Extracted from tiie Transactions of the Medical Society of the 
State of Pennsylvania, for 1877. 
URETHRAL FISTULA, 
TREATED BY MEANS OF THE ELASTIC LIGATURE. 
By JOHN H. PACKARD, M.D., 
OF PHILADELPHIA. 
Mr. President : 
I beg to occupy the time of the Society for a few moments with 
an account of a case in which a very difficult condition of things was 
remedied by the employment of a method which, although not old, 
has been already somewhat extensively used, but which, in this 
application, I believe to be new. 
The lesion was a perineal fistula at the peno-scrotal angle; the 
remedy was the elastic ligature. 
The patient, Edward 13., was a boy 14 years of age, stunted, small, 
and delicate looking, who had had urinary trouble for seven years. 
Neither he nor his friends could give any accurate history of his 
case; but on his admission to the Episcopal Hospital, Oct. 7, 1876, 
he had some narrowing of the urethral canal, and three fistulous 
openings communicating with it. One, at the peno-scrotal angle, 
had existed ever since an attack of sickness when he was about seven 
years of age. The other two were situated, one on either side, about 
half way between the anus and the tuber iscliii, and were said to 
have been first noticed in the-autumn of 1875. 
There was no history of injury so far as known. 
Until within the last year he had been unable to control the 
evacuations from his bladder, day or night; and his clothes had 
been constantly saturated with urine. He now, by passing water 2 
frequently, could avoid this. The stream was of fair size. The 
urine was loaded with a heavy }Tellow deposit, consisting of pus, 
mucus, and vesical epithelium, with some black granular amorphous 
matter, probably broken-down blood. 
Latterly there had been some dribbling of urine from the left 
perineal opening. 
Oct. 10, 1816. He was etherized, and perineal section performed 
on a small staff. In introducing the staff a slight roughness was 
felt, as of a calcareous deposit. A free incision was made in the 
median line. Probes introduced at the fistulous orifices were 
brought out through the wound of operation, and by means of them 
a seton of ligature-silk was passed through each sinus. 
21th. An oakum seton was substituted for the silk in the anterior 
fistula, the sinus showing no tendency to heal. 
Nov. 16. An elastic ligature was tied to the oakum seton, drawn 
through, tightened so as to produce slight constriction, and its ends 
tied together with a thread. By this means, the constriction being 
renewed every two or three days as the tissues yielded, the division 
was being very satisfactorily accomplished, when 
Dec. 10. The rash of scarlatina tleveloped itself, and the local 
treatment was for the time suspended. 
21sf. Elastic ligatures were passed through the other sinuses, 
brought out at the wound of operation, and tightened. 
Jan. 26, 1871. The fistulous tracts had become so superficial, the 
tissues having closed in behind the advancing ligatures, that they 
were laid open by the knife, and healing took place very readily, 
though I think not quite so soon as would have been the case had 
the elastic ligature been allowed to do the whole work. 
The difficulty of dealing with cases of this kind is probably known 
to every practical surgeon ; cases, I mean, where a fistulous track 
extends forward to the peno-scrotal angle from some point far back 
in the urethra. By a very careful and painstaking dissection the 
tissues may be divided so as to lay the sinus open ; but this involves 
so much trouble and risk that most surgeons would hesitate long 
before undertaking it. The plan adopted in the case now reported 
is easy, painless or nearly so (after the perineal section has been 3 
performed), and devoid of danger. The diagram will show, perhaps 
more clearly than would be possible by any description, the work 
accomplished by the elastic ligature. 
It is noticeable that the tissues closed up behind the ligature 
very kindly, as it made its way through. This has been the usual 
experience of the reporter in cases of fistula in ano, etc., although 
some surgeons have found the healing process less prompt.