Treatment.—In examining a patient who has had an injury or condition which could give rise to rupture of the urethra, the parts should be inspected for any external evidences of injury. Inquiry should be made as to the ap pearance of blood at the meatus and whether urine has been voided. If there are signs of rupture of the urethra, an attempt should then be made to pass a soft-rubber catheter of medium size. Preparatory to this the glans and prepuce should be cleansed thoroughly. The catheter, having been boiled previ ously, should be connected with a fount ain-syringe containing an antiseptic so lution, then oiled in carbolized vaselin or other suitable lubricant, the solution permitted to pass for a moment, and finally it should be slowly introduced into the urethra with great gentleness, the fluid meanwhile being allowed to flow.
The urethra is thus thoroughly irri gated, the fluid escaping around the catheter. Among the antiseptic fluids appropriate for this purpose may be mentioned a solution of potassium per manganate, 1 part in 5000; bichloride of mercury, 1 part in 10,000; or carbolic acid, 1 part in 500; and boric-acid solu tion, 10 or 15 grains to the ounce of sterile water. If the catheter passes into the bladder easily, the urine should be withdrawn and the catheter removed. The patient should be thus catheterized about every six or eight hours. If the catheter passes with great difficulty and only after repeated efforts, it should be allowed to remain, being securely held by any appropriate means. If the cath eter fails to pass the point of rupture, other sizes may be tried as well as other forms. The Nelaton catheter is a very useful form, the point being kept on the roof of the urethra, which in partial tears is less apt to be involved than is the floor. If a catheter enters the blad der it should be allowed to remain.
If no catheter whatever will pass into the bladder, a metal Bougie or other firm instrument should be introduced until it is arrested. The point of the instrument should then be exposed by an incision in the middle line. The tip of the instrument will guide the opera tor to the distal end of the torn canal and the proximal end should then be sought for. When found, a soft-rubber catheter should be passed into the blad der from the meatus, and the divided urethra sutured with fine, chromicized catgut, if at all possible. In searching
for the proximal end of the urethra very careful search should be made in the wound before much dissecting has been done, as this would tend to add to the difficulty of locating it. When the usual means fail, pressure above the pubes will frequently cause a few drops of urine to exude and thus locate the urethra. The external wound should be united by sutures if the conditions will permit, drainage being introduced if necessary.
When a catheter is retained in the bladder it should be kept thoroughly clean by irrigating through and around it with boric-acid solution or other mild antiseptic. The catheter may be moved in from five to ten days, depend ing upon the extent of the injury. Sub sequently steel sounds should be passed every second day, using great gentleness in their introduction, but gradually using larger sizes until the full calibre for the particular patient has been reached. After the wound has healed firmly the boogies must be continued, at first once a week; later, once a month: and with diminishing frequency for one or two years, to prevent, as far as possible, the formation of a stricture.
In all cases this tendency continues throughout life, so that the occasional use of the boogie must be continued.
Five cases of rupture of urethra per sonally treated by external urethrotomy and suture. Conclusions: 1. In eases of ruptured urethra immediate perinea] section with suture of the urethra should be practiced. 2. By this procedure not only is the danger of urinary infiltration and abscess greatly lessened, but in a large proportion of cases one may hope to prevent the formation of close intractable strictures. 3. In an early operation the search for the posterior end of the ure thra is much easier than it is later. The haanorrbage from the branches of the artery of the bulb serves as a guide to that end of the canal. Cabot (Boston Med. and Surg. Jour., July 16, '96).
During the early treatment of these eases, whether an operation has been per formed or not, frequent examinations should be made of the region of the wound in order to detect the earliest evi dences of infiltration of urine if this should occur. This would indicate that the catheter was not efficiently draining the bladder. Extravasation, accom panied by swelling, pain, and heat, re quires early and free incisions, frequent antiseptic irrigations, and dressings.