* X
OX THE
EMPLOYMENT OF A NEW AGENT
IN THE TREATMENT OF
STRICTURES OE THE  URETHRA.
   BY HENRY J. BIGELOW, M. D.,
ONE OF THE SURGEONS OF THE MASSACHUSETTS GENERAL HOSPITAL.
i&3?tf
          BOSTON:
DAVID CLAPP, PRINTER....184 WASHINGTON STREET.
            1849. 
 
          ON THE  EMPLOYMENT OF A NEW AGENT

                                IN THE

TREATMENT OF STRICTURES OF THE URETHRA.

                      BY HENRY J. BIGELOW, M.D.
[From the Boston Medical and Surgical Journal.]
   This method consists essentially in the use of gutta percha in taking the
impression of a stricture ; and also avails itself of the plasticity of this
gum in dilating the stricture.*
   There is, in general, no great difficulty in the treatment of a stricture
near the orifice of the urethra.  On the other  hand, a contraction of the
canal far back towards the  perineum often presents serious  difficulties.
The  introduction  of an  instrument is  then  sometimes impracticable, or
requires  a tedious and  very careful manipulation.   It is  plain that one
great difficulty exists in  the  inability on the part of the surgeon  to as-
certain the precise character of the lesion ; the  geography  of the part
to be traversed by the bougie.  It is well known that this contraction is
susceptible  of infinite variation.   It is abrupt  or  gradual, concentric or
lateral, straight, angular, curved  or spiral, smooth or  knobbed, long or
short, and finally partial  or  exaggerated; and  against all  these varieties
the principal weapon in  the  hands of  the surgeon is the bougie.   This
instrument, with little available  variety, either in its material or confor-
mation, is a point attenuated or obtuse,  urged  by a  force applied at per-
haps six inches distance ; and  is  expected to thread its way among the
complicated  and  winding labyrinth which often constitutes a  stricture.
Fortunately, the healthy canal  traversed by the bougie generally so di-

  * The use of gutta percha bougies is not new; it is attributed to a physician at Singapore ;
but I have neither seen nor heard any allusion to their being employed to take impressions of stric-
tures, which, so far as I can judge, constitutes their chief if not their only value.  I have received
within a day or two, through the politeness of Mr. Burnett, apothecary in Tremont Row, a sample
of bougies with which he  has been furnished by the Gutta Percha Company in New York, ex-
cellent in appearance, but which I havd not had an opportunity of testing.
               1 
o
rectsit, that when the contraction is not great, the point enters its orifice
after more or less  manipulation.    Yet it will  be  conceded  that  this
manipulation, however delicate and skilful,  is often,  and of necessity,
only a series of tentative thrusts or offers, made in the dark, in the hope of
ultimately  discovering and traversing some interval  or  interstice should
such exist.
   Other circumstances, such as the  density and character of the opposing
tissue, and the necessity of employing or of avoiding protracted pressure,
complicate the problem.
   The  common  method, it is true, is often  quite  effectual and satisfac-
tory ; especially in the ordinary run  of cases of simple or partial contrac-
tion.   Yet there is  something  gross in it.  It  is  wanting in the nicer
modifications  of  art  which should  characterize surgical  manipulation,
when they do not interfere  with its simplicity.   Nor are the  results of
this process always satisfactory ;  especially when  the case is difficult, or
the operator inexpert.  It will soon be shown that false  passage is  very
common in connection with old stricture ;  simply because  the  propelled
instrument, finding no natural canal, has made one for itself.   Or, as not
unfrequently occurs, when the  urine dribbles away, no canal can be de-
tected and no instrument of dilatation passed.
   These difficulties are not new.   Different methods have been devised
to bring the  part to  be operated upon more directly in  contact  with the
senses of the operator; such as a lamp to  illuminate the stricture, and a
tube to see it.  Ducamp insisted upon the great advantage of impressions
in wax,  as conveying an  idea of the conformation of a stricture, and
contrived hollow tubes, containing  eccentric bougies  sliding  out like  a
telescope at one side  of the distorted canal.
   Whoever  has  tried this wax has probably found, that however  good
the impression received in  the interior may be, it is  lost, either when the
material  is extricated from  the  stricture or subsequently from  the canal.
It is of  questionable utility in this  point of view.    Besides, the wax  is
soft and liable to break ;  and  lastly, when moulded to the  canal, it  is
itself of no  use in dilating it, and  another instrument of corresponding
outline must be arranged for this purpose.
   The advantages of gutta percha are, first, that  it is probably the only
material  in the world capable of receiving an acute impression at a tem-
perature quite comfortable to the  skin, and at the  same time of retaining
it entirely, at about the actual  temperature of the body ; then becoming
hard and  resisting, besides  being exceedingly tough, even in attenuated
filaments.  It follows, that upon being withdrawn from the urethra, it pre- 
3
sents a perfect impression  of  the  most minute  inequalities of the callus
against which it has impinged.
   In the second place, it may be  used when thus moulded as  a dilator
of the stricture;  and it can be made to enter with unerring certainty any
of its orifices.
   A few words will suffice to describe the method I have adopted in em-
ploying these bougies.   A medium size  answers a good purpose, unless
there be strictures anterior to the one to be treated, in which case a  small
calibre is sometimes requisite.  Let the bougie be oiled and the tip passed
to and fro  rapidly  in  the edge  of the  flame of a candle, until it is so
warm that the nail will indent it;  the mass will  remain  plastic  after the
surface has ceased  to  be  hot, and  may be  rapidly passed  down  to the
stricture, being  very smooth  and  pliable.   If it be pressed against the
stricture for a minute with a force  equivalent to an ounce or two of weight,
and  then left to cool during the succeeding  three or four minutes, it will
present, when slowly and  carefully disengaged  from  the stricture, a firm
and unyielding impression of the most minute inequality and indentations of
the callous surface.  The tip  may be cut off  and preserved,  furnishing,
with others, a complete history of the conformation of the stricture under
treatment.
   If water be employed to heat the gum,  it will be found that the steam
from the surface will soften the  rod for  the length of an inch or more ;
rendering it liable to curl up against the stricture, as small elastic bougies
are apt to do.  The tip  alone should be softened. On the other hand, care
should be taken  not  to burn  the gum ; its texture  and ability  to harden
are thus destroyed, and a piece may be left in the stricture.  Such a case
occurred to me.   A plug was thus left in a small stricture, causing reten-
tion  of urine during eighteen  hours ; when the orifice having become di-
lated, the  plug was forced  out by the urine ;  which then  flowed  more
freely than for many months before.
   Pure gutta percha softens most readily and cools with least elasticity and
shrinking.  It is therefore far better for impressions than when adulterated,
as is common, with caoutchouc.   But  when pure, a little oiling and use
soon raises a fur upon its  surface ;  so  that it is probable that some  com-
pound will answer  better  for mere bougies.
   I have hitherto made these rods from  pure  gum, of the thickness of
sole leather, cut into square strips, plunged into boiling water, and rolled
between two boards, care being taken to prevent twisting.
   When the bougie is imbedded  in  the stricture, let its head, or external
end, be warmed  and flattened in  a vertical or  transverse  direction  with 
4
reference to the pubis, and it will  indicate, when withdrawn, the position
of the inequalities in regard to the periphery of the canal.
  Suppose, now, that the impression, as is frequently the case, is forked.
Examination of the extremities often indicates which  is  the true passage
and which  the false; or  if not, the  larger is generally  the true  passage.
Let the false extremity be carefully shaved  off and  the bougie  returned
into the urethra, its flattened head maintaining its relative position to the
pubis.   It  forms  a conical bougie  of the best description, exactly adapt-
ed to the form of the true passage, which it  inevitably  enters.   Impres-
sions also record  and especially direct  the  progress  of a cutting instru-
ment, as seen in the annexed sketches.
  The general pathology of stricture is not here discussed ;  but it  will
be quite obvious that there are cases of irritable and inflammatory stric-
ture in which this method of dilatation, as well as all  other  active  me-
chanical treatment, would be inappropriate.   Nor are the relative merits
of dilatation, incision  and cauterization here  considered.  Each is occa-
sionally a  valuable resource ;  the progress  of all  is incalculably aided
by the knowledge derived from impressions; while  the first, by far the
most  valuable  mode  of treatment, is  considerably  accelerated  by the
actual  employment of the gutta percha.
  The annexed  sketches will give  an  idea of the character  of the
impressions.  They  are a few, selected  from a considerable  number, to
illustrate several points.
  The first line of the annexed print presents impressions with false  pas-
sages, taken in  the course of the treatment of the first case detailed below.
The three  first  figures represent different  impressions  taken early in the
treatment.   The fourth and fifth  represent the  bougies  used as  dilators
after the  impression  of the false passage  was  removed ; and  the  last
figure  shows the impression when  the canal  was easily pervious  to a
moderate-sized  bougie.
  The figures  numbered 2 are different impressions of the same stricture
at different periods of treatment.
  3.  An old stricture, nearly impervious, from a patient who died of in-
flammation of the membranous portion of the urethra.
  4, 5. Impressions of incisions.   These incisions were made with Ra-
tier's instrument,  sketched below,  in this connection,  and which  is by far
the best of a number  I have employed.   The blade slides back obliquely
into the canula.
  6.  An excellent impression  of  an  old stricture.  Two perfectly  simi-
lar  impressions were  taken  upon succeeding days ; indicating that no 
5
doubt could exist  of the character of its outline.  The  stricture was in-
cised  exactly at the point  calculated, the  parallel lines  indicating where
the impression of  the two incisions, seen in the small figure, corresponds
with the original impression.
   At 8  is seen the  last  impression  of these and subsequent incisions;
three  days after which, the canal was entirely pervious.  These are from
the second case detailed below.
   7, 9,  are given  as good impressions of curious strictures.
   The following  are two cases of bad  strictures which had resisted pre-
vious  treatment.   I believe  the success  attending their ultimate  treat-
ment  to  be due  to the  assistance derived from the gutta percha.  They
are here detailed as the  first  cases subjected to this  treatment,  and they
were  examined by  various professional gentlemen  from different parts
of the country, who happened to visit the Hospital during the summer of
1848, and an account of them was read to  the Boston Society for Medi-
cal Improvement soon after their occurrence.
   Obstinate Traumatic Stricture, with Fistula behind Scrotum.-----
-----, set. 38.  Patient has had gonorrhoea many times—last time four years
ago. In 1832, after exposure to cold and wet, great  difficulty in micturition.
Again in 1837 had a similar attack.
   June  1,  1848.—Eighteen months ago,  fell astride  of the  rail of  a
ship ;  was made insensible, and afterwards had much difficulty in urinat-
ing, and  passed bloody urine.  Last July, after much difficulty in mic-
turition,  a swelling formed  in  perineum, just  behind  scrotum, opened
externally,  and through the  opening pus  and urine escaped  together.
Urine has flowed more or less in this way since.
   Now, penis and scrotum swollen ; the scrotum quite dense,  firm, en-
larged and thickened, especially at posterior part.
   Just behind scrotum is a small red eminence which marks the entrance
of a fistula, from which urine drops at every emission.
   The smallest sized catheter passes  through a stricture just  before  the
scrotum, but is arrested about two and a half inches farther by a stric-
ture into which it  passes about half an inch.
   Has had much fruitless treatment with instruments before entering the
house, and is sure  none have ever entered  bladder  until about a month
ago, when a small steel wire was passed twice or three times by the pa-
tient himself, and which was followed by much constitutional irritation.
   Patient states that he is unable now to discover this canal, to which
chance directed the instrument.   In the course of several explorations, I
succeeded in passing the wire once ; but tire  mass was dense and  carti- 
6
laginous  to  the feel, and it was  evident  that nothing  could be gained
except by consecutive dilatation ;  which it was  impossible to adopt, on
account of the uncertainty of entering  the stricture, without protracted
and irritating manipulation.   This was a stricture of  the worst class, oc-
cupying a long and  dense  cicatrix, and complicated both  with a  false
passage at its entrance, which was liable to  engage the bougie, and  with
an old  fistulous sinus.
  June 3d.—An  impression  of the stricture was taken with engravers'
wax ;  but this being  unsatisfactory in  its  indications, the gutta percha
was tried  the next day, and yielded, from the orifice of the stricture, one
of the three first impressions of which a sketch is given.   In the course
of the  week, as the patient was able to bear the treatment, the false spur
was removed from the bougie, as  seen in the sketch, and the rod, guided
by the flattened head, was passed into the true canal.
  On  the 16th, by the  same guide,  incisions were made with  Ratier's
instrument; and on the  23d,  three weeks from  the  beginning of  treat-
ment, a small silver catheter  was  easily passed into the bladder  and left
there.
  July 6th, the patient was able   to retain a medium-sized flexible  bou-
gie for an hour or  two without pain.
   15th.—" Now  introduces, and  wears with ease, a No. 11 flexible ca-
theter."   The last impression is seen in the plate.
  At this time he suffered from a severe constitutional attack.   Pain in
the scrotum, with swelling—general  heat—pulse  100—tongue furred.
On the second day, anorexia and  nausea—pulse 116.  Not relieved by
an emetic.  On the third day, pulse 160—much nausea.   Being unable
to discover other  local difficulty, after  careful exploration of the viscera
and functions, and the patient looking  badly, I determined to divide the
scrotum on  its posterior  aspect;  which was done.   The patient being
etherized and  placed as for lithotomy, and with the valuable assistance of
Dr. Townsend, a grooved staff was passed into the bladder, and an incision
about  three  and a half or four  inches  long was made in the perineum,
through  the thickened callus, until, at  the depth of nearly three inches,
the sound was exposed and the urethra divided to some extent, and nearly
as far as the bladder,  for the purpose  of dividing, if possible, the  internal
orifice  of  the  old  fistula.  The source  of the constitutional trouble ap-
peared in a small collection of pus  in the heart of the callus and  quite
near  the urethra.  During  the  three succeeding days  the pulse was
successively  128,  120,  90,  with returning appetite and corresponding
improvement in appearance. 
/
  From this time the patient steadily improved.   Ointments,  fomenta-
tions and poultices, compression and bandages, were applied as indicated,
the  patient soon taking  into  his own  hands the treatment by bougies, of
which he wore or passed with ease the  larger sizes, until  in  November
the  urine flowed in a good  stream, with a drop or two from the perineum
once in  two or three days.  The patient left the Hospital, at the  end of
the  year, with  a bougie to gauge occasionally the calibre of his urethra,
and much gratified with his improved condition.

  Stricture of the Cavernous Portion, with Fistula.----------, set. 72.
" Reports that after exposure to cold  eleven years ago, stricture was first
troublesome.  A year  ago, after another severe exposure, stricture again
came on, and was treated  with bougies.   Five months ago suffered from
retention of urine, and  at this time a  fistula was formed below the stric-
ture, through which most of the urine has since escaped."
  Sept. 20, 1848.—" Now a fistula  exists at  the right side of the scro-
tum, of considerable size.  Urine passes  chiefly  through this passage."
  21st.—" A gutta percha bougie was passed, which retained, on being
withdrawn, the perfect  form of the stricture."
  This impression, numbered 6 in  the plate,  was  twice taken at  the in-
terval  of two  days, leaving no doubt of its  accuracy ; and exhibits a
minute  prolongation  like the head of a snake, indicating an almost com-
plete obliteration of the canal.
  From this period till  the end of the month  the  stricture was  several
times incised, and a number of impressions  taken,  the first of  which,
with two incisions, is represented at No.  6 bis;  while  the last is given at
No. 8, showing how large  a calibre the  canal  had then attained.  The
stream of urine was  now tolerably free,  while the dribbling of the fistula
had decreased ;  and the canal being somewhat sore  at the incised portion,
I forebore at this time to  pass an instrument into the bladder.   A few
days after, my friend Dr. Warren, Jr., who  at this time succeeded me in
the charge of the ward,  informed  me  that an instrument had  readily
passed the former strictures into the bladder.
  In the course of three weeks the  patient left the hospital with a canal
of good diameter, and provided with a flexible  bougie for  his own use.
The fistula was not entirely healed, yet no urine passed by it.
  It is well known that old fistulas in  the urethra  rarely heal.  On  the
other hand, the stricture which accompanies and produces them is capa-
ble  of causing infinite mischief.  A case  of this sort occurred to me while
the  above cases were under treatment. 
8
   A patient, about 45 years of age, had a stricture of a number of years
standing.   Exposure  aggravated  it, with  retention.   The urethra burst
behind the scrotum, and  when I saw him on the fifth day, the penis and
scrotum were  tumefied  and gangrenous.   A  little oedema  only existed
about and above Poupart's ligament; yet I deemed it advisable to incise,
besides the former regions, the integuments of the abdomen on both sides.
Much urine escaped from the scrotum and cellular tissue of the penis,
while that of  the abdomen appeared healthy in  the course of an oblique
incision in each  iliac  region  three or four inches in length, and as  deep
as the tendon  of the external  oblique.   Yet a few  days sufficed to show
that here, also, the cellular membrane  beneath the superficial fascia was
infiltrated  with urine, for an apron of  slough was soon  formed   between
skin and muscle,  as high as the navel  and laterally backward,  discharg-
ing profusely pus  with  urine, and the  patient succumbed on the seven-
teenth day.

   Both the first  were  cases  of  obstinate  stricture  of  long  duration.
Both had undergone protracted  treatment without success; the former
in  two  hospitals  ; and  the voluntary  attestations of both,  inasmuch as
patients with old  strictures usually get  to  be in  some  measure connois-
seurs of local  treatment, may be  considered as having some weight in
favor of the facility and efficacy of the treatment by gutta percha. 
 
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