ORIGINAL CORRESPONDENCE. 
On the Button-holing of the Female Urethra as a Principle of 
Practice. 
SIR : In the March issue of your journal appeared a resume of an article 
in the Maryland Medical Journal, entitled “ Recent Progress in the Diagnosis 
and Treatment of the Diseases of the Female Urethra*” in which the teachings 
of Dr. Emmet are presented in the strongest possible light of commendation, 
without the slightest reference to the literature of the subject, and from which 
the reader is left to infer that the subject has no literature, or rather had re- 
mained in complete obscurity, so far as the “ profession at large ” was concerned, 
until Dr. Emmet suddenly lifted it into the light of day. 
To the Editor of Gurnard's Medical Journal— 
From this resume the object of the writer is apparent, to wit—to emphasize 
the importance alone which he attached to Dr. Emmet’s views upon certain 
hitherto neglected points of practice, especially the button-holing of the urethra, 
for prolapse of its mucous membrane, as set forth in the third edition of his 
book on the Principles and Practice of Gynaecology, which appeared in the 
autumn of last year. 
While such a review of the subject does not actually charge ignorance on 
the part of previous writers, still it must be regarded as a manifest injustice to 2 
ORIGINAL CORRESPONDENCE. 
them, simply because they are not allowed to speak; though it is true that an 
author has the right, if he chooses, to embody his own individual experience in 
a book, and present it to the public, to the almost total exclusion of the con- 
tributions of his predecessors and cotemporaries, as Dr. Emmet has done to a 
very great extent, and in that way encompass them with a larger show of 
research and originality than they may be entitled to. 
The writer of the article in question, whether prompted from motives of 
fitness, duty, ambition, or whatever other incentive, although unacquainted 
with the subject, serves up a sort of ragout, flavored to suit the 
palates of the benighted “ profession at large,” for which he evidently has 
great regard, as shown by his keen sense of taste in supplying the much- 
needed knowledge upon the process of button-holing the urethra. But this 
is not truth; neither is it conducive to the advancement of “the profession 
at large,” for which so much interest is manifested, nor does it comport with 
the highest aims and requirements of scientific investigation. 
For my part, as one of “the profession at large,” I do not share with Dr. 
Emmet his high estimate of the value attached to the button-holing of the 
urethra for prolapsus of its mucous membrane; nor would it seem that he is 
individually justified in attaching so much importance to the procedure, having, 
in his exceptionally large experience, met with it only once where it extended 
to the entire canal. 
As to any superior advantages belonging to it over the old method of snip- 
ping off longitudinally hypertrophied folds of mucous membrane sometimes 
found just within the meatus urinarius, as taught by Sir Charles Mansfield 
Clark long before Dr. Emmet was born, I fail to appreciate them, to say nothing 
of the inconveniences and sometimes difficulties and dangers attending the 
closing of this so-called button-hole, made just behind the meatus urinarius. I 
say difficulties and dangers, because the structures at the point of election are 
occasionally exceedingly thin, and the coaptation and closure of the edges of 
which require more skill than “ the profession at large ” can be supposed to 
always have. I have myself lately seen three button-holes in the locality 
pictured by Dr. Emmet in his book, in all of which there was complete incon- 
tinence of urine, arising partly from the overstretching of the urethra for 
purposes of exploration, and partly from the cutting away of the tissues 
in unsuccessful attempts to close the openings; from which it would 
appear that the closure of such openings in the urethra, as were said to 
have “ been performed by the house surgeons in the Woman’s Hospital, 
and given them for practice as one of the simplest,” is far from being a 
simple affair. I have only to say that, after thirty odd years of 
observation and experience in such matters, I have yet to meet 
with my first case of the entire prolapsus of the urethra; and from my 
knowledge of the anatomical structure of the canal, I have no reason to 
believe that I shall in the future be any more fortunate, or unfortunate, as 
it may be considered. Should it fall to my lot, however, to meet with ORIGINAL CORRESPONDENCE. 
3 
such a case, I would feel myself quite as competent to drag the prolapsed 
mucous membrane through the meatus urinarius from the upper extremity 
of the canal and cut it off, as I would through the so-called button-hole 
made just behind the orifice. Besides, where is the advantage of a nicely 
made button-hole over an ordinary round opening at the same site, which I 
commended thirteen years ago (1872) for the drainage of a hypertrophied 
urethra or urethrocele ? The latter is a term which I coined, and gave to this 
lesion at that time in a paper which I had the honor of reading before the 
Medical Society of the State of New York. (See Trans.) I then described the 
lesion at length in its relations, particularly to cystitis and ulceration and disinte- 
gration of the mucous coat of the bladder, and designated it “ tapping of the 
urethra.” Dr. Emmet does not show the slightest recognition of my priority 
respecting this point in any of the editions of his work, although he adopts it 
as a valuable principle of practice, as well as my addition of the term urethro- 
cele to the nomenclature of this class of diseases. 
But, again, as to the procedure of button-holing the urethra in order to 
draw out and cut off the thickened mucous membrane, always found, according 
to my observations, just within the meatus urinarius, I do not see why the old 
method, taught by Sir Charles Mansfield Clark, would not be just as convenient, 
thus placing the tissues in a state of drainage, so to speak, such as I insisted 
upon by “ tapping ” the canal in cases of urethrocele. 
Should I now, however, meet with a case of prolapse of the entire mucous 
membrane of the urethra, protruding through the meatus urinarius in great 
folds, and it should be thought desirable to draw it from the upper part of the 
canal (the forbidden limits of the button-holing process), or for that part of 
“tapping,” I would most unquestionably make an opening in the trigone of the 
bladder at its junction with the urethra. In this way I should expect, by 
putting both the urethra and bladder at complete rest, to accomplish the desired 
result of a cure, without further ado concerning the membrane protruding from 
the meatus. Should this fortunate result, however, not be secured in due 
course of time when it should become necessary to close up the artificial 
urethro-vesico-vaginal fistule, I would then draw the prolapsed membrane of the 
urethra towards the bladder, instead of towards the button-hole just behind the 
meatus, and then cut it off to the exact extent required to free the canal 
from obstruction. Should there be a redundancy, also, of mucous membrane 
on the vesical side of the artificial opening, I would draw this out likewise, and 
cut it off; thus leaving a free and unobstructed passage for the urine both in 
the urethra and bladder when the cure was completed. This would all be in 
strict accord with the performance of the physiological functions of both 
structures. I should expect by this procedure at least to secure one advantage, 
if no other, namely, the election of a more eligible site as regards the abundance 
of vesical tissue for experimental operations, than upon the urethra, which is 
less suited, from the more delicate nature of its structure and functions, for a 
similar purpose. 4 
ORIGINAL CORRESPONDENCE. 
In conclusion, I would say that neither do I endorse Dr. Emmet’s mode of 
operating for incontinence of urine, arising from over-stretching and paralyza- 
tion of the urethra, nor admit his claim of originality in the adoption of the pro- 
cedure, as based on the case of Lizzie Chatfield, recorded in the New York Med- 
ical Journal, August, 1881, and in the last edition of his book. All the facts 
pertaining to this case I hope soon to submit to the profession, as a defense of 
my claims of originality in this procedure. 
Respectfully yours, 
New York, May 12, 1885. 
Nathan Bozeman.