SURGICAL ANOMALIES OF THE GENITO-URINARY SYSTEM.

Wounds of the kidney may be very severe without causing death, and even

one entire kidney may be lost without interfering with the functions of

life. Marvand, the Surgeon-Major of an Algerian regiment, reports the

case of a young Arab woman who had been severely injured in the right

lumbar region by a weapon called a "yataghan," an instrument which has

only one cutting edge. On withdrawing this instrument the right kidney

was extruded, became strangulated between the lips of the wound, and

caused considerable hemorrhage. A ligature was put around the base of

the organ, and after some weeks the mass separated. The patient

continued in good health the whole time, and her urinary secretion was

normal. She was discharged in two months completely recovered. Price

mentions the case of a groom who was kicked over the kidney by a horse,

and eighteen months later died of dropsy. Postmortem examination

showed traces of a line of rupture through the substance of the gland;

the preparation was deposited in St. George's Hospital Museum in

London. The case is singular in that this man, with granular

degeneration of the kidney, recovered from so extensive a lesion, and,

moreover, that he remained in perfect health for over a year with his

kidney in a state of destructive disease. Borthwick mentions a dragoon

of thirty who was stabbed by a sword-thrust on the left side under the

short rib, the sword penetrating the pelvis and wounding the kidney.

There was no hemorrhage from the external wound, nor pain in the

spermatic cord or testicle. Under expectant treatment the man

recovered. Castellanos mentions a case of recovery from punctured wound

of the kidney by a knife that penetrated the tubular and cortical

substance, and entered the pelvis of the organ. The case was peculiar

in the absence of two symptoms, viz., the escape of urine from the

wound, and retraction of the corresponding testicle. Dusenbury reports

the case of a corporal in the army who was wounded on April 6, 1865,

the bullet entering both the liver and kidney. Though there was injury

to both these important organs, there was no impairment of the

patient's health, and he recovered.

Bryant reports four cases of wound of the kidney, with recovery. All

of these cases were probably extraperitoneal lacerations or ruptures.

Cock found a curious anomaly in a necropsy on the body of a boy of

eighteen, who had died after a fall from some height. There was a

compound, transverse rupture of the left kidney, which was twice as

large as usual, the ureter also being of abnormal size. Further search

showed that the right kidney was rudimentary, and had no vein or artery.

Ward mentions a case of ruptured kidney, caused by a fall of seven

feet, the man recovering after appropriate treatment. Vernon reports a

case of serious injury to the kidney, resulting in recovery in nine

weeks. The patient fell 40 feet, landing on some rubbish and old iron,

and received a wound measuring six inches over the right iliac crest,

through which the lower end of the right kidney protruded; a piece of

the kidney was lost. The case was remarkable because of the slight

amount of hemorrhage.

Nephrorrhaphy is an operation in which a movable or floating kidney is

fixed by suture through its capsule, including a portion of

kidney-substance, and then through the adjacent lumbar fascia and

muscles. The ultimate results of this operation have been most

successful.

Nephrolithotomy is an operation for the removal of stone from the

kidney. The operation may be a very difficult one, owing to the

adhesions and thickening of all the perinephric tissues, or to the

small size or remote location of the stone.

There was a recent exhibition in London, in which were shown the

results of a number of recent operations on the kidney. There was

one-half of a kidney that had been removed on account of a

rapidly-growing sarcoma from a young man of nineteen, who had known of

the tumor for six months; there was a good recovery, and the man was

quite well in eighteen months afterward. Another specimen was a right

kidney removed at St. Bartholomew's Hospital. It was much dilated, and

only a small amount of the kidney-substance remained. A calculus

blocked the ureter at its commencement. The patient was a woman of

thirty-one, and made a good recovery. From the Middlesex Hospital was a

kidney containing a uric acid calculus which was successfully removed

from a man of thirty-five. From the Cancer Hospital at Brompton there

were two kidneys which had been removed from a man and a woman

respectively, both of whom made a good recovery. From the King's

College Hospital there was a kidney with its pelvis enlarged and

occupied by a large calculus, and containing little secreting

substance, which was removed from a man of forty-nine, who recovered.

These are only a few of the examples of this most interesting

collection. Large calculi of the kidney are mentioned in Chapter XV.

Rupture of the ureter is a very rare injury. Poland has collected the

histories of four cases, one of which ended in recovery after the

evacuation by puncture, at intervals, of about two gallons of fluid

resembling urine. The other cases terminated in death during the first,

fourth, and tenth weeks respectively. Peritonitis was apparently not

present in any of the cases, the urinary extravasation having occurred

into the cellular tissue behind the peritoneum.

There are a few recorded cases of uncomplicated wounds of the ureters.

The only well authenticated case in which the ureter alone was divided

is the historic injury of the Archbishop of Paris, who was wounded

during the Revolution of 1848, by a ball entering the upper part of the

lumbar region close to the spine. Unsuccessful attempts were made to

extract the ball, and as there was no urine in the bladder, but a

quantity escaping from the wound, a diagnosis of divided ureter was

made. The Archbishop died in eighteen hours, and the autopsy showed

that the ball had fractured the transverse process of the 3d lumbar

vertebra, and divided the cauda equina just below its origin; it had

then changed direction and passed up toward the left kidney, dividing

the ureter near the pelvis, and finally lodged in the psoas muscle.

It occasionally happens that the ureter is wounded in the removal of

uterine, ovarian, or other abdominal tumors. In such event, if it is

impossible to transplant to the bladder, the divided or torn end should

be brought to the surface of the loin or vagina, and sutured there. In

cases of malignant growth, the ureter has been purposely divided and

transplanted into the bladder. Penrose, assisted by Baldy, has

performed this operation after excision of an inch of the left ureter

for carcinomatous involvement. The distal end of the ureter was

ligated, and the proximal end implanted in the bladder according to Van

Hook's method, which consists in tying the lowered end of the ureter,

then making a slit into it, and invaginating the upper end into the

lower through this slit. A perfect cure followed. Similar cases have

been reported by Kelly, Krug, and Bache Emmet. Reed reports a most

interesting series in which he has successfully transplanted ureters

into the rectum.

Ureterovaginal fistulae following total extirpation of the uterus,

opening of pelvic abscesses, or ulcerations from foreign bodies, are

repaired by an operation termed by Bazy of Paris ureterocystoneostomy,

and suggested by him as a substitute for nephrectomy in those cases in

which the renal organs are unaffected. In the repair of such a case

after a vaginal hysterectomy Mayo reports a successful reimplantation

of the ureter into the bladder.

Stricture of the ureter is also a very rare occurrence except as a

result of compression of abdominal or pelvic new growths. Watson has,

however, reported two cases of stricture, in both of which a ureter was

nearly or quite obliterated by a dense mass of connective tissue. In

one case there was a history of the passage of a renal calculus years

previously. In both instances the condition was associated with

pyonephrosis. Watson has collected the reports of four other cases from

medical literature.

A remarkable procedure recently developed by gynecologists,

particularly by Kelly of Baltimore, is catheterization and sounding of

the ureters. McClellan records a case of penetration of the ureter by

the careless use of a catheter.

Injuries of the Bladder.--Rupture of the bladder may result from

violence without any external wound (such as a fall or kick) applied to

the abdomen. Jones reports a fatal case of rupture of the bladder by a

horse falling on its rider. In this case there was but little

extravasation of urine, as the vesical aperture was closed by omentum

and bowel. Assmuth reports two cases of rupture of the bladder from

muscular action. Morris cites the history of a case in which the

bladder was twice ruptured: the first time by an injury, and the second

time by the giving way of the cicatrix. The patient was a man of

thirty-six who received a blow in the abdomen during a fight in a

public house on June 6, 1879. At the hospital his condition was

diagnosed and treated expectantly, but he recovered perfectly and left

the hospital July 10, 1879. He was readmitted on August 4, 1886, over

seven years later, with symptoms of rupture of the bladder, and died on

the 6th. The postmortem showed a cicatrix of the bladder which had

given way and caused the patient's death.

Rupture of the bladder is only likely to happen when the organ is

distended, as when empty it sinks behind the pubic arch and is thus

protected from external injury. The rupture usually occurs on the

posterior wall, involving the peritoneal coat and allowing

extravasation of urine into the peritoneal cavity, a condition that is

almost inevitably fatal unless an operation is performed. Bartels

collected the data of 98 such cases, only four recovering. When the

rent is confined to the anterior wall of the bladder the urine escapes

into the pelvic tissues, and the prognosis is much more favorable.

Bartels collected 54 such cases, 12 terminating favorably. When

celiotomy is performed for ruptured bladder, in a manner suggested by

the elder Gross, the mortality is much less. Ashhurst collected the

reports of 28 cases thus treated, ten of which recovered--a mortality

of 64.2 per cent. Ashhurst remarks that he has seen an extraperitoneal

rupture of the anterior wall of the bladder caused by improper use of

instruments, in the case of retention of urine due to the presence of a

tight urethral stricture.

There are a few cases on record in which the bladder has been ruptured

by distention from the accumulation of urine, but the accident is a

rare one, the urethra generally giving way first. Coats reports two

cases of uncomplicated rupture of the bladder. In neither case was a

history of injury obtainable. The first patient was a maniac; the

second had been intoxicated previous to his admission to the hospital,

with symptoms of acute peritonitis. The diagnosis was not made. The

first patient died in five days and the second in two days after the

onset of the illness. At the autopsies the rent was found to be in both

instances in the posterior wall of the bladder a short distance from

the fundus; the peritoneum was not inflamed, and there was absolutely

no inflammatory reaction in the vesical wound. From the statistics of

Ferraton and Rivington it seems that rupture of the bladder is more

common in intoxicated persons than in others--a fact that is probably

explained by a tendency to over-distention of the bladder which

alcoholic liquors bring about. The liquor imbibed increases the amount

of urine, and the state of blunted consciousness makes the call to

empty the bladder less appreciated. The intoxicated person is also

liable to falls, and is not so likely to protect himself in falling as

a sober person.

Gunshot Wounds of the Bladder.--Jackson relates the remarkable recovery

of a private in the 17th Tennessee Regiment who was shot in the pelvis

at the battle of Mill Springs or Fishing Creek, Ky. He was left

supposedly mortally wounded on the field, but was eventually picked up,

and before receiving any treatment hauled 164 miles, over mountainous

roads in the midst of winter and in a wagon without springs. His urine

and excretions passed out through the wounds for several weeks and

several pieces of bone came away. The two openings eventually healed,

but for twenty-two months he passed pieces of bone by the natural

channels.

Eve records the case of a private in the Fifth Tennessee Cavalry who

was shot in the right gluteal region, the bullet penetrating the

bladder and making its exit through the pubis. He rode 30 miles, during

which the urine passed through the wound. Urine was afterward voided

through the left pubic opening, and spicules of bone were discharged

for two years afterward; ultimate recovery ensued.

Barkesdale relates the history of the case of a Confederate soldier who

was shot at Fredericksburg in the median line of the body, 1 1/2 inches

above the symphysis, the wound of exit being in the median line at the

back, 1/2 inch lower down. Urine escaped from both wounds and through

the urethra. There were no bad symptoms, and the wounds healed in four

weeks.

The bladder is not always injured by penetration of the abdominal wall,

but may be wounded by penetration through the anus or vagina, or even

by an instrument entering the buttocks and passing through the smaller

sacrosciatic notch. Camper records the case of a sailor who fell from a

mast and struck upon some fragments of wood, one of which entered the

anus and penetrated the bladder, the result being a rectovesical

fistula. About a year later the man consulted Camper, who

unsuccessfully attempted to extract the piece of wood; but by incising

the fistula it was found that two calculi had formed about the wooden

pieces, and when these were extracted the patient recovered. Perrin

gives the history of a man of forty who, while adjusting curtains, fell

and struck an overturned chair; one of the chair-legs penetrated the

anus. Its extraction was followed by a gush of urine, and for several

days the man suffered from incontinence of urine and feces. By the

tenth day he was passing urine from the urethra, and on the

twenty-fifth day there was a complete cicatrix of the parts; fifteen

days later he suffered from an attack of retention of urine lasting

five days; this was completely relieved after the expulsion of a small

piece of trouser-cloth which had been pushed into the bladder at the

time of the accident. Post reports the case of a young man who, in

jumping over a broomstick, was impaled upon it, the stick entering the

anus without causing any external wound, and penetrating the bladder,

thus allowing the escape of urine through the anus. A peculiar sequela

was that the man suffered from a calculus, the nucleus of which was a

piece of the seat of his pantaloons which the stick had carried in.

Couper reports a fatal case of stab-wound of the buttocks, in which the

knife passed through the lesser sacrosciatic notch and entered the

bladder close to the trigone. The patient was a man of twenty-three, a

seaman, and in a quarrel had been stabbed in the buttocks with a long

sailor's knife, with resultant symptoms of peritonitis which proved

fatal. At the autopsy it was found that the knife had passed through

the gluteal muscles and divided part of the great sacrosciatic

ligament. It then passed through the small sacrosciatic notch,

completely dividing the pudic artery and nerve, and one vein, each end

being closed by a clot. The knife entered the bladder close to the

trigone, making an opening large enough to admit the index finger.

There were well-marked evidences of peritonitis and cellulitis.

Old-time surgeons had considerable difficulty in extracting arrow-heads

from persons who had received their injuries while on horseback. Conrad

Gesner records an ingenious device of an old surgeon who succeeded in

extracting an arrow which had resisted all previous attempts, by

placing the subject in the very position in which he was at the time of

reception of the wound. The following noteworthy case shows that the

bladder may be penetrated by an arrow or bullet entering the buttocks

of a person on horseback. Forwood describes the removal of a vesical

calculus, the nucleus of which was an iron arrow-head, as follows:

"Sitimore, a wild Indian, Chief of the Kiowas, aged forty-two, applied

to me at Fort Sill, Indian Territory, August, 1869, with symptoms of

stone in the bladder. The following history was elicited: In the fall

of 1862 he led a band of Kiowas against the Pawnee Indians, and was

wounded in a fight near Fort Larned, Kansas. Being mounted and leaning

over his horse, a Pawnee, on foot and within a few paces, drove an

arrow deep into his right buttock. The stick was withdrawn by his

companions, but the iron point remained in his body. He passed bloody

urine immediately after the injury, but the wound soon healed, and in a

few weeks he was able to hunt the buffalo without inconvenience. For

more than six years he continued at the head of his band, and traveled

on horseback, from camp to camp, over hundreds of miles every summer. A

long time after the injury he began to feel distress in micturating,

which steadily increased until he was forced to reveal this sacred

secret (as it is regarded by these Indians), and to apply for medical

aid. His urine had often stopped for hours, at which times he had

learned to obtain relief by elevating his hips, or lying in different

positions. The urine was loaded with blood and mucus and with a few pus

globules, and the introduction of a sound indicated a large, hard

calculus in the bladder. The Indians advised me approximately of the

depth to which the shaft had penetrated and the direction it took, and

judging from the situation of the cicatrix and all the circumstances it

was apparent that the arrow-head had passed through the glutei muscles

and the obturator foremen and entered the cavity of the bladder, where

it remained and formed the nucleus of a stone. Stone in the bladder is

extremely rare among the wild Indians, owing, no doubt, to their almost

exclusive meat diet and the very healthy condition of their digestive

organs, and this fact, in connection with the age of the patient and

the unobstructed condition of his urethra, went very far to sustain

this conclusion. On August 23d I removed the stone without difficulty

by the lateral operation through the perineum. The lobe of the prostate

was enlarged, which seemed to favor the extent of the incision beyond

what would otherwise have been safe. The perineum was deep and the

tuberosities of the ischii unnaturally approximated. The calculus of

the mixed ammoniaco-magnesian variety was egg-shaped, and weighed 19

drams. The arrow-point was completely covered and imbedded near the

center of the stone. It was of iron, and had been originally about 2

1/2 inches long, by 7/8 inch at its widest part, somewhat reduced at

the point and edges by oxidation. The removal of the stone was

facilitated by the use of two pairs of forceps,--one with broad blades,

by which I succeeded in bringing the small end of the stone to the

opening in the prostate, while the other, long and narrow, seized and

held it until the former was withdrawn. In this way the forceps did not

occupy a part of the opening while the large end of the stone was

passing through it. The capacity of the bladder was reduced, and its

inner walls were in a state of chronic inflammation. The patient

quickly recovered from the effects of the chloroform and felt great

relief, both in body and mind, after the operation, and up to the

eighth day did not present a single unfavorable symptom. The urine

began to pass by the natural channel by the third day, and continued

more or less until, on the seventh day, it had nearly ceased to flow at

the wound. But the restless spirit of the patient's friends could no

longer be restrained. Open hostility with the whites was expected to

begin at every moment, and they insisted on his removal. He needed

purgative medicine on the eighth day, which they refused to allow him

to take. They assumed entire charge of the case, and the following day

started with him to their camps 60 miles away. Nineteen days after he

is reported to have died; but his immediate relatives have since

assured me that his wound was well and that no trouble arose from it.

They described his symptoms as those of bilious remittent fever, a

severe epidemic of which was prevailing at the time, and from which

several white men and many Indians died in that vicinity." The calculus

was deposited in the Army Medical Museum at Washington, and is

represented in the accompanying photograph, showing a cross-section of

the calculus with the arrow-head in situ.

As quoted by Chelius, both Hennen and Cline relate cases in which men

have been shot through the skirts of the jacket, the ball penetrating

the abdomen above the tuberosity of the ischium, and entering the

bladder, and the men have afterward urinated pieces of clothing,

threads, etc., taken in by the ball. In similar cases the bullet itself

may remain in the bladder and cause the formation of a calculus about

itself as a nucleus, as in three cases mentioned by McGuire of

Richmond, or the remnants of cloth or spicules of bone may give rise to

similar formation. McGuire mentions the case of a man of twenty-three

who was wounded at the Battle of McDowell, May 8, 1862. The ball struck

him on the horizontal ramus of the left pubic bone, about an inch from

the symphysis, passed through the bladder and rectum, and came out just

below the right sacrosciatic notch, near the sacrum. The day after the

battle the man was sent to the general hospital at Staunton, Va., where

he remained under treatment for four months. During the first month

urine passed freely through the wounds made by the entrance and exit of

the ball, and was generally mixed with pus and blood. Fecal matter was

frequently discharged through the posterior wound. Some time during the

third week he passed several small pieces of bone by the rectum. At the

end of the fifth week the wound of exit healed, and for the first time

after his injury urine was discharged through the urethra. The wound of

entrance gradually closed after five months, but opened again in a few

weeks and continued, at varying intervals, alternately closed and open

until September, 1865. At this time, on sounding the man, it was found

that he had stone; this was removed by lateral operation, and was found

to weigh 2 1/4 ounces, having for its nucleus a piece of bone about 1/2

inch long. Dougherty reports the operation of lithotomy, in which the

calculus removed was formed by incrustations about an iron bullet.

In cases in which there is a fistula of the bladder the subject may

live for some time, in some cases passing excrement through the

urethra, in others, urine by the anus. These cases seem to have been of

particular interest to the older writers, and we find the literature of

the last century full of examples. Benivenius, Borellus, the

Ephemerides, Tulpius, Zacutus Lusitanus, and others speak of excrement

passing through the penis; and there are many cases of vaginal anus

recorded. Langlet cites an instance in which the intestine terminated

in the bladder. Arand mentions recovery after atresia of the anus with

passage of excrement from the vulva. Bartholinus, the Ephemerides,

Fothergill, de la Croix, Riedlin, Weber, and Zacutus Lusitanus mention

instances in which gas was passed by the penis and urethra. Camper

records such a case from ulcer of the neighboring or connecting

intestine; Frank, from cohesion and suppuration of the rectum;

Marcellus Donatus, from penetrating ulcer of the rectum; and Petit,

from communication of the rectum and bladder in which a cure was

effected by the continued use of the catheter for the evacuation of

urine.

Flatus through the vagina, vulva, and from the uterus is mentioned by

Bartholinus, the Ephemerides, Meckel, Mauriceau, Paullini, Riedlin,

Trnka, and many others in the older literature. Dickinson mentions a

Burmese male child, four years old, who had an imperforate anus and

urethra, but who passed feces and urine successfully through an opening

at the base of the glans penis. Dickinson eventually performed a

successful operation on this case. Modern literature has many similar

instances.

In the older literature it was not uncommon to find accounts of persons

passing worms from the bladder, no explanations being given to account

for their presence in this organ. Some of these cases were doubtless

instances of echinococcus, trichinae, or the result of rectovesical

fistula, but Riverius mentions an instance in which, after drinking

water containing worms, a person passed worms in the urine. In the old

Journal de physique de Rozier is an account of a man of forty-five who

enjoyed good health, but who periodically urinated small worms from the

bladder. They were described as being about 1 1/2 lines long, and

caused no inconvenience. There is also mentioned the case of a woman

who voided worms from the bladder. Tupper describes a curious case of a

woman of sixty-nine who complained of a severe, stinging pain that

completely overcame her after micturition. An ulceration of the neck of

the bladder was suspected, and the usual remedies were applied, but

without effect. An examination of the urine was negative. On

recommendation of her friends the patient, before going to bed, steeped

and drank a decoction of knot-grass. During the night she urinated

freely, and claimed that she had passed a worm about ten inches long

and of the size of a knitting-needle. It exhibited motions like those

of a snake, and was quite lively, living five or six days in water. The

case seems quite unaccountable, but there is, of course, a possibility

that the animal had already been in the chamber, or that it was passed

by the bowel. A rectovaginal or vesical fistula could account for the

presence of this worm had it been voided from the bowel; nevertheless

the woman adhered to her statement that she had urinated the worm, and,

as confirmatory evidence, never complained of pain after passing the

animal.

Foreign bodies in the bladder, other than calculi (which will be spoken

of in Chapter XV), generally gain entrance through one of the natural

passages, as a rule being introduced, either in curiosity or for

perverted satisfaction, through the urethra. Morand mentions an

instance in which a long wax taper was introduced into the bladder

through the urethra by a man. At the University Hospital, Philadelphia,

White has extracted, by median cystotomy, a long wax taper which had

been used in masturbation. The cystoscopic examination in this case

was negative, and the man's statements were disbelieved, but the

operation was performed, and the taper was found curled up and covered

by mucus and folds of the bladder. It is not uncommon for needles,

hair-pins, and the like to form nuclei for incrustations. Gross found

three caudal vertebrae of a squirrel in the center of a vesical

calculus taken from the bladder of a man of thirty-five. It was

afterward elicited that the patient had practiced urethral masturbation

with the tail of this animal. Morand relates the history of a man of

sixty-two who introduced a sprig of wheat into his urethra for a

supposed therapeutic purpose. It slipped into the bladder and there

formed the nucleus of a cluster calculus. Dayot reports a similar

formation from the introduction of the stem of a plant. Terrilon

describes the case of a man of fifty-four who introduced a pencil into

his urethra. The body rested fifteen days in this canal, and then

passed into the bladder. On the twenty-eighth day he had a chill, and

during two days made successive attempts to break the pencil. Following

each attempt he had a violent chill and intense evening fever. On the

thirty-third day Terrilon removed the pencil by operation. Symptoms of

perivesical abscess were present, and seventeen days after the

operation, and fifty days after the introduction of the pencil, the

patient died. Caudmont mentions a man of twenty-six who introduced a

pencil-case into his urethra, from whence it passed into his bladder.

It rested about four years in this organ before violent symptoms

developed. Perforation of the bladder took place, and the patient died.

Poulet mentions the case of a man of seventy-eight, in whose bladder a

metallic sound was broken off. The fractured piece of sound, which

measured 17 cm. in length, made its exit from the anus, and the

patient recovered. Wheeler reports the case of a man of twenty-one who

passed a button-hook into his anus, from whence it escaped into his

bladder. The hook, which was subsequently spontaneously passed,

measured 2 1/2 inches in length and 1/2 inch in diameter.

Among females, whose urethrae are short and dilatable, foreign bodies

are often found in the bladder, and it is quite common for smaller

articles of the toilet, such as hair-pins, to be introduced into the

bladder, and there form calculi. Whiteside describes a case in which a

foreign body introduced into the bladder was mistaken for pregnancy,

and giving rise to corresponding symptoms. The patient was a young girl

of seventeen who had several times missed her menstruation, and who was

considered pregnant. The abdomen was more developed than usual in a

young woman. The breasts were voluminous, and the nipples surrounded by

a somber areola. At certain periods after the cessation of

menstruation, she had incontinence of urine, and had also repeatedly

vomited. The urine was of high specific gravity, albuminous, alkaline,

and exhaled a disagreeable odor. In spite of the signs of pregnancy

already noted, palpitation and percussion did not show any augmentation

in the size of the uterus, but the introduction of a catheter into the

bladder showed the existence of a large calculus. Under chloroform the

calculus and its nucleus were disengaged, and proved to be the handle

of a tooth-brush, the exact size of which is represented in the

accompanying illustration. The handle was covered with calcareous

deposits, and was tightly fixed in the bladder. At first the young

woman would give no explanation for its presence, but afterward

explained that she had several times used this instrument for relief in

retention of urine, and one day it had fallen into the bladder. A short

time after the operation menstruation returned for the first time in

seven months, and was afterward normal. Bigelow reports the case of a

woman who habitually introduced hair-pins and common pins into her

bladder. She acquired this mania after an attempt at dilatation of the

urethra in the relief of an obstinate case of strangury. Rode reports

the case of a woman who had introduced a hog's penis into her urethra.

It was removed by an incision into this canal, but the patient died in

five days of septicemia. There is a curious case quoted of a young

domestic of fourteen who was first seen suffering with pain in the

sides of the genital organs, retention of urine, and violent tenesmus.

She was examined by a midwife who found nothing, but on the following

day the patient felt it necessary to go to bed. Her general symptoms

persisted, and meanwhile the bladder became much distended. The patient

had made allusion to the loss of a hair-pin, a circumstance which

corresponded with the beginning of her trouble. Examination showed the

orifice of the urethra to be swollen and painful to the touch, and from

its canal a hair-pin 6.5 cm. long was extracted. The patient was unable

to urinate, and it was necessary to resort to catheterization. By

evening the general symptoms had disappeared, and the next day the

patient urinated as usual.

There are peculiar cases of hair in the bladder, in which all history

as to the method of entrance is denied, and which leave as the only

explanation the possibility that the bladder was in communication with

some dermoid cyst. Hamelin mentions a case of this nature. It is said

that all his life Sir William Elliot was annoyed by passing hairs in

urination. They would lodge in the urethra and cause constant

irritation. At his death a stone was taken from the bladder, covered

with scurf and hair. Hall relates the case of a woman of sixty, from

whose bladder, by dilatation of the urethra, was removed a bundle of

hairs two inches long, which, Hall says, without a doubt had grown from

the vesical walls.

Retention of Foreign Bodies in the Pelvis.--It is a peculiar fact that

foreign bodies which once gain entrance to the pelvis may be tolerated

in this location for many years. Baxter describes a man who suffered an

injury from a piece of white board which entered his pelvis, and

remained in position for sixteen and a half years; at this time a piece

of wood 7 1/2 inches long was discharged at stool, and the patient

recovered. Jones speaks of a case in which splinters of wood were

retained in the neighborhood of the rectum and vagina for sixteen

years, and spontaneously discharged. Barwell mentions a case in which a

gum elastic catheter that had been passed into the vagina for the

purpose of producing abortion became impacted in the pelvis for twenty

months, and was then removed.

Rupture of the Male Urethra.--The male urethra is occasionally ruptured

in violent coitus. Frank and the Philosophical Transactions are among

the older authorities mentioning this accident. In Frank's case there

was hemorrhage from the penis to the extent of five pounds. Colles

mentions a man of thirty-eight, prone to obesity, and who had been

married two months, who said that in sexual congress he had hurt

himself by pushing his penis against the pubic bone, and added that he

had a pain that felt as though something had broken in his organ. The

integuments of the penis became livid and swollen and were extremely

painful. His urine had to be drawn by a catheter, and by the fifth day

his condition was so bad that an incision was made into the tumor, and

pus, blood, urine, and air issued. The patient suffered intense rigors,

his abdomen became tympanitic, and he died. Postmortem examination

revealed the presence of a ruptured urethra.

Watson relates an instance of coitus performed en postillon by a man

while drunk, with rupture of the urethra and fracture of the corpus

spongiosum only. Loughlin mentions a rupture of the corpus spongiosum

during coitus. Frank cites a curious case of hemorrhage from a fall

while the penis was erect. It is not unusual to find ruptured urethrae

following traumatism, and various explanations are given for it in the

standard works on surgery.

Fracture of the Penis.--A peculiar accident to the penis is fracture,

which sometimes occurs in coitus. This accident consists in the

laceration of the corpora cavernosa, followed by extensive

extravasation of blood into the erectile tissue. It has also occurred

from injury inflicted accidentally or maliciously, but always happening

when the organ was erect. An annoying sequel following this accident is

the tendency to curvature in erection, which is sometimes so marked as

to interfere with coitus, and even render the patient permanently

impotent.

There is an account of a laborer of twenty-seven who, in attempting to

micturate with his penis erect, pressed it downward with considerable

force and fractured the corpora cavernosa. Veazie relates a case of

fracture of the corpora cavernosa occurring in coitus. During the act

the female suddenly withdrew, and the male, following, violently struck

the pubes, with the resultant injury. Recovery ensued. M'Clellan speaks

of removing the cavernous septum from a man of fifty-two, in whom this

part had become infiltrated with lime-salts and resembled a long,

narrow bone. When the penis was erect it was bent in the form of a

semicircular bow.

The Transactions of the South Carolina Medical Association contain an

account of a negro of sixty who had urethral stricture from gonorrhea

and who had been treated for fifteen years by caustics. The penis was

seven inches in circumference around the glans, and but little less

near the scrotum. The glans was riddled with holes, and numerous

fistulae existed on the inferior surface of the urethra, the meatus

being impermeable. So great was the weight and hypertrophy that

amputation was necessary. John Hunter speaks of six strictures

existing in one urethra at one time; Lallemand of seven; Bolot of

eight; Ducamp of five; Boyer thought three could never exist together;

Leroy D'Etoilles found 11, and Rokitansky met with four.

Sundry Injuries to the Penis.--Fabricius Hildanus mentions a curious

case of paraphimosis caused by violent coitus with a virgin who had an

extremely narrow vagina. Joyce relates a history of a stout man who

awoke with a vigorous erection, and feeling much irritation, he

scratched himself violently. He soon bled copiously, his shirt and

underlying sheets and blankets being soaked through. On examination the

penis was found swollen, and on drawing back the foreskin a small jet

of blood spurted from a small rupture in the frenum. The authors have

knowledge of a case in which hemorrhage from the frenum proved fatal.

The patient, in a drunken wager, attempted to circumcise himself with a

piece of tin, and bled to death before medical aid could be summoned.

It sometimes happens that the virile member is amputated by an animal

bite. Paullini and Celliez mention amputation of the penis by a

dog-bite. Morgan describes a boy of thirteen who was feeding a donkey

which suddenly made a snap at him, unfortunately catching him by the

trousers and including the penis in one of the folds. By the violence

of the bite the boy was thrown to the ground, and his entire prepuce

was stripped off to the root as if it had been done by a knife. There

was little hemorrhage, and the prepuce was found in the trousers,

looking exactly like the finger of a glove. Morgan stated that this was

the third case of the kind of which he had knowledge. Bookey records a

case in which an artilleryman was seized by the penis by an infuriated

horse, and the two crura were pulled out entire.

Amputation of the penis is not always followed by loss of the sexual

power and instinct, but sometimes has the mental effect of temporarily

increasing the desire. Haslam reports the case of a man who slipped on

the greasy deck of a whaler, and falling forward with great violence

upon a large knife used to cut blubber, completely severed his penis,

beside inflicting a wound in the abdomen through which the intestines

protruded. After recovery there was a distinct increase of sexual

desire and frequent nocturnal emissions. In the same report there is

recorded the history of a man who had entirely lost his penis, but had

supplied himself with an ivory succedaneum. This fellow finally became

so libidinous that it was necessary to exclude him from the workhouse,

of which he was an inmate.

Norris gives an account of a private who received a gunshot wound of

the penis while it was partly erect. The wound was acquired at the

second battle of Fredericksburg. The ball entered near the center of

the glans penis, and taking a slightly oblique direction, it passed out

of the right side of the penis 1 1/2 inches beyond the glans; it then

entered the scrotum, and after striking the pelvis near the symphysis,

glanced off around the innominate bone, and finally made its exit two

inches above the anus. The after-effects of this injury were

incontinence of urine, and inability to assume the erect position.

Bookey cites the case of six wounds from one bullet with recovery. The

bullet entered the sole and emerged from the dorsum of the foot. It

then went through the right buttock and came out of the groin, only to

penetrate the dorsum of the penis and emerge at the upper part of the

glans. Rose speaks of a case in which a man had his clothes caught in

machinery, drawing in the external genital organs. The testicles were

found to be uninjured, but the penis was doubled out of sight and

embedded in the scrotum, from whence it was restored to its natural

position and the man recovered.

Nelaton describes a case of luxation of the penis in a lad of six who

fell from a cart. Nelaton found the missing member in the scrotum,

where it had been for nine days. He introduced Sir Astley Cooper's

instrument for tying deeply-seated arteries through a cutaneous tube,

and conducting the hook under the corporus cavernosum, seized this

crosswise, and by a to-and-fro movement succeeded in replacing the

organ.

Moldenhauer describes the case of a farmer of fifty-seven who was

injured in a runaway accident, a wheel passing over his body close to

the abdomen. The glans penis could not be recognized, since the penis

in toto had been torn from its sheath at the corona, and had slipped or

been driven into the inguinal region. This author quotes Stromeyer's

case, which was that of a boy of four and a half years who was kicked

by a horse in the external genital region. The sheath was found empty

of the penis, which had been driven into the perineum.

Raven mentions a case of spontaneous retraction of the penis in a man

of twenty-seven. While in bed he felt a sensation of coldness in the

penis, and on examination he found the organ (a normal-sized one)

rapidly retracting or shrinking. He hastily summoned a physician, who

found that the penis had, in fact, almost disappeared, the glans being

just perceptible under the pubic arch, and the skin alone visible. The

next day the normal condition was restored, but the patient was weak

and nervous for several days after his fright. In a similar case,

mentioned by Ivanhoff, the penis of a peasant of twenty-three, a

married man, bodily disappeared, and was only captured by repeated

effort. The patient was six days under treatment, and he finally became

so distrustful of his virile member that, to be assured of its

constancy, he tied a string about it above the glans.

Injuries of the penis and testicles self-inflicted are grouped together

and discussed in Chapter XIV.

As a rule, spontaneous gangrene of the penis has its origin in some

intense fever. Partridge describes a man of forty who had been the

victim of typhus fever, and whose penis mortified and dried up,

becoming black and like the empty finger of a cast-off glove; in a few

days it dropped off. Boyer cites a case of edema of the prepuce,

noticed on the fifteenth day of the fever, and which was followed by

gangrene of the penis. Rostan mentions gangrene of the penis from

small-pox. Intermittent fever has been cited as a cause. Koehler

reports a fatal instance of gangrene of the penis, caused by a

prostatic abscess following gonorrhea. In this case there was

thrombosis of the pelvic veins. Hutchinson mentions a man who, thirty

years before, after six days' exposure on a raft, had lost both legs by

gangrene. At the age of sixty-six he was confined to bed by subacute

bronchitis, and during this period his whole penis became gangrenous

and sloughed off. This is quite unusual, as gangrene is usually

associated with fever; it is more than likely that the gangrene of the

leg was not connected with that of the penis, but that the latter was a

distinct after-result. Possibly the prolonged exposure at the time he

lost his legs produced permanent injury to the blood-vessels and nerves

of the penis. There is a case on record in which, in a man of

thirty-seven, gangrene of the penis followed delirium tremens, and was

attributed to alcoholism. Quoted by Jacobson, Troisfontaines records a

case of gangrene of the skin and body of the penis in a young man, and

without any apparent cause. Schutz speaks of regeneration of the penis

after gangrenous destruction.

Gangrene of the penis does not necessarily hinder the performance of

marital functions. Chance mentions a man whose penis sloughed off,

leaving only a nipple-like remnant. However, he married four years

later, and always lived in harmony with his wife. At the time of his

death he was the father of a child, subsequent to whose birth his wife

had miscarried, and at the time of report she was daily expecting to be

again confined.

Willett relates the instance of a horseman of thirty-three who, after

using a combination of refuse oils to protect his horse from gnats, was

prompted to urinate, and, in so doing, accidentally touched his penis

with the mixture. Sloughing phagedena rapidly ensued, but under medical

treatment he eventually recovered.

Priapism is sometimes seen as a curious symptom of lesion of the spinal

cord. In such cases it is totally unconnected with any voluptuous

sensation and is only found accompanied by motor paralysis. It may

occur spontaneously immediately after accident involving the cord, and

is then probably due to undue excitement of the portion of the cord

below the lesion, which is deprived of the regulating influence of the

brain. Priapism may also develop spontaneously at a later period, and

is then due to central irritation from extravasation into the substance

of the cord, or to some reflex cause. It may also occur from simple

concussion, as shown by a case reported by Le Gros Clark. Pressure on

the cerebellum is supposed to account for cases of priapism observed in

executions and suicides by hanging. There is an instance recorded of an

Italian "castrate" who said he provoked sexual pleasure by partially

hanging himself. He accidentally ended his life in pursuance of this

peculiar habit. The facts were elicited by testimony at the inquest.

There are, however, in literature, records of long continued priapism

in which either the cause is due to excessive stimulation of the sexual

center or in which the cause is obscure or unknown. There may or may

not be accompanying voluptuous feelings. The older records contain

instances of continued infantile priapism caused by the constant

irritation of ascarides and also records of prolonged priapism

associated with intense agony and spasmodic cramps. Zacutus Lusitanus

speaks of a Viceroy of India who had a long attack of stubborn priapism

without any voluptuous feeling. Gross refers to prolonged priapism, and

remarks that the majority of cases seem to be due to excessive coitus.

Moore reports a case in a man of forty who had been married fifteen

years, and who suffered spasmodic contractions of the muscles of the

penis after an incomplete coitus. This pseudopriapism continued for

twenty-three days, during which time he had unsuccessfully resorted to

the application of cold, bleeding, and other treatment; but on the

twenty-sixth day, after the use of bladders filled with cold water,

there was a discharge from the urethra of a glairy mucus, similar in

nature to that in seminal debility. There was then complete relaxation

of the organ. During all this time the man slept very little, only

occasionally dozing. Donne describes an athletic laborer of twenty-five

who received a wound from a rifle-ball penetrating the cranial parietes

immediately in the posterior superior angle of the parietal bone, and a

few lines from the lambdoid suture. The ball did not make egress, but

passed posteriorly downward. Reaction was established on the third

day, but the inflammatory symptoms influenced the genitalia. Priapism

began on the fifth day, at which time the patient became affected with

a salacious appetite, and was rational upon every subject except that

pertaining to venery. He grew worse on the sixth day, and his medical

adviser was obliged to prohibit a female attendant. Priapism

continued, but the man went into a soporose condition, with occasional

intervals of satyriasis. In this condition he survived nine days; there

was not the slightest abatement of the priapism until a few moments

before his death. Tripe relates the history of a seaman of twenty-five,

in perfect health, who, arriving from Calcutta on April 12, 1884,

lodged with a female until the 26th. At this time he experienced an

unusually fierce desire, with intense erection of the penis which, with

pain, lasted throughout the night. Though coitus was frequently

resorted to, these symptoms continued. He sought aid at the London

Hospital, but the priapism was persistent, and when he left, on May

10th, the penis formed an acute angle with the pubes, and he again had

free intercourse with the same female. At the time of leaving England

the penis made an angle of about 45 degrees with the pubes, and this

condition, he affirmed, lasted three months. On his return to England

his penis was flaccid, and his symptoms had disappeared.

Salzer presents an interesting paper on priapism which was quoted in

The Practitioner of London. Salzer describes one patient of forty-six

who awoke one morning with a strong erection that could not be reduced

by any means. Urine was voided by jerks and with difficulty, and only

when the subject was placed in the knee and elbow position. Despite all

treatment this condition continued for seven weeks. At this time the

patient's spleen was noticed to be enormously enlarged. The man died

about a year after the attack, but a necropsy was unfortunately

refused. Salzer, in discussing the theories of priapism, mentions eight

cases previously reported, and concludes, that such cases are

attributable to leukemia. Kremine believes that continued priapism is

produced by effusion of blood into the corpora cavernosa, which is

impeded on its return. He thinks it corresponds to bleeding at the nose

and rectum, which often occurs in perfectly healthy persons. Longuet

regards the condition of the blood in leukemia as the cause of such

priapism, and considers that the circulation of the blood is retarded

in the smaller vessels, while, owing to the great increase in the

number of white corpuscles, thrombi are formed. Neidhart and Matthias

conclude that the origin of this condition might be sought for in the

disturbance of the nerve-centers. After reviewing all these theories,

Salzer states that in his case the patient was previously healthy and

never had suffered the slightest hemorrhage in any part, and he

therefore rejects the theory of extravasation. He is inclined to

suppose that the priapism was due to the stimulation of the nervi

erigentes, brought about either by anatomic change in the nerves

themselves, or by pressure upon them by enlarged lumbar glands, an

associate condition of leukemia.

Burchard reports a most interesting case of prolonged priapism in an

English gentleman of fifty-three. When he was called to see the man on

July 15th he found him suffering with intense pain in the penis, and in

a state of extreme exhaustion after an erection which had lasted five

hours uninterruptedly, during the whole of which time the organ was in

a state of violent and continuous spasm. The paroxysm was controlled by

3/4 grain morphin and 1/50 grain atropin. Five hours later, after a

troubled sleep, there was another erection, which was again relieved by

hypodermic medication. During the day he had two other paroxysms, one

lasting forty-five minutes; and another, three hours later, lasting

eighteen minutes. Both these were controlled by morphin. There was no

loss of semen, but after the paroxysms a small quantity of glairy mucus

escaped from the meatus. The rigidity was remarkable, simulating the

spasms of tetanus. No language could adequately describe the suffering

of the patient. Burchard elicited the history that the man had suffered

from nocturnal emissions and erotic dreams of the most lascivious

nature, sometimes having three in one night. During the day he would

have eight or ten erections, unaccompanied by any voluptuous emotions.

In these there would rarely be any emission, but occasionally a small

mucous discharge. This state of affairs had continued three years up to

the time Burchard saw him, and, chagrined by pain and his malady, the

patient had become despondent. After a course of careful treatment, in

which diet, sponging, application of ice-bags, and ergot were features,

this unfortunate man recovered.

Bruce mentions the case of an Irishman of fifty-five who, without

apparent cause, was affected with a painful priapism which lasted six

weeks, and did not subside even under chloroform. Booth mentions a case

of priapism in a married seaman of fifty-five, due to local

inflammation about the muscles, constricting the bulb of the penis. The

affection lasted five weeks, and was extremely painful. There was a

similar case of priapism which lasted for three weeks, and was

associated with hydrocele in a man of forty-eight.

Injuries of the testicle and scrotum may be productive of most serious

issue. It is a well-known surgical fact that a major degree of shock

accompanies a contusion of this portion of the body. In fact, Chevers

states that the sensitiveness of the testicles is so well known in

India, that there are cases on record in which premeditated murder has

been effected by Cossiah women, by violently squeezing the testicles of

their husbands. He also mentions another case in which, in frustrating

an attempt at rape, death was caused in a similar manner. Stalkartt

describes the case of a young man who, after drinking to excess with

his paramour, was either unable, or indifferent in gratifying her

sexual desire. The woman became so enraged that she seized the scrotum

and wrenched it from its attachments, exposing the testicles. The left

testicle was completely denuded, and was hanging by the vas deferens

and the spermatic vessels. There was little hemorrhage, and the wound

was healed by granulation.

Avulsion of the male external genitalia is not always accompanied by

serious consequences, and even in some cases the sexual power is

preserved. Knoll described a case in 1781, occurring in a peasant of

thirty-six who fell from a horse under the wheels of a carriage. He was

first caught in the revolving wheels by his apron, which drew him up

until his breeches were entangled, and finally his genitals were torn

off. Not feeling much pain at the time, he mounted his horse and went

to his house. On examination it was found that the injury was

accompanied with considerable hemorrhage. The wound extended from the

superior part of the pubes almost to the anus; the canal of the urethra

was torn away, and the penis up to the neck of the bladder. There was

no vestige of either the right scrotum or testicle. The left testicle

was hanging by its cord, enveloped in its tunica vaginalis. The cord

was swollen and resembled a penis stripped of its integument. The

prostate was considerably contused. After two months of suffering the

patient recovered, being able to evacuate his urine through a fistulous

opening that had formed. In ten weeks cicatrization was perfect. In his

"Memoirs of the Campaign of 1811," Larrey describes a soldier who,

while standing with his legs apart, was struck from behind by a bullet.

The margin of the sphincter and, the skin of the perineum, the bulbous

portion of the urethra, some of the skin of the scrotum, and the right

testicle were destroyed. The spermatic cord was divided close to the

skin, and the skin of the penis and prepuce was torn. The soldier was

left as dead on the field, but after four months' treatment he

recovered.

Madden mentions a man of fifty who fell under the feet of a pair of

horses, and suffered avulsion of the testicles through the scrotum. The

organs were mangled, the spermatic cord was torn and hung over the

anus, and the penis was lacerated from the frenum down. The man lost

his testicles, but otherwise completely recovered. Brugh reports an

instance of injury to the genitalia in a boy of eighteen who was caught

in a threshing-machine. The skin of the penis and scrotum, and the

tissue from the pubes and inguinal region were torn from the body.

Cicatrization and recovery were complete. Brigham cites an analogous

case in a youth of seventeen who was similarly caught in threshing

machinery. The skin of the penis and the scrotum was entirely torn

away; both sphincters of the anus were lacerated, and the perineum was

divested of its skin for a space 2 1/2 inches wide. Recovery ensued,

leaving a penis which measured, when flaccid, three inches long and 1

1/2 inches in diameter.

There is a case reported of a man who had his testicles caught in

machinery while ginning cotton. The skin of the penis was stripped off

to its root, the scrotum torn off from its base, and the testicles were

contused and lacerated, and yet good recovery ensued. A peculiarity of

this case was the persistent erection of the penis when cold was not

applied.

Gibbs mentions a case in which the entire scrotum and the perineum,

together with an entire testicle and its cord attached, and nearly all

the integument of the penis were torn off, yet the patient

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