cannot be effected through the natural passages; (2) in the presence of injuries of the urethra; (3) in the presence of strictures of the urethra which are either impermeable or not accessible to treatment by dilatation for various reasons; (4) for the establishment of a urethral fistula; (5) as a preliminary operation to median section for stone.

The mucous membrane of the urethra is readily reached with the knife in its pendulous portion after division of the skin, the dense fascia, and the corpus spongiosum. The bulb of the urethra is accessible in the middle line through an incision in the perineal raphe, after division of the skin, the tunica dartos, the superficial perineal fascia, and the bulbocavernosus muscle. The corpus

spongiosoum is thicker in this situation than elsewhere, so that the urethra lies at greater depth than common. To the central side of the bulb the urethra recedes more and more from the superficial level of the perineum, passing in an arch upward and backward to the orifice of the bladder. The rectum lies with its anterior wall in close

relation to the prostate gland and is indirectly attached to the bulb of the urethra at its perineal curve through some fibers of the sphincter ani and bulbocavernosus muscles. If it is desired to reach the membranous or the prostatic portion, the muscular and fibrous connections between the anus and the prostate gland must be divided transversely, when after blunt dissection of the rectum,

which is reflected toward the sacrum, the proximal portions of the urethra, the membranous portion and the prostate are rendered visible and accessible to surgical intervention.

The performance of urethrotomy is subject to various modifications in accordance with the indications for the operation. The patient lies upon his back with the lower extremities flexed at the knee and the hip (position for cutting for stone). The operator is seated in front of the patient. The urethra is invariably opened in the median line through the raphe of the perineum.

Urethrotomy with a Guide.-A metallic sound grooved upon its convexity is introduced into the urethra to a point beyond the constriction that is to be divided. The guide is held by an assistant accurately in the middle line. If the incision is to be made into the perineum, the scrotum is lifted up. The operator determines by touch with the finger the position of the resistant portion of the urethra, which is perhaps a stricture surrounded by callus, and

makes an incision over it in the middle line. If the narrowing be at the junction between the bulbous and membranous portions, the incision passes from the root of the scrotum almost to the anus. By dissecting layer by layer in the median line the callous and narrowed portion of the urethra is reached and an incision is made in the line of the cutaneous wound until the groove in the guide is exposed. The callus is divided up to a point where the urethra is of normal caliber. The introduction of a retention-catheter concludes the operation.

Urethrotomy without a guide is an incomparably more difficult operation than that just described. The operator occupies the same position as in cutting for stone. The sound can be introduced only to the anterior portion of the stricture if this be impermeable. The cutaneous incision is made as in the operation just described, in the median line through the perineal raphe. The portion of the urethra lying to the distal side of the constriction is incised and the margins of the wound are separated by

means of small tenacula. An effort is made to find the lumen of the constriction and to gain entrance by means of a thin bulbous instrument. If this can be done, the cicatricial tissue is divided in the middle line on its under surface to the sound, and the incision is continued beyond the narrowing of the urethra.

As a rule, the detection of the canal of the urethra at the distal extremity of the stricture is attended with difficulty. The tissues are changed from the presence of cicatrices, and the hemorrhage from the cavernous bodies and from the bulb is often considerable, so that it can be readily understood that the small lumen of the urethra may escape detection in the limited field of operation. Indiscriminate incision into the callus is not to be commended. By means of manual expression of the bladder it may be possible under circumstances to cause the escape of a few drops of urine into the wound and in this way to gain an idea as to the situation of the orifice of the stricture. If it has been possible by this means, under guidance of the eye, to introduce a bulbous bougie into the orifice of the stricture, the division of the narrowed portion of the urethra will be unattended with any further difficulty.

After division of the stricture a catheter of considerable caliber can always be introduced with aid from the wound through the entire urethra into the bladder. In the event of failure to divide the stricture through the wound there remains yet the resource of retrograde sounding of the stricture, posterior catheterization. This may be undertaken:

(1) Through the urethra, after exposure and incision of the urethra to the proximal side of the stricture;

(2) Through the bladder, after this has been opened by means of a suprapubic incision.

In performing retrograde catheterization through the urethra the deeper portions of this canal (the membranous portion) are exposed by detaching the lowermost extremity of the rectum. To this end the perineal longi

tudinal incision is either prolonged to the anus or the detachment of the rectum is undertaken through a prerectal curved incision. After division of the skin the connections between the sphincter ani and the bulbocavernosus muscles are divided transversely and then the anterior wall of the rectum is freed by blunt dissection from the cutaneous covering. If the bulb of the urethra is retracted upward and the rectum downward, the membranous portion can be dissected in the upper angle of the wound. The membranous portion, which is readily palpable as a rounded prominence, is incised longitudinally for a distance of about 1 cm., and retrograde sounding can be practised through the narrowed portion, which is then divided.

Retrograde sounding of the stricture can be practised also from the bladder, after this has been opened through a suprapubic incision. The patient lies upon his back, with the pelvis elevated, and the bladder is opened in the usual manner above the symphysis pubis. The incision in the bladder is held open by tenacula and an English catheter of small caliber is pushed forward under the guidance of a finger through the neck of the bladder into the urethra to the point of obstruction. The patient may be placed in the position as for the operation for stone, the wound in the perineum held open by tenacula and the stricture is passed or merely entered by pushing the catheter forward from the bladder. In the first event the stricture is divided down to the catheter; in the second, the portion of the urethra lying to the proximal side of the stricture is opened and the stricture itself is successively divided with scissors from behind forward. The last step is, as a rule, effected without difficulty.

Urethrotomy is indicated after traumatic rupture of the urethra, complete or incomplete, when catheterization is attended with difficulty, or urinary infiltration is threatened. The incision is made through the perineum in the raphe, over the greatest prominence of the perineal bulging that is always present. After division of the skin