RUPTURE OF THE URETHRA, 
-WITH 
EXTRAVASATION OF URINE, ETO. 
IE3 AT 
THOMAS R. WRIGHT, M. D., 
Demonstrator of Anatomy Medical Department University of Georgia at Augusta. 
Read before the “ Augusta Academy of Medicine,” March 2 d, 1881. 
Among the multitude of surgical troubles to which human flesh is 
heir, there is possibly none which causes the surgeon more anxiety and 
trouble than one of extensive urinary infiltration ; and especially one 
in which the perimeum and scrotum have been infiltrated and dis- 
tended with offensive decomposed urine. The following case, illustra- 
tive of this condition, may be ot interest: 
On the 22d of November, 1880, I was sent for to see Dennis A., a 
negro man about fifty years of age, the messenger stating “that the 
old man could not pass his water, and that what he did make went 
into his bag, which was as large as a baby’s head.” Upon seeing the 
patient, the following history was obtained: Some years before he had 
trouble in making water, and was then treated by a doctor who re- 
lieved him, and he had no more trouble until ten days before he sent 
for me, when he again had some difficulty in voiding his urine. 
Thinking this was a small matter, he took some domestic remedies, 
hoping to get relieved, but failing with these, by the advice of friends, 
he partook very freely of watermelon-seed tea. After taking this tea 
his desire to pass water was so great he thought if he would strain with 
all his might he would be relieved; he did so, and making a violent 
effort he said he felt something give way, and was relieved for a while. 
Shortly after this, his privates began to swell and burn and pain him. 2 
On examination the perinseum, scrotum and lower portion of the ab- 
dominal wall were found infiltrated with urine, his scrotum, in fact, be- 
ing “as large as a baby’s head.” From the history and condition of 
the patient I suspected the trouble, and tried to pass a No. 7 elastic 
catheter, but failed, the instrument meeting with what seemed, and 
afterwards proved to be, a very tight stricture a little anterior to the 
bulbous portion of the urethra, An attempt was then made to pass a 
filiform bougie, which was finally successful. After the bougie passed 
the stricture it entered any number of false passages, making it appear 
as though the urethra back of the stricture had been torn up by the 
rough use of instruments, and it was only after long and patient trial 
that the instrument was carried into the bladder. An attempt was 
then made to pass a larger instrument, but was unsuccessful. Not 
having my dilator or urethratome with me, I decided to incise his scro- 
tum freely, put him thoroughly under quinine, and leave him until next 
morning, it being late in the afternoon when I saw him and some dis- 
tance from the city. 
Calling the next morning, with Prof. DeS. Ford, whom I had asked 
to see the case, we again tried to pass a large bougie, but failed. 
Ether was then given and another attempt made only to fail. The 
filiform guide was then passed, and upon it Gouley’s tunnelled dilator 
and urethratome was carried through the stricture, when it was dilated 
and then cut. This was then withdrawn and a Gross’ dilator intro- 
duced and the stricture dilated to 25 on the scale. A catheter was 
then easily carried into the bladder, a little ammoniacal urine flowing 
out, the instrument being left in the bladder. The scrotum had 
diminished some but was still very large, and was again incised. Five 
grains of quinine were ordered given every four hours with 15 drops 
of tinct. ferri chlor. three times a day, with brandy, milk and eggs. 
On the third day my patient’s general condition was a little better; 
he had removed the catheter, however, and his scrotum was larger 
than ever. His wife stated that he pulled the instrument out, and 
then desiring to urinate had gotten up to do so, and on making the 
effort “his privates (as she expressed it) swelled right out,” no urine 
coming by the urethra. A catheter was again introduced into his 
bladder, and the necessity of its remaining there explained to him, the 
same directions for quinine, iron and nourishing diet being continued. 
On the fourth day (25th) the man’s condition was not so good; the 
scrotum and perinaeal tissues in about the same condition, with the 
catheter again removed, no urine having passed since its withdrawal 3 
in the early part of the night. The condition of the man was now 
such that I began to think of the propriety of performing perinaeal 
section; the man could only void his urine by the aid of the catheter, 
and this he would not allow to remain in his bladder, and any attempt 
to pass his water without it seemed only to force the urine through the 
ruptured urethra into the already distended scrotum and perinaeum, 
and even while the catheter was in the bladder, there was no appreci- 
able change in the infiltrated parts, thus leading me to believe the 
urine was passing along the outside of the instrument and getting into 
the tissues. I thought if the section was made and the urethra entered 
behind the seat of rupture and free passage given to the flow of urine, 
it might be of service to him, although I feared the operation had al- 
ready been too long delayed. The operation, with its possible termi- 
nation, was then explained to him and his family, when all agreed that 
it should be done. Accordingly the operation was decided upon, and 
with the assistance of Drs. DeS. Ford and Perrin, performed as fol- 
lows : The patient being in the lithotomy position, a small grooved 
staff was introduced into the bladder and an incision made in the 
median perinaeal line down upon the groove, and the urethra entered a 
little anterior to its bulbous portion. A female catheter was then 
passed through the perinaeal opening into the bladder, a little urine 
flowing out. This instrument was withdrawn, and there being no 
-fileed the wound was left entirely open. In passing the finger into 
the wound it entered the false passages spoken of before, and could 
be passed through these into different parts of the perinaeum and down 
into the scrotal tissues; the parts, to the touch, felt very hard and in- 
durated, and cut like cartilage. The patient reacted from the opera- 
tion very well; a grain sulph. morphia was given to relieve pain, 
with quinine, iron and nourishing diet, as before. 
At my evening visit he expressed himself as being very comfortable, 
had suffered very little pain, and had voided his urine several times 
through the wound in the perinaeum. The next morning after the 
operation his condition seemed very favorable, he had passed a com- 
fortable night, had relished his breakfast, and felt better.every way. 
The scrotum had diminished considerably in size, and he was passing 
his urine freely through the perinaeal opening. At this visit, from my 
patient’s general condition, I felt very much encouraged as to a favor- 
able result, and hoped he might finally get well. But my visit next 
morning banished all my hopes, for a decided change for the worse 
was evident; his pulse was very feeble and frequent, with appetite 4 
gone, and he was lying in a semi-unconscious state. Brandy and milk 
was given him very freely, but to no avail; he gradually grew worse and 
died the next day, about 72 hours after the operation. 
The treatment of this case is that which I believe is given by nearly 
all authorities upon the subject, i. e., to give free passage to the 
flow of urine, incise freely the infiltrated tissues and support the sys- 
tem by tonics and stimulants, all of which was done in this case before 
the operation of pennaeal section was resorted to, and it was only after 
seeing these measures fail that the operation was thought of. I believe 
now had the operation been performed at first the chances for my 
patient would have been better, for the strong constitution which he 
seemed to possess might then have enabled him to overcome the 
trouble. Indeed, should another case of the kind fall into my hands,. 
I shall adopt the treatment so emphatically laid down by Prof. Van 
Buren, to perform external perinaeal urethrotomy at once, and thus 
insure a free passage to the out flow of urine, leaving the stricture to be 
treated at a subsequent time.