THE 
MULTIPLE WEDGE PRINCIPLE 
IN THE 
TREATMENT OF ORGANIC STRICTURES 
OF THE URETHRA. 
JOHN S. COLEMAN, M.I)., 
OK AUGUSTA, GA. 
Extracted from the 
Transactions of the American Surgical Association, 
Vol. II. 1884. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1884. THE 
MULTIPLE WEDGE PRINCIPLE 
IN THE 
TREATMENT OF ORGANIC STRICTURES 
OF THE URETHRA. 
BY 
JOHN S. COLEMAN, M.D., 
OF AUGUSTA, GA. 
Extracted from the 
Transactions of the American Surgical Association, 
Vol. II. 1884. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 884. THE MULTIPLE WEDGE PRINCIPLE IN THE 
TREATMENT OF ORGANIC STRICTURES 
OF THE URETHRA. 
It is now nine years since I published, in the Medical Record, 
of New York, my application of the multiple wedge principle to 
the treatment of organic strictures of the urethra. 
To quote from that paper: “ It ought to be a self-evident pro- 
position, that it is easier to introduce singly the component 
parts of a wedge, than to introduce it as a whole. Take, for ex- 
ample, a No. 12 conical bougie, even capillary at its point, and 
attempt to introduce it into a stricture. Where is the point of 
friction and resistance ? Is it not around the entire circumference 
of the stricture ? Diminish the size of the instrument, and, in a 
direct ratio, you diminish the amount of resistance. After 
having passed into a stricture one of these whalebone guides, 
the second has to overcome the friction and resistance of but 
half the circumference of the stricture, and the line of contact 
with the other bougie. Now that we have passed these two, 
we have a groove in front and behind them, through which we 
can readily pass the third and fourth, having now to overcome 
the resistance of but one-fourth the circumference of the stricture 
and the two lines of contact with the instruments already in 
position.” 
Since that time I have treated by this method some twenty- 
five or thirty cases with invariable success. There was not, in 
any case, marked febrile disturbance. But in some few cases 
there was sufficient constitutional irritation to cause me to sus- 
pend the treatment for a day or two. 4 
It is my habit to give, as a prophylactic, full doses of quinine, 
say fifteen to twenty grains per day. 
I will give in detail one case, as it fully illustrates my method. 
Capt. H. D. F. presented himself for treatment of a stricture of 
twenty years’ duration. 
His urine was always voided with difficulty, and the act usually 
consumed from twenty to thirty minutes of his time. 
There was marked cystitis, as evidenced by the abundant mucus 
and the decomposition of his urine. The fetor of his urine was so 
great as to necessitate the immediate removal of the “pot de cham- 
bre.” His strictures had been ruptured twice during the year 1866, 
and once in 1867, with Holt’s divulsor. 
Since the last operation he had wholly neglected himself. 
March 16, 1879. After a prolonged and tedious effort, I suc- 
ceeded in worming through his stricture one of the smallest sized 
French filiform bougies, and securely tied it in situ. Five days 
afterwards I succeeded in introducing a second by the side of the 
first, but the cicatricial tissue was so dense and unyielding that it 
was not until the fifteenth day that I could pass the third. 
On the twenty-fifth day I readily passed a fourth and fifth 
bougie. 
On the twenty-eighth day I readily passed the sixth. At no time 
was there any hindrance to the passage of the urine. Feeling 
assured that now the calibre of the urethra would admit a good 
sized instrument, I attempted to remove the bundle of filiforms. 
In this I was disappointed \ for a sufficient amount of concretion 
had formed to prevent their removal en masse. The string binding 
them together was cut, when they were readily removed, until the 
last (the first one introduced), which required some little force to 
withdraw it. Three inches of its distal end had been covered by 
a phospliatic concretion. About one-half the deposit had slipped 
off the bougie in its withdrawal. (In subsequent cases I have obvi- 
ated this contretemp by removing, from time to time, those first 
introduced, and replacing them by new instruments.) 
My patient was now so nervous that he would not permit me to 
use a sound. 
On the twenty-ninth day, retention of urine having occurred, the 
patient was chloroformed, and a No. 9 steel sound (Am. scale) 
readily passed until it reached the prostatic urethra, where it was 5 
arrested by the calculous mass. With a little force it easily entered 
the bladder. To prevent the possibility of another stoppage, to 
still further cause the absorption of the cicatricial material, and, for 
the purpose of irrigation, I now introduced and tied in a No. 16 
Nelaton catheter. Twice daily, a solution of salicylic acid and 
quinine was injected into the bladder, thoroughly washing it out. 
On the thirty-eighth day, No. 16 was removed and No. 18 intro- 
duced and kept in place four days. 
Steel sounds were now passed, from time to time, until the 
urethra was dilated up to No. 30 of the French scale. The concre- 
tions left in the bladder were all extruded within a week. (These 
specimens, together with the bougie, are here presented.) 
The patient was instructed to pass, from time to time, a large 
sized sound. 
It is now five years since Capt. F. was under treatment, and 
there has not been, so far as I know, a single symptom of a 
return of his disease. I know that many of my associates will 
object to the multiple wedge because of its tediousness. 
I claim for it safety, certainty, and a greater immunity from 
a return of the disease, than by any other treatment known to me. 
Also that it will obviate the necessity for divulsion, internal or 
external urethrotomy. My reasons for not accepting any of the 
above operations are, first, that they subject the patient to an 
unnecessary risk of life; second, that in internal urethrotomy 
from behind forwards, it is necessary to dilate the stricture to 
the calibre of a No. 7 or 9 English scale, before the instrument 
can be used; third, that internal urethrotomy from without 
inwards is, under favorable circumstances, uncertain. Even 
with Mr. Teevan’s tunnelled urethrotome (which I consider least 
objectionable) mishaps are liable to occur, vide his article in the 
American reprint of the London Lancet for 1874, page 210, 
wherein he states that one of Dr. Gouley’s whalebone guides 
“ was cut in two about its centre, six inches of the whalebone 
being left behind in the stricture. As the patient experienced 
no pain from its presence, I determined to leave it in the 
urethra, in the hope that it would set up a profuse discharge, 
and so facilitate the treatment. In this expectation I was, how- 6 
ever, disappointed, and on December ist, I removed the broken 
portion of the bougie after its seven days’ imprisonment.” 
One of the gravest and most obstinate of my cases, was that 
of a gentleman who, under the care of another practitioner (one 
whom Sir Henry Thompson characterizes as a “ knowing man 
at anatomy”), had been subjected to a forced entrance into the 
bladder. Pyaemia followed as a result of this violence with the 
formation of five abscesses. 
One at the posterior border of the right scapula, and from 
which was evacuated at least one gill of pus; one beneath the 
left tensor vaginae femoris; one beneath the right vastus interims, 
and which I believe reached the popliteal space, and one upon 
each internal maleolus. 
The life of this patient trembled in the balance for weeks, 
but he finally made a thorough and complete recovery. His 
stricture was subsequently relieved by the multiple wedge. My 
friend, Dr. H. F. Campbell, who saw this case in consultation 
with me, said that it was the only case of pyaemia which he had 
ever known to recover. I concur in the axiom first enunciated 
by Professor Syme, that “ whenever urine passes outwards 
through a stricture, an instrument ought with care and perse- 
verance be got in.” 
Also, in the dictum of Sir Henry Thompson, “ first and fore- 
most, dilatation, dilatation always, dilatation without exception 
whenever it will succeed.” (Italics mine.) In corroboration of 
my position I beg leave to make the following quotations. 
Dr. Frank H. Hamilton, in his Principles and Practice of 
Surgery, says of organic stricture : “ To the question so often 
repeated by inexperienced surgeons, What proportion of organic 
strictures can be successfully treated by gradual dilatation ? we 
answer unhesitatingly, almost every stricture into which the 
smallest sound or bougie can be introduced. And, to the ques- 
tion which naturally follows, Are there any strictures through 
which urine can pass which cannot be entered by instruments? 
we reply that we have seldom or never met with them ; and 
that such examples must at least be exceedingly rare. It is 
not pretended that all strictures of this class can be entered at 7 
once; but only with patience, perseverance, and skill, within a 
few weeks or months at most, they will in all probability yield 
to the instruments, and the bladder will be safely entered. 
“ It is an error to suppose that a stricture treated by caustic or 
incision is cured any more thoroughly than when it has been 
treated by dilatation, or, as it might be more properly called, by 
absorption. There is no soundness in the theory upon which 
the claim is attempted to be sustained; and there is no expe- 
rience to justify the assumption. We have observed the results 
of all-these forcible methods in many cases; and there is the 
same tendency in all of them to a return of the stricture, unless 
the dilatation is afterwards maintained by the occasional and 
regular introduction of instruments. The only objection that 
can be offered to gradual dilatation, then, is the length of time 
it may require to complete the cure, as contrasted with forcible 
dilatation, caustic, incision, and perineal section; but, on the 
other hand, it cannot be denied that, in point of safety, gradual 
dilatation has greatly the advantage. Death is seldom or never 
the result of the latter procedure; but, from all we have seen 
and heard of the other methods, they are followed by a mor- 
tality equal to five or seven per cent. Nor does it seem to vary 
much whether caustic, internal incision, forcible dilatation, or 
perineal section were employed. Indeed, some gentlemen of 
large experience, who favor frequent incisions, admit a mor- 
tality of not less than seven per cent., and regard it as a flatter- 
ing testimony to the excellency of their practice, because in 
very many surgical operations which are deemed justifiable, the 
mortality is twenty-five or fifty per cent. The fallacy of the 
argument is too apparent to require exposure. If one is con- 
vinced, however, that the condition of the patient demands 
speedy relief, or if it should happen that the stricture will not 
yield to gradual dilatation, the surgeon may resort to some one 
of the other methods already named, and which we shall now 
proceed to describe.” 
Dr. Otis, in his paper on Stricture of the Male Urethra; Its 
Radical Cure, published in 1875, doses with the following para- 
graph : “Strictures of a calibre of less than 16 or 18 of the 8 
French scale (7 or 9 of the English), and hence below the capacity 
of the dilating urethrotome as at present constructed, require 
enlargement by gradual dilatation with soft bougies, when this 
is well borne; if not by divulsion or the urethrotome of M. 
Maisonneuve. 
“ After having been brought by any one of these methods, 
above referred to, up to a capacity permitting the passage of the 
dilating urethrotome, complete divulsion of the stricture by 
means of this instrument may readily be effected.” (Italics 
mine.) 
In Dr. Sands’s reply to Dr. Otis, on spasmodic stricture of the 
urethra, he says: “ I have seen, in consultation, persons who 
have suffered from troublesome hemorrhage, varying in duration 
from a few days to a month, in consequence of having been cut 
with the dilating urethrotome—an excellent instrument of its 
kind, but the use of which has been carried to a dangerous ex- 
cess. Finally I have heard of a number of cases in which death 
has resulted from the employment of the dilating urethrotome. 
It is hard to obtain access to these fatal cases, which are not 
usually reported, and which are generally considered a kind of 
private property. I can state with authority, however, that 
three fatal cases of operation with the dilating urethrotome 
have lately happened in our city hospitals; two of which occurred 
last week in one hospital. 
“In two of the cases mentioned, death took place from pyaemia 
within a week of the operation. In the third case, death oc- 
curred from uraemia on the sixteenth day after the operation, 
which was performed for the division of an anterior stricture so 
slight as to be detectable only with a bulbous sound No. 24 
French. At the autopsy, three deep incisions were found, 
involving the anterior three and a half inches of the floor of 
the urethra, the mucous membrane of which, in this situation, was 
not thickened, and showed no appearance of disease to the eye# 
“ A tight organic stricture, undivided, was noticeable at the 
bulbo-membranous junction. This during life had been treated 
by dilatation.” 
In the American reprint of the London Lancet for 1874, page 9 
404, Mr. Teevan in his “ description of a catheter urethrotome 
with conducting bougie,” says: “Then again, most of the 
urethrotomes are so large at their vesical extremity that they 
cannot be used, unless the urethra has been previously dilated 
up to a certain calibre. This remark especially applies to those 
urethrotomes that divide from behind forwards. For a urethro- 
tome to be a safe and efficient instrument for the division of tight 
strictures in the deeper portions of the urethra, it must possess 
two important qualities. 
“ First, its vesical extremity must be so fine that it can be 
introduced through very tight strictures. It consequently 
follows, that the urethrotome must be one which divides from 
before backwards, for, if the stricture be capacious enough to per- 
mit an instrument to pass, which cuts from behind forwards, the 
indication for any operation is doubtful; again, if we have dilatea 
the urethra up to half its natural calibre, why should we not per- 
severe with the treatment which has been so successful, and that 
too, in the worst and most troublesome stage of the complaint? 
(Italics mine.) What we want is to save time in certain cases 
where patients have, for instance, to go to sea suddenly, and 
where time does not permit of a course of treatment by gradual 
dilatation.” 
In the abstract of Guy’s Hospital Reports in the American 
Journal of the Medical Sciences for January 1879, page 178, the 
following views are quoted from Mr. Cooper Forster : “He has 
done external urethrotomy only once in the last seven years, 
and then regretted it . afterwards, and he has never performed 
internal urethrotomy. 
“ He relies on the hot bath, opium, and gradual dilatation.” 
(Italics mine.) 
M. Despres, in a communication to the Societe de Chirurgie, 
October 16th, 1878, on the extraction of prostatic calculus, “ did 
not wish to perform urethrotomy, as he considers this an ope- 
ration which renders the stricture more fibrous and resisting." 
(Italics mine.) 
In the American reprint of the London Lancet for February, 
1879, page 71,1 find the following emphatic language from Mr. S. 
Messenger Bradley upon the subject of internal urethrotomy :— 10 
“In boldly criticising it, then, as dangerous and unsatisfactory, 
I would have you remember that it is criticism of one who has 
never performed it, and who, I think I may add, never will.” 
Sir Henry Thompson, in his Clinical Lectures on Diseases of 
the Urinary Organs, and than whom, upon this subject, there 
is no higher authority, fully sustains me in the position I have 
assumed. Vide page 32 of the above-mentioned monograph. 
“I will touch but lightly on the continuous dilatation, or the 
tying in of the instrument. There is a patient up stairs who is 
now undergoing it successfully. You have tried, we will sup- 
pose, the simple dilatation and have not made the amount of 
progress desired; or, perhaps, the patient’s avocations may make 
it necessary to have a more speedy cure. In either case you 
may say, if you can give me ten or fourteen days in your room, 
not necessarily in bed, but on the sofa quietly at home, I can 
almost certainly bring you from the smallest number up to the 
highest; that is by continuous dilatation.” As to the length of 
time required, Sir Henry claims greater potency for the contin- 
uous method than I have, as yet, been able to attain. “ In 
simple dilatation the instrument is simply introduced and with- 
drawn ; in continuous you tie the instrument in, and allow it to 
remain for several days. You tie in a small catheter, which if 
possible, is to be gum-elastic, and so that it just enters the blad- 
der. And you should always take care that it is small enough 
to pass easily, so that it lies loosely in the canal. Those three 
conditions being granted this is one of the safest and best modes 
of treating stricture.” (Italics mine.) 
In response to a note of inquiry, my friend, Dr. Eugene 
Foster, member of the American Public Health Association, and 
Ex-Vice-President of the Georgia State Medical Association, 
kindly furnishes me with the following communication. 
Augusta, Ga., Nov. 23, 1883. 
Dear Doctor : In reply to your letter of the 22d, asking my 
experience in treating strictures of the urethra by your multiple 
wedge principle, I beg to submit the following answer : I have 
treated sixteen cases of close organic stricture by your method 
(several of them of years’ standing) and every one of them success- 11 
fully. Your plan of treatment has in my hands proven itself all that 
you claim for it. I am amazed that surgeons generally have not 
tested its merits, and long since given you credit for your valuable 
suggestions. 
Signed, 
To Dr. Jno. S. Coleman. 
Very truly yours, 
EUGENE FOSTER. 
Conclusions.—In the foregoing paper the following are the 
principal precepts that have been advocated:— 
First: That in the treatment of organic strictures of the 
urethra, urethrotomy, whether internal or external, and also the 
method by divulsion, are attended with serious risk to the patient 
on account of hemorrhage, pyaemia, and uraemia. 
Second: That strictures treated by these methods are no 
less liable to recurrence than those treated by gradual dilatation. 
Indeed, unless followed by persistent dilatation they are subject 
to early relapse. 
Third: That gradual dilatation of urethral strictures, though 
of slower progress in the beginning, is almost entirely free from 
danger, more permanent in its results, and upon the whole the 
shortest and most perfect method of cure. 
Fourth: That in the treatment of tight urethral strictures the 
multiple wedge principle devised by the writer, viz., that of 
introducing side by side and one at a time successively a number 
of filiform bougies, whether applied to the interrupted, or the 
continuous method, offers to the surgeon the easiest, safest, and 
best method for effecting the solution, or absorption of the mod- 
ular tissue, and for removing the obstruction. 
Note.—In the discussion of the above paper, as reported by 
the Medical Record of New York, “ Dr. Sayre thought it some- 
what strange that the author of this paper claimed to be the 
originator of the multiple wedge system, since to his personal 
knowledge it had been in use in Bellevue Hospital, New York, 
for at least twenty years.” 
To me, it is passing strange that my friend, Prof. J. W. S. 
Gouley, a member of the staff of Bellevue, and the author of 
one of the best monographs on “ Diseases of the Urinary 12 
Organs,” should not have appreciated a system, which, accord- 
ing to Dr. Sayre, had then been in use in the Hospital for 
eleven years. That he did not do so is manifest from the fol- 
lowing language in his let.tr to me of date Dec. 9th, 1874. 
“ I have myself wedged in two and sometimes three of these 
bougies side by side, and have thus rendered otherwise impass- 
able strictures amenable to ordinary dilatation. Three years ago 
I had some probe-pointed whalebone bougies made very small 
(capillary), for the first two inches from the vesical .end and 
thence increasing gradually to Nos. J, 1,2, 3, and 4, so that I 
could accomplish more dilatation with a single bougie at one sitting 
than I could with two or three ordinary whalebone capillary 
bougies introduced side by side!' (Italics mine.) 
I claim to have made the multiple wedge principle a system 
for the treatment of tight, close, and otherwise impassable stric- 
tures, to have given it a name, and to have been the first to 
make it known to the profession. 
Whewell says “ names record discoveries.”