is far from being sustained, since 
there are too many well-attested cures of resilient stricture— 
strictures which have proved rebellious to dilatation—which 
have been thoroughly relieved and permanently cured by the 
simpler operation of internal urethrotomy; thus sustaining the 
well-established fact that when a stricture is not impassable to 
instruments, external division is contraindicated. 
3. If we can rely upon the testimony of Mr. Lizars—and his 
assertions have not been refuted—Mr. Syme’s own cases were 
not with certainty and safety relieved. Mr. Lizars conclusively 
showed that the statements of Mr. Syme were not to be relied 
upon, since his cases had not been fairly or even correctly re- 
ported by himself, and that a large number of his operations 12 
MASTIN, 
proved failures, since in many instances the patients were placed 
in a most terrible condition as the result of his method: pro- 
fuse hemorrhage occurring in quite a number of them, and also 
extravasation of urine followed by extensive sloughing, ter- 
minating in numerous fistulae. Mr. Syme himself acknowledges 
the dangers of the operation when he writes, giving the history 
of some “eighty or ninety cases,” that “alarming symptoms 
were by no means rare, since every third or fourth patient 
suffered from rigors, vomiting, delirium, or suppression of 
urine.” 1 Besides these troubles, he met with two fatal cases 
which he attributed to contact of the urine with the wound. 
It is not the purpose of this paper to cast the least reflection 
upon the distinguished surgeon whose name has been so inti- 
mately associated with this operation, nor to condemn the oper- 
ation of external section. I am writing its history, and desire 
simply to give the result of my investigations, and show what 
objections are sustained against it. It is certainly proved, that 
from the most remote times it has been considered a dangerous 
and difficult operation, and even in our own day, when sur- 
rounded by all the appliances of improved surgery, and encour- 
aged by the success which has attended it, some of the best 
modern authorities pronounce it an operation not free from 
danger, but one which requires the most consummate skill for 
its successful execution. 
The venerable, gifted, and distinguished founder of this Asso- 
ciation, a man who made, and has left his impress indelibly 
stamped upon the surgery of the nineteenth century, used this 
forcible language when writing of the operation : 
“The operation is by no means free from danger and requires the 
most consummate skill for its successful execution. None but a mad- 
man or a fool would attempt it unless he had the most profound knowl- 
edge of the anatomy of the parts, and a thorough acquaintance with 
the use of instruments. Of all operations of surgery, this is the least 
to be coveted.”2 
1 Lancet, August 21, 1858, p. 191. 
2 S. D. Gross, Diseases, Injuries, and Malformations of Urinary Organs. Second 
edition, 1855, Page 801. URETHRAL STRICTURE. 
13 
The operation has not been fully accepted in France, and was 
rejected by a commission of the French Academy which was 
appointed to sit in judgment upon it. Civiale, than whom no 
sounder authority in matters pertaining to genito-urinary sur- 
gery has lived, himself never performed it, although he was 
known frequently to have had resort to the old operation of 
“ la boutonniere.” 
With all the objections brought to bear upon the various 
operations of external section, still we are, as I before stated, 
sometimes called upon to relieve a patient from retention of 
urine caused by obstinate and impassable or impermeable stric- 
ture : and when that rare contingency does arise, and when 
milder measures have utterly failed, the urethra remaining abso- 
lutely impervious,—letting in no catheter, letting out no urine— 
then undoubtedly this condition will establish a necessity, a 
legitimate and imperative and urgent necessity, for our making 
an artificial vent for the discharge of the contents of the dis- 
tended bladder. 
This brings me to the consideration of the indications which 
render such an operation necessary. 
Indications.— 1st. The impossibility of passing a sound into 
the bladder through the urethral canal, when a firm organic 
contraction blocks up the urethra and proves rebellious to either 
dilatation or internal urethrotomy. Here we are imperatively 
called upon to relieve an over-distended bladder, else we find 
cystitis being developed, bladder walls becoming hypertrophied, 
ureters dilated, and kidneys disorganized. The nervous sys- 
tem, overwhelmed by the absorption of urea, cerebral symptoms 
speedily ensue, and the patient dies comatose. In such cases, 
the constitutional distress is urgent, and the demand for relief 
imperative ; it then becomes dangerous to temporize with milder 
methods, and as a rational but dernier ressort we must perform 
an external section. But even in such cases it is not always 
necessary to do an operation through the perineum, or from 
without inward; for in some cases it is possible to cut down 
through the axis of the urethra into and through the stricture, 
although it may be impassable to the smallest instrument. Of 14 
MASTIN, 
this I speak advisedly, since I have myself done such an opera- 
tion upon several occasions where I was not willing to subject 
the patients to the gravity of an external section. It is true the 
operations were exceedingly difficult, yet they were completed 
with perfect safety and relief to the patients.1 
2d. Infiltration of urine resulting in abscess may necessitate 
an external section. I do not here refer to those sudden cases 
where from direct injury the urethra has been ruptured and 
infiltration is the consequence, but I allude to those cases where 
a tight stricture has existed for a length of time; where a peri- 
urethral abscess has resulted from a small opening in the urethra 
behind the stricture, and the gradual infiltration of urine has 
lighted up inflammation to a degree sufficient to form a circum- 
scribed deposit of pus. In such cases it is necessary to open 
the abscess for the purpose of relieving the sufferings of the 
patient. To do this more effectually, it will be well to carry the 
incision still deeper, and lay open the urethra at the site of rup- 
ture, then carry the knife forward through the stricture to the 
point of a sound introduced down to the anterior face of the 
coarctation. 
3d. The third indication might be placed where certain cases 
of old tight strictures complicated with urinary fistulae through 
which a great part of the urine escapes at every act of mic- 
turition. 
Many surgeons contend that here is a clear and unmistakable 
indication for an external section, but, unless in some exceptional 
cases, I cannot give my unqualified assent to the proposition, 
since experience has clearly shown that in almost all cases of 
urethral fistula, so soon as the lumen of the canal is fully restored, 
the fistula heals; and very soon thereafter, when the normal 
calibre of the urethra has become established, the innodular tis- 
sue which surrounds the fistulous opening becomes absorbed. 
Such being true, I prefer an internal section as less dangerous 
and equally efficacious. 
1 For report of cases, see Richmond and Louisville Medical Journal, Sept. 1873, 
vol. xvi. page 285. URETHRAL STRICTURE. 
15 
4th. The most important indication which may arise, is when 
the urethra has been ruptured by a violent blow, and when the 
effects of such injury are rapid and severe. In some of these 
cases serious results do not take place immediately after the 
injury; but in others, enormous extravasation of blood may 
occur immediately upon the reception of the injury—then re- 
tention takes place, and the whole cellular tissue becomes infil- 
trated with urine. 
In such cases the operation of external section becomes an 
absolute necessity, not only for the purpose of evacuating 
extravasated blood and infiltrated urine, but for the immediate 
purpose of getting a catheter into the bladder; for it becomes 
an almost impossible matter to introduce an instrument pervias 
naturales when the urethra has been lacerated. If, however, a 
free incision is made through the perineum upon the point of a 
large sound, first passed carefully down the canal to the point 
of injury, then the sound can be carried into the bladder and the 
patient placed in comparative safety. 
5th. Traumatic stricture—that is, where a stricture has been 
formed as the result of a direct injury done to the urethra ; for 
example, where fractures of the pelvis have injured the urethra 
and blocked up with a dense deposit the perineal and ischio- 
rectal regions. It is very well known how intractable such 
strictures prove, and how difficult, in many cases, it is to intro- 
duce an instrument of even the smallest size into and through 
such coarctations. In these cases ordinary dilatation proves 
inefficient, and internal urethrotomy is often of little or no avail. 
Here, then, we have an evident and clear indication for external 
section, as the speediest method by which we can gain access to 
the bladder. 
6th. A calculus impacted in the urethra behind a stricture, if 
large, may be an indication for opening the urethral canal. In 
some of these cases it is very difficult and oftentimes impossible 
to thread even the smallest filiform guide through the stricture 
for the purpose of conducting the staff of an internal urethro- 
tome. In such cases, when an imperative necessity exists for 
the evacuation of an over-distended bladder, we have only the 16 
MASTIN', 
alternative of aspiration or external section remaining; and of 
the two, external section seems preferable, and should be done, 
thus removing the calculus and at the same time opening the 
stricture by an incision directed from behind forward through 
the coarctation. Even here an exception may arise should the 
calculus be small, in which event it is best to open the face of 
the stricture through the axis of the urethra, so as to expose the 
calculus, which can then be broken up and removed by the 
urethral brisepierre of Reliquet (Fig. 1), an ingenious instru- 
ment for this purpose, which this distinguished surgeon pre- 
sented to the French Academy for its consideration in 1871. 
Fig. 1. 
7th. The next indication is when extravasation of urine has 
occurred from sudden rupture of the urethra, and in a short time 
extensive sloughing has taken place from infiltration of urine 
into the loose tissue of perineum, penis, scrotum, and groins. 
Here is an absolute necessity for making free incisions for the 
purpose of evacuating necrotic tissue together with pus and 
urine. In these cases it is well, if possible, to open the urethra 
at the site of stricture, so as to admit of the introduction of a 
catheter into the bladder. This is, however, not always possible 
when we come to consider the disorganized condition of the 
parts. In such cases nothing is left the surgeon save to meet 
the emergencies as they may arise. 
8th. The last indication, if I may term it such, is the one in 
which Mr. Reginald Harrison advocates the combined operation 
of internal and external section. He advocates doing an exter- 
nal section immediately following an internal operation, and 
then keeping the bladder emptied through a large elastic drain- 
age tube carried from the external opening into the bladder, and 
retained until the internal urethrotomy has healed. His reasons 
for this are, that patients, in his hands, have usually suffered URETHRAL STRICTURE. 
17 
from urethra] fever after the first passage of urine, and that they 
do not have that trouble until the incision has been bathed by the 
urine in its passage along the canal. To avoid this complication, 
he advises doing the external section and draining the bladder. 
As it would necessarily increase the length of this paper for me 
to enter into a long detail of his special views upon this subject, 
I shall now close the indications for the operation by calling the 
attention of those who desire to know more of his paper to 
The British Medical Journal, of July 18, 1885. 
In a given case, where an operation has been decided upon, 
the question arises as to what form of operation offers the best 
prospects of success, and which, under the circumstances, can 
be done with most ease to the surgeon. As for myself, I have 
found the operation as recommended, by Mr. Syme, not only 
difficult to perform, but unsatisfactory in its results. An estab- 
lished maxim with surgeons has been that “a stricture being 
permeable to instruments, an external division is contraindi- 
cated.” Mr. Syme, on the other hand, has reversed this, and 
made permeability an indispensable prerequisite to the perform- 
ance of an external section. To this I cannot give my unquali- 
fied assent, since, in a very large experience, I have found that 
whenever I have been enabled to pass a guide through the stric- 
ture, I have almost always been enabled to perform a successful 
internal urethrotomy. Mr. Syme has unhesitatingly admitted 
the danger of his operation, and mentions hemorrhage as being 
often alarming. This trouble I have not encountered in my 
internal sections, and when I come to examine the records of 
several hundred cases in which I have done this operation I find 
only two instances in which hemorrhage has proved a trouble- 
some factor, and both of these made good recoveries. In my 
operation for internal section I always carry my incisions through 
the upper portion of the roof of the urethra, as by so doing I am 
convinced the danger of hemorrhage is reduced to the mini- 
mum, because there are no arteries to cut, and the small venous 
bleeding soon ceases. On the other hand, extensive incisions 
made into the floor of the urethra and through the integument 
are done in the line of important structures, and vessels of con- 18 
MASTIN, 
Fig. 2. 
Fig. 3. URETHRAL STRICTURE. 
19 
siderable size, which, if wounded, give rise to profuse hemor- 
rhage, and not infrequently serious consequences. 
Again, in tight strictures it is extremely difficult to carry the 
small probe-like director (Fig. 2) from the meatus down the 
urethra and through the stricture; especially is it difficult to do 
so if there be false passages in the urethra, or within the 
stricture itself, and even if there be none already formed it is a 
very easy matter to make them. Hence it is that I should 
prefer to select the modification of this operation as proposed 
and introduced to the profession by my friend Dr. Gouley, of 
New York. 
The main points in his operation consist in the manipulation 
of a delicate whalebone guide through the stricture, upon which 
guide he threads his tunnelled sound (Fig. 3) and passes it 
down to the anterior face of the coarctation; after which he 
opens the urethra from the outside upon the groove of the 
sound just in front of the stricture. This being accomplished, 
he searches for the whalebone guide, which then serves to 
conduct a very delicate, narrow-bladed knife (Fig. 4) into and 
through the obstruction ; then the whalebone guide is removed 
and its place supplied by a delicate probe director (Fig. 6), 
which is pushed on into the bladder, and then the urethra, 
superficial fascia, and integuments are freely opened. His first 
incision is made directly in the median line of the perineum 
from the base of the scrotum to within half an inch of the 
margin of the anus, and is usually one to one and a half inches 
in length. 
In opening the stricture he directs that the edge of the knife 
be held downward, and that the coarctation shall be freely 
divided, taking care to carry the incision into the'uncontracted 
canal about half an inch posteriorly. The case is then left to 
nature, and the urethra and the wound to the unobstructed 
passage of urine. The objections to Dr. Gouley’s method are, 
the large size of the external incision, and the length of time 
required for the wound to granulate and heal. His incision 
through the stricture being made in the floor of the urethra 
endangers bloodvessels of importance, which become difficult 20 
MAST1N, 
Fig. 4. 
Fig. 5. 
Fig. 6. 
Fig. 7 URETHRAL STRICTURE. 
21 
of ligation if cut. The wound left to granulate is liable to the 
formation of numerous fistules, and a long time elapses before 
the patient is well enough to resume his ordinary vocations. 
In this connection, I may refer to the method of Mr. Wheel- 
house, which is known as “the Leed’s operation.” It possesses 
some advantages over the other forms which have been men- 
tioned, chiefly so, from the ease with which it is performed; 
but it has still the disadvantage of leaving an open wound in 
the perineum to heal by granulation, and consequently it is liable 
to the after-consequences of perineal fistula. Mr. Wheelhouse 
certainly deserves great credit for the very ingenious and prac- 
tical manner in which he has planned his operation, and his 
procedure has the advantage of greatly increased precision over 
any other form with which I am acquainted. By it an operation 
which was hitherto one of the most difficult in surgery, has been 
rendered comparatively easy, and the published reports go to 
show that the results have been vastly more favorable than from 
any other method yet described. 
This operation is done upon a special staff designed for the 
purpose, which instrument is fully grooved through the greater 
part, but not through the whole of its extent, the last half inch 
of the groove being stopped and terminating in a rounded button- 
like end (Fig. 8). The urethra is opened in the groove of the 
staff, not upon the point; in this way, certainly securing at least 
Fig. 8. 
a quarter of an inch of healthy tube in advance of the stricture; 
the opening in the urethra being held apart by two pairs of 
fixation forceps, applied one on either side, and the upper angle 
held up by the button extremity of the staff hooked in it. This 
opens the urethra and fully exposes the face of the stricture, in 
which the opening is searched for with a probe-pointed director, 
which, when it enters the bladder, is turned down so that the 
groove faces toward the perineum. Then the knife is directed 22 
MASTIN', 
along the groove and the stricture is carefully and deliberately 
opened on its under surface, and the passage thus cleared. This 
being accomplished, the probe-gorget of Mr. Teale (Fig. 9) is 
passed into the bladder with its concavity looking toward the 
Fig. 9. 
pubis, so as to receive the point of a catheter, which is now 
introduced along the urethra until it reaches the gorget, by which 
it is conducted into the bladder; the gorget is now removed 
and the catheter tied in to remain three or four days. After the 
expiration of that length of time the catheter is removed, only 
to be reintroduced each day or every second day, so as to keep 
the urethra in a state of patency until the wound in the perineum 
has thoroughly healed. The operation is ingenious, and, as a 
form of “la boutonniere,” it deserves to be recommended; still 
it has, to my mind, the disadvantage which attends all of these 
operations, viz., leaving an extensive wound in the perineum to 
heal by granulation, exposing the patient to the dangers of 
pyaemia, and the liability of urinary fistulae as a sequence. A 
very interesting description of this operation is to be found in 
the British Medical Journal for June 24, 1876, from the pen of 
Mr. Wheelhouse himself. 
The idea has prevailed that, when the external incision is not 
large and free, urinary infiltration will necessarily take place; 
but this is an erroneous conception like that which has existed URETHRAL STRICTURE. 
23 
in reference to cutting for stone. The urine, obeying the 
natural law of gravity, does not infiltrate and burrow under 
tissues when it has an open channel through which it can 
escape. So it is, whenever a stricture has been fully divided, 
the urine necessarily follows the course of the urethra. 
The healing and suppuration of an open wound being long 
and tedious, and consequently exposing a patient to the risks 
of pyaemia, whilst structures having no connection with the 
existence of the stricture are unnecessarily divided, naturally 
induced the profession to seek other and less formidable 
measures of relief. These facts led Mr. Henry Dick, of 
London, in the year 1853, to publish, in the Medical Times and 
Gazette, a critique upon the operation of Mr. Syme, and at the 
same time to lay before the profession a description of a new 
operation, which he termed “ The Subcutaneous Division of 
Stricture.” Subsequently he presented, in 1855, a memoir to 
the Academy of Medicine of France upon the same subject, 
and therein gave the histories of several successful operations 
which he had performed. After this, the operation was adopted 
by Mr. William Allingham, and also by Mr. William Adams, 
both of whom made favorable reports of successful operations. 
I will now briefly describe the method of Mr. Dick, and then 
close this paper with an illustration of an operation which I 
devised in 1868, and which, to the present time, I have seen no 
valid cause to discard. 
His method consists in first dilating the stricture sufficiently 
to admit the director of his catheter, which is a medium-sized 
catheter of moderate curve, upon the end of which are two 
buttons or knobs having a groove between them, which groove 
is continued on, into, and along the director; the catheter con- 
tains the small grooved director which can be drawn in or 
pushed out, so as to traverse the stricture (Fig. 10). 
The operation is done in the following manner: The catheter, 
with the director concealed within it, is passed down the urethra 
until its point reaches the anterior face of the stricture, when, 
by a gentle manipulation, the point of the director is made to 
engage the stricture, and is then passed on until it enters the 24 
MASTIN, 
bladder; the surgeon then takes a very small sharp-pointed 
tenotome (Fig. 11), and, feeling in the perineum with the index 
finger of his left hand for the buttons or knobs, plunges the 
Fig io. 
Fig. ii. URETHRAL STRICTURE. 
25 
knife between them into the groove and along the director 
through the stricture, being at the same time careful to see, or 
rather to feel, that the stricture is freely cut throughout its entire 
length, the edge of the tenotome being directed downward. 
After the stricture has been freely incised, the director is with- 
drawn into the catheter, which is now removed from the urethra, 
and a full-sized catheter passed into the bladder to ascertain 
whether the urethra has been fully cleared, and also to empty 
the bladder of any urine which may be present. The little 
wound is covered by a bit of adhesive plaster, a compress with 
a T-bandage completes the dressing. No retained catheter is 
left in the urethra, but whenever there are calls to urinate, the 
water is drawn off with either a silver or soft catheter. This is 
certainly a very unique and ingenious operation, and one which 
strikes at the chief point of objection to all external operations 
done in the old way, viz., an open wound in the perineum 
which, in most cases, must heal by the slow process of granu- 
lation. Still there are objections to Mr. Dick’s operation which 
will necessarily prevent its coming into general use. In the 
first place, it is difficult to perform, and requires a degree of 
dexterity which does not belong to the profession at large; 
then we have no absolute proof that the director has traversed 
the stricture, for it may have penetrated a false route, and the 
incision made subcutaneously, in that event, might be produc- 
tive of serious consequences. Then, again, he holds as a neces- 
sity that the stricture must, to a small extent, first be dilated; this 
is required before his conductor can be introduced. Now, if it 
is possible to dilate the stricture sufficiently large to admit his 
director, I hold, upon the same grounds of objection to the 
operation of Mr. Syme, that there is no necessity for an external 
operation for the reason that, if a director can be passed, it is 
possible to dilate, or, this failing, then to do the safer operation 
of internal urethrotomy. 
Mr. W. F. Teevan, of London, has proposed and executed a 
modification of the operation of Mr. Dick, having the same end 
in view, viz., to do away with a large external incision, and 
substitute in its place a small opening through which he prac- 26 
MASTIN, 
tised a subcutaneous urethrotomy. The method employed was 
simply one in which a small whalebone guide was worked 
Fig. i2. URETHRAL STRICTURE. 
27 
through the stricture, and over this a small conducting catheter 
was in its turn introduced into the bladder; then along its 
groove the tenotome of Mr. Dick carried through the contrac- 
tion, and the after-treatment conducted as in the operation of 
Mr. Dick. I am not informed of the success which has attended 
this procedure of Mr. Teevan; but if permitted to judge of the 
operation by the instruments which he used (Fig. 12), I am 
not very favorably impressed with it. 
I now desire to describe briefly an operation which I have 
employed since the year 1868, whenever an occasion has de- 
manded an external section. Thus far it has proved entirely 
satisfactory to me, and especially so to those upon whom I have 
had an occasion to perform it. 
In the year 1872 I wrote a paper upon the result of my 
operations by this method, and since that date to the present, 
with an increased experience, I have seen no reasons to alter 
the views which were then expressed. I now claim nothing of 
originality for the operation, since it is based almost entirely 
upon the old la boutonnilre; the incision being very small, and 
made anterior to the stricture ; then, a very small probe-pointed 
director, or whalebone guide is passed along through the 
stricture, and a delicate tenotome incises its upper wall subcu- 
taneously; the small wound in the integuments is closed by pin 
sutures, and left to heal by primary union. Adhering to the 
maxim, “ dilate where you can, cut where you cannot,” I only 
resort to this operation in those cases where no catheter or 
guide can be made to traverse the urethra from the meatus to 
the bladder; cases which require some operation for the imme- 
diate evacuation of retained urine, and in which it is not pos- 
sible for me perform an internal urethrotomy. 
The patient, duly prepared by opening the bowels freely with 
an enema, and a hot hip bath given to tranquillize the nervous 
system, is placed upon a table, then secured in the ordinary posi- 
tion for cystotomy, and anaesthetized. I now pass down the 
urethra the tube of Benique (Fig. 13), which is a plain silver 
tube open at both ends, about nine millimetres in diameter, and 
from six to eight inches in length; this tube protects the walls 28 
MASTIN, 
of the urethra, and puts on the stretch the face of the stricture. 
The tube is now filled with a bundle of small filiform whalebone 
probes which are carefully passed down to the stricture; by 
trying first one and then another it is possible that one may 
Fig. 13. 
engage the opening and pass on into the stricture. This being 
accomplished, I remove the disengaged probes together with 
the tube, and after securing the probe in the bladder, I pass 
over it a Wheelhouse staff which has been drilled through its 
end to answer the purpose of a Gouley staff, and carry it down 
to the stricture; it is now handed to the assistant, who holds it 
lightly, yet firmly, against the coarctation, whilst I open the 
urethra in the groove of the staff, making an incision about 
half an inch in length. I then draw outward the staff just 
sufficiently to enable me to find the whalebone probe as it passes 
through its end and on into the stricture; this I secure by 
passing a small blunt hook behind it, after which the staff is 
removed entirely from the urethra, and the distal end of the 
probe drawn out through the little wound which has been made; 
and now, over the probe I pass a little gorgeret (Fig. 14); this 
Fig. 14. 
has its blade directed upward, and being run along the probe, 
as its guide, it passes through the opening into the urethra, and 
then down the stricture, which is cut on its superior face. A 
catheter is now passed along the entire urethra into the bladder 
and the urine evacuated, after which I carefully examine the URETHRAL STRICTURE. 
29 
site of the stricture with graduated metallic ball probes (Fig. 15) 
for the purpose of detecting any bands which, perchance, may 
Fig. 15. 
remain ; if found, they are divided by the retrograde urethrotome 
of Civiale (Fig. 16), and the full calibre of the urethra restored. 
Fig. 16. 
In the event, however, that it is not found possible to pass a 
whalebone probe in the first instance, so as to gain command of 
the stricture before opening the urethra, I then pass either the 
staff of Wheelhouse, Gouley, or an ordinary staff of slight curve 
with deep groove, down to the face of the stricture and practise 
the Leed’s operation, with the exception that I do not rip open 
the whole stricture; but having gotten the whalebone probe 
through the coarctation, I thread over it the little gorgeret and 
incise it on its superior face, just as described in the instance 
where the probe was passed along the tube of Benique, always 
taking care to sever any and all bands which may remain. This 
opening simply serves the purpose of shortening the canal and 
bringing us nearer the obstruction; it furnishes us a passage of 
only some few lines in length in which to manipulate our instru- 
ments, in place of a canal of several inches in extent, as would 
be the case if the urethra had not been opened. I thus, vir- 
tually perform an internal section; I do not rip open the whole 
coarctated canal and lay bare to the external wound the cavity 
of the urethra, but I leave it, so far as the stricture is in ques- 
tion, just in the same condition as an urethra upon which I had 
done an internal urethrotomy. 
In the absence of the little gorgeret, I have found a very nar- 30 
MASTIN, 
row-bladed urethrotome of Maissonneuve, conducted by a small 
filiform bougie passed through the external opening and coiled 
within the bladder, to serve a most excellent purpose, provided 
the staff is grooved on its concavity, so as to insure the incision 
being made upon the roof of the urethra. Such, in brief, is the 
method I have adopted of operating externally, and find that it 
is easy of execution, and satisfactory in its results. 
Having carefully divided any existing bands, and restored the 
lumen of the urethra, I then pass a sound into the urethra, and, 
after the slight oozing of blood has ceased, I wash the parts 
thoroughly with cold water, to which may be added either a 
chlorine or weak mercury solution for the purpose of cleansing 
and disinfecting the wound; now I close the wound accurately 
with two or three pin sutures, passed deep enough to engage the 
divided edges of the urethral canal, and, after coaptating the 
edges of the skin, I encircle the pins with a flat thread in the 
form of the figure 8; then the sound is removed, and its place 
occupied by a full-sized catheter passed down to the prostatic 
urethra, but not into the bladder. The patient is put in bed and 
kept on his side, with instructions to push the catheter into the 
bladder when he has a call to urinate, and always, so soon as 
the urine has been discharged, to withdraw the catheter suffi- 
ciently far to get it out of the bladder, but not beyond the stric- 
ture. This catheter is used for only twenty-four to thirty-six 
hours, just long enough to insure the protection of the wound 
from the passage of the urine until it has been in a measure 
glazed over, and the strictured portion softened up by the pres- 
ence of the inlying catheter. On general principles I am opposed 
to the sonde a demean or retained catheter, and for obvious 
reasons too patent to need mentioning here; but the sound or 
catheter, used as I suggest, answers all the purposes for which 
it is intended, and keeps the urine from the wound until it is 
sufficiently protected by a glaze which prevents the urine pass- 
ing into the external incision. At the expiration of this time 
the catheter is dispensed with and the patient left to pass his 
urine at will. About the fourth, or, at latest, the sixth day, I 
remove the pins, and do nothing more to the wound save keep URETHRAL STRICTURE. 
31 
up the dressing of lead-water and opium—which is applied im- 
mediately after the operation—for two or three days longer. 
Now the patient is permitted to get up and stirabout, and within 
eight or ten days he resumes his former vocations. The after- 
attention is such as is usual in all operations for stricture, 
whether they be external or internal, viz., the systematic use of 
gradually increasing steel sounds until the maximum calibre 
attainable in the special urethra has been reached. 
With this course judiciously pursued, I find that I am able to 
discharge my patients perfectly healed within from eight to 
twelve days; and in not a single instance, out of some twenty- 
five to thirty operations, have I had to contend with any hemor- 
rhage or the annoying complication of urinary fistulae. 
The advantages to be derived from this operation are, the 
short time of confinement for the patient, freedom from hemor- 
rhage, quick union by primary adhesion, and the small amount 
of resultant cicatricial tissue, which is always deposited in greater 
proportion the longer the healing process continues. The re- 
tained catheter for the first day or two does good rather than 
harm, since it protects the fresh incision from the toxic effects 
of the urine until it has become glazed over with lymph, and 
acts, at the onset, by pressure upon the divided stricture, com- 
pressing the vessels which have been divided and which might 
bleed after reaction; it also sustains the urethra as a splint, and 
prevents the stricture from reuniting until we have time to begin 
gradual and systematic dilatation with the steel sound. The 
comparative immunity from urethral fever which my patients 
have enjoyed after this operation, I feel certain, is due almost 
entirely to the use of the inlying catheter as I employ it. I do 
not desire to be understood that I advocate the use of a retained 
catheter throughout the entire confinement of the patient to bed, 
but that I use it for only the first twenty-four to thirty-six hours 
—just sufficiently long to permit the wound to glaze over with 
lymph, and model, as it were, the granulations by gentle pressure. 
In examining the details of the last ten operations which I 
have done by this method—all of them bad cases—I find that 
they were enabled to get out and be around the city in the fol- 32 
MASTIN, URETHRAL STRICTURE. 
lowing order: 3 on the fourth day after the operation, 1 on the 
fifth day, 2 on the sixth, 2 on the seventh, 1 on the ninth, and 
1 on the twelfth. The others recovered in about the same pro- 
portions. 
I am not apprised if any other method of performing external 
urethrotomy has afforded like rapid results. 
Summary. 
1. Antiquity of operation. 
2. Brief history of its progress. 
3. Methods of performing it. 
4. Objections to performing it, when possible to pass a con- 
ductor into and through the stricture. 
5. Objections to leaving an open wound in the perineum to 
heal by granulation. 
6. The advantages of subcutaneous urethrotomy, when unable 
to relieve the patient by either dilatation or internal urethrotomy.