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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