The fatality of rupture of the spleen is quite high. Out of 83 cases of injury to this organ collected by Elder, and quoted by MacCormac, only 11 recovered; but the mortality is less in punctured or incised wounds of this organ, the same authorities mentioning 29 recoveries out of 35 cases. In his "Surgery" Gooch says that at the battle of Dettingen one of Sir Robert Rich's Dragoons was left all night on the field, weltering in his blood, his spleen hanging out of his body in a gangrenous state. The next morning he was carried to the surgeons who ligated the large vessels, and extirpated the spleen; the man recovered and was soon able to do duty. In the Philosophical Transactions there is a report of a man who was wounded in the spleen by a large hunting-knife. Fergusson found the spleen hanging from the wound and ligated it. It separated in ten days and the patient recovered.

Williams reports a stab-wound of the spleen in a negro of twenty-one. The spleen protruded, and the protruding part was ligated by a silver wire, one-half of the organ sloughing off; the patient recovered. Sir Astley Cooper mentions a curious case, in which, after vomiting, during which the spleen was torn from its attachments, this organ produced a swelling in the groin which was supposed to be a hernia. The vomiting continued, and at the end of a week the woman died; it was then found that the spleen had been turned half round on its axis, and detached from the diaphragm; it had become enlarged; the twist interrupted the return of the blood. Portal speaks of a rupture of the spleen simply from engorgement. There was no history of a fall, contusion, or other injury. Tait describes a case of rupture of the spleen in a woman who, in attempting to avoid her husband's kick, fell on the edge of the table. There were no signs of external violence, but she died the third day afterward. The abdomen was found full of blood, and the spleen and peritoneal covering was ruptured for three inches.

Splenectomy, excision of the spleen, has been performed a number of times, with varying results, but is more successful when performed for injury than when for disease. Ashhurst has tabulated a total of 109 operations, 27 having been for traumatic causes, and all but five having terminated successfully; of 82 operations for disease, only 32 recovered. Vulpius has collected 117 cases of splenectomy, with a death-rate of 50 per cent. If, however, from these cases we deduct those suffering with leukocythemia and lardaceous spleen, in which the operation should not be performed, the mortality in the remaining 85 cases is reduced to 33 per cent. Terrier speaks of splenectomy for torsion or twisting of the pedicle, and such is mentioned by Sir Astley Cooper, who has found records of only four such cases. Conklin reports a successful case of splenectomy for malarial spleen, and in reviewing the subject he says that the records of the past decade in operations for simple hypertrophy, including malaria, show 20 recoveries and eight deaths. He also adds that extirpation in cases of floating or displaced spleen was attended with brilliant results. Zuccarelli is accredited with reporting two cases of splenectomy for malarial spleen, both of which recovered early. He gives a table of splenectomies performed in Italy, in which there were nine cases of movable spleen, with two deaths; eight cases of simple hypertrophy, with three deaths; 12 cases of malarial spleen, with three deaths; four cases of leukemia and pseudoleukemia, with two deaths. In his experiments on rabbits it was proved by Tizzoni, and in his experiments on dogs, by Crede, that an individual could live without a spleen; but these observations were only confirmatory of what had long been known, for, in 1867, Pean successfully removed a spleen from a woman of twenty. Tricomi reports eight cases in which he had extirpated the spleen for various morbid conditions, with a fortunate issue in all but one. In one case he ligated the splenic artery. In The Lancet there is an account of three recent excisions of the spleen for injury at St. Thomas Hospital in London, and it is added that they are among the first of this kind in Great Britain.

Abnormalities of Size of the Spleen.—The spleen may be extremely small. Storck mentions a spleen that barely weighed an ounce; Schenck speaks of one in the last century that weighed as much as 20 pounds. Frank describes a spleen that weighed 16 pounds; there is another record of one weighing 15 pounds. Elliot mentions a spleen weighing 11 pounds; Burrows one, 11 pounds; Blasius, four pounds; Osiander, nine pounds; Blanchard, 31 pounds; Richardson, 3 1/2 pounds; and Hare, 93 ounces.

The thoracic duct, although so much protected by its anatomical position, under exceptional circumstances has been ruptured or wounded. Kirchner has collected 17 cases of this nature, two of which were due to contusions of the chest, one each to a puncture, a cut, and a shot-wound, and three to erosion from suppuration. In the remaining cases the account fails to assign a definite cause. Chylothorax, or chylous ascites, is generally a result of this injury. Krabbel mentions a patient who was run over by an empty coal car, and who died on the fifth day from suffocation due to an effusion into the right pleural cavity. On postmortem examination it was found that the effusion was chyle, the thoracic duct being torn just opposite the 9th dorsal vertebra, which had been transversely fractured. In one of Kirchner's cases a girl of nine had been violently pushed against a window-sill, striking the front of her chest in front of the 3d rib. She suffered from pleural effusion, which, on aspiration, proved to be chyle. She ultimately recovered her health. In 1891 Eyer reported a case of rupture of the thoracic duct, causing death on the thirty-eighth day. The young man had been caught between a railroad car and an engine, and no bones were broken.

Manley reports a case of rupture of the thoracic duct in a man of thirty-five, who was struck by the pole of a brewery wagon; he was knocked down on his back, the wheel passing squarely over his abdomen. There was subsequent bulging low down in the right iliac fossa, caused by the presence of a fluid, which chemic and microscopic examination proved was chyle. From five to eight ounces a day of this fluid were discharged, until the tenth day, when the bulging was opened and drained. On the fifteenth day the wound was healed and the man left the hospital quite restored to health.

Keen has reported four instances of accidental injury to the thoracic duct, near its termination at the base of the left side of the neck; the wounding was in the course of removals for deep-seated growths in this region. Three of the cases recovered, having sustained no detriment from the injury to the thoracic duct. One died; but the fatal influence was not specially connected with the wound of the duct.

Possibly the boldest operation in the history of surgery is that for ligation of the abdominal aorta for inguinal aneurysm. It was first practiced by Sir Astley Cooper in 1817, and has since been performed several times with a uniformly fatal result, although Monteiro's patient survived until the tenth day, and there is a record in which ligature of the abdominal aorta did not cause death until the eleventh day. Loreta of Bologna is accredited with operating on December 18, 1885, for the relief of a sailor who was suffering from an abdominal aneurysm caused by a blow. An incision was made from the ensiform cartilage to the umbilicus, the aneurysm exposed, and its cavity filled up with two meters of silver-plated wire. Twenty days after no evidence of pulsation remained in the sac, and three months later the sailor was well and able to resume his duties.

Ligation of the common iliac artery, which, in a case of gunshot injury, was first practiced by Gibson of Philadelphia in 1812, is, happily, not always fatal. Of 82 cases collected by Ashhurst, 23 terminated successfully.

Foreign bodies loose in the abdominal cavity are sometimes voided at stool, or may suppurate externally. Fabricius Hildanus gives us a history of a person wounded with a sword-thrust into the abdomen, the point breaking off. The sword remained one year in the belly and was voided at stool. Erichsen mentions an instance in which a cedar lead-pencil stayed for eight months in the abdominal cavity. Desgranges gives a case of a fish-spine in the abdominal cavity, and ten years afterward it ulcerated through an abscess in the abdominal wall. Keetley speaks of a man who was shot when a boy; at the time of the accident the boy had a small spelling-book in his pocket. It was not until adult life that from an abscess of the groin was expelled what remained of the spelling-book that had been driven into the abdomen during boyhood. Kyle speaks of the removal of a corn-straw 33 inches in length by an incision ten inches long, at a point about equidistant from the umbilicus to the anterior spinous process of the right ilium.

There are several instances on record of tolerance of foreign bodies in the skin and muscles of the back for an extended period. Gay speaks of a curious case in which the point of a sheath-knife remained in the back of an individual for nine years. Bush reported to Sir Astley Cooper the history of a man who, as he supposed, received a wound in the back by canister shot while serving on a Tartar privateer in 1779. There was no ship-surgeon on board, and in about a month the wound healed without surgical assistance. The man suffered little inconvenience and performed his duties as a seaman, and was impressed into the Royal Navy. In August, 1810, he complained of pain in the lumbar region. He was submitted to an examination, and a cicatrix of this region was noticed, and an extraneous body about 1/2 inch under the integument was felt. An incision was made down it, and a rusty blade of a seaman's clasp-knife extracted from near the 3d lumbar vertebra. The man had carried this knife for thirty years. The wound healed in a few days and there was no more inconvenience.

Fracture of the lower part of the spine is not always fatal, and notwithstanding the lay-idea that a broken back means certain death, patients with well-authenticated cases of vertebral fracture have recovered. Warren records the case of a woman of sixty who, while carrying a clothes-basket, made a misstep and fell 14 feet, the basket of wet clothes striking the right shoulder, chest, and neck. There was fracture of the 4th dorsal vertebra at the transverse processes. By seizing the spinous process it could be bent backward and forward, with the peculiar crepitus of fractured bone. The clavicle was fractured two inches from the acromial end, and the sternal end was driven high up into the muscles of the neck. The arm and hand were paralyzed, and the woman suffered great dyspnea. There was at first a grave emphysematous condition due to the laceration of several broken ribs. There was also suffusion and ecchymosis about the neck and shoulder. Although complicated with tertiary syphilis, the woman made a fair recovery, and eight weeks later she walked into a doctor's office. Many similar and equally wonderful injuries to the spine are on record.

The results sometimes following the operation of laminectomy for fracture of the vertebrae are often marvelous. One of the most successful on record is that reported by Dundore. The patient was a single man who lived in Mahanoy, Pa., and was admitted to the State Hospital for Injured Persons, Ashland, Pa., June 17, 1889, suffering from a partial dislocation of the 9th dorsal vertebra. The report is as follows—"He had been a laborer in the mines, and while working was injured March 18, 1889, by a fall of top rock, and from this date to that of his admission had been under the care of a local physician without any sign of improvement. At the time of his admission he weighed but 98 pounds, his weight previous to the injury being 145. He exhibited entire loss of motion in the lower extremities, with the exception of very slight movement in the toes of the left foot; sensation was almost nil up to the hips, above which it was normal; he had complete retention of urine, with a severe cystitis. His tongue was heavily coated, the bowels constipated, and there was marked anorexia, with considerable anemia. His temperature varied from 99 degrees to 100 degrees in the morning, and from 101 degrees to 103 degrees in the evening. The time which had elapsed since the accident precluded any attempt at reduction, and his anemic condition would not warrant a more radical method.

"He was put on light, nourishing diet, iron and strychnin were given internally, and electricity was applied to the lower extremities every other day; the cystitis was treated by irrigating the bladder each day with Thiersch's solution. By August his appetite and general condition were much improved, and his weight had increased to 125 pounds, his temperature being 99 degrees or less each morning, and seldom as high as 100 degrees at night. The cystitis had entirely disappeared, and he was able, with some effort, to pass his urine without the aid of a catheter. Sensation in both extremities had slightly improved, and he was able to slightly move the toes of the right foot. This being his condition, an operation was proposed as the only means of further and permanent improvement, and to this he eagerly consented, and, accordingly, on the 25th of August, the 9th dorsal vertebra was trephined.

"The cord was found to be compressed and greatly congested, but there was no evidence of laceration. The laminae and spinous processes of the 8th and 9th dorsal vertebrae were cut away, thus relieving all pressure on the cord; the wound was drained and sutured, and a plaster-of-Paris jacket applied, a hole being cut out over the wound for the purpose of changing the dressing when necessary. By September 1st union was perfect, and for the next month the patient remained in excellent condition, but without any sign of improvement as to sensation and motion. Early in October he was able to slightly move both legs, and had full control of urination; from this time on his paralysis rapidly improved; the battery was applied daily, with massage morning and evening; and in November the plaster-of-Paris jacket was removed, and he propelled himself about the ward in a rolling chair, and shortly after was able to get about slowly on crutches. He was discharged December 23d, and when I saw him six months later he walked very well and without effort; he carried a cane, but this seemed more from habit than from necessity. At present date he weighs 150 pounds, and drives a huckster wagon for a living, showing very little loss of motion in his lower extremities."

Although few cases show such wonderful improvement as this one, statistics prove that the results of this operation are sometimes most advantageous. Thorburn collects statistics of 50 operations from 1814 to 1885, undertaken for relief of injuries of the spinal cord. Lloyd has compiled what is possibly the most extensive collection of cases of spinal surgery, his cases including operations for both disease and injury. White has collected 37 cases of recent date; and Chipault reports two cases, and collected 33 cases. Quite a tribute to the modern treatment by antisepsis is shown in the results of laminectomy. Of his non-antiseptic cases Lloyd reports a mortality of 65 per cent; those surviving the operation are distributed as follows: Cured, one; partially cured, seven; unknown, two; no improvement, five. Of those cases operated upon under modern antiseptic principles, the mortality was 50 per cent; those surviving were distributed as follows: Cured, four; partially cured, 15; no improvement, 11. The mortality in White's cases, which were all done under antiseptic precautions, was 38 per cent. Of those surviving, there were six complete recoveries, six with benefit, and 11 without marked benefit. Pyle collects 52 cases of spinal disease and injury, in which laminectomy was performed. All the cases were operated upon since 1890. Of the 52 cases there were 15 deaths (a mortality of 29.4 per cent), 26 recoveries with benefit, and five recoveries in which the ultimate result has not been observed. It must be mentioned that several of the fatal cases reported were those of cervical fracture, which is by far the most fatal variety.

Injury to the spinal cord does not necessarily cause immediate death. Mills and O'Hara, both of Philadelphia, have recorded instances of recovery after penetrating wound of the spinal marrow. Eve reports three cases of gunshot wound in which the balls lodged in the vertebral canal, two of the patients recovering. He adds some remarks on the division of the spinal cord without immediate death.

Ford mentions a gunshot wound of the spinal cord, the patient living ten days; after death the ball was found in the ascending aorta. Henley speaks of a mulatto of twenty-four who was stabbed in the back with a knife. The blade entered the body of the 6th dorsal vertebra, and was so firmly embedded that the patient could be raised entirely clear of the bed by the knife alone. An ultimate recovery ensued.

Although the word hernia can be construed to mean the protrusion of any viscus from its natural cavity through normal or artificial openings in the surrounding structures, the usual meaning of the word is protrusion of the abdominal contents through the parietes—what is commonly spoken of as rupture. Hernia may be congenital or acquired, or may be single or multiple—as many as five having been seen in one individual. More than two-thirds of cases of rupture suffer from inguinal hernia In the oblique form of inguinal hernia the abdominal contents descend along the inguinal canal to the outer side of the epigastric artery, and enter the scrotum in the male, and the labium majus in the female. In this form of hernia the size of the sac is sometimes enormous, the accompanying illustration showing extreme cases of both scrotal and labial hernia. Umbilical hernia may be classed under three heads: congenital, infantile, and adult. Congenital umbilical hernia occurs most frequently in children, and is brought about by the failure of the abdominal walls to close. When of large size it may contain not only the intestines, but various other organs, such as the spleen, liver, etc. In some monsters all the abdominal contents are contained in the hernia. Infantile umbilical hernia is common, and appears after the separation of the umbilical cord; it is caused by the yielding of the cicatrix in this situation. It never reaches a large size, and shows a tendency to spontaneous cure. Adult umbilical hernia rarely commences in infancy. It is most commonly seen in persons with pendulous bellies, and is sometimes of enormous size, in addition to the ordinary abdominal contents, containing even the stomach and uterus. A few years since there was a man in Philadelphia past middle age, the victim of adult umbilical hernia so pendulous that while walking he had to support it with his arms and hands. It was said that this hernia did not enlarge until after his service as a soldier in the late war.

Abbott recites the case of an Irish woman of thirty-five who applied to know if she was pregnant. No history of a hernia could be elicited. No pregnancy existed, but there was found a ventral hernia of the abdominal viscera through an opening which extended the entire length of the linea alba, and which was four inches wide in the middle of the abdomen.

Pim saw a colored woman of twenty-four who, on December 29, 1858, was delivered normally of her first child, and who died in bed at 3 A.M. on February 12, 1859. The postmortem showed a tumor from the ensiform cartilage to the symphysis pubis, which contained the omentum, liver (left lobe), small intestines, and colon. It rested upon the abdominal muscles of the right side. The pelvic viscera were normally placed and there was no inguinal nor femoral hernia.

Hulke reports a case remarkable for the immense size of the rupture which protruded from a spot weakened by a former abscess. There was a partial absence of the peritoneal sac, and the obstruction readily yielded to a clyster and laxative. The rupture had a transverse diameter of 14 1/2 inches, with a vertical diameter of 11 1/2 inches. The opening was in the abdominal walls outside of the internal inguinal ring. The writhings of the intestines were very conspicuous through the walls of the pouch.

Dade reports a case of prodigious umbilical hernia. The patient was a widow of fifty-eight, a native of Ireland. Her family history was good, and she had never borne any children. The present dimensions of the tumor, which for fifteen years had been accompanied with pain, and had progressively increased in size, are as follows: Circumference at the base, 19 1/2 inches; circumference at the extremity, 11 1/4 inches; distance of extremity from abdominal wall, 12 3/4 inches. Inspection showed a large lobulated tumor protruding from the abdominal wall at the umbilicus. The veins covering it were prominent and distended. The circulation of the skin was defective, giving it a blue appearance. Vermicular contractions of the small intestines could be seen at the distance of ten feet. The tumor was soft and velvety to the touch, and could only partially be reduced. Borborygmus could be easily heard. On percussion the note over the bulk was tympanitic, and dull at the base. The distal extremity contained a portion of the small intestine instead of the colon, which Wood considered the most frequent occupant. The umbilicus was completely obliterated. Dade believed that this hernia was caused by the weakening of the abdominal walls from a blow, and considered that the protrusion came from an aperture near the umbilicus and not through it, in this manner differing from congenital umbilical hernia.

A peculiar form of hernia is spontaneous rupture of the abdominal walls, which, however, is very rare. There is an account of such a case in a woman of seventy-two living in Pittsburg, who, after a spasmodic cough, had a spontaneous rupture of the parietes. The rent was four inches in length and extended along the linea alba, and through it protruded a mass of omentum about the size of a child's head. It was successfully treated and the woman recovered. Wallace reports a case of spontaneous rupture of the abdominal wall, following a fit of coughing. The skin was torn and a large coil of ileum protruded, uncovered by peritoneum. After protracted exposure of the bowel it was replaced, the rent was closed, and the patient recovered.



CHAPTER XIII.

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 recovered with preservation of sexual powers. The patient was a negro of twenty-two who, while adjusting a belt, had his coat (closely buttoned) caught in the shafting, and his clothes and external genitals torn off. On examination it was found that the whole scrotum was wrenched off, and also the skin and cellular tissue, from 2 1/2 inches above the spine of the pubes down to the edge of the sphincter ani, including all the breadth of the perineum, together with the left testicle with five inches of its cord attached, and all the integument and cellular covering of the penis except a rim nearly half an inch wide at the extremity and continuous with the mucous membrane of the prepuce. The right testicle was hanging by its denuded cord, and was apparently covered only by the tunica vaginalis as high up as the abdominal ring, where the elastic feeling of the intestines was distinctly perceptible. There was not more than half an ounce of blood lost. The raw surface was dressed, the gap in the perineum brought together, and the patient made complete recovery, with preservation of his sexual powers. Other cases of injuries to the external genital organs (self-inflicted) will be found in the next chapter.

The preservation of the sexual power after injuries of this kind is not uncommon. There is a case reported of a man whose testicles were completely torn away, and the perineal urethra so much injured that micturition took place through the wound. After a tedious process the wound healed and the man was discharged, but he returned in ten days with gonorrhea, stating that he had neither lost sexual desire nor power of satisfaction. Robbins mentions a man of thirty-eight who, in 1874, had his left testicle removed. In the following year his right testicle became affected and was also removed. The patient stated that since the removal of the second gland he had regular sexual desire and coitus, apparently not differing from that in which he indulged before castration. For a few months previous to the time of report the cord on the left side, which had not been completely extirpated, became extremely painful and was also removed.

Atrophy of the testicle may follow venereal excess, and according to Larrey, deep wounds of the neck may produce the same result, with the loss of the features of virility. Guthrie mentions a case of spontaneous absorption of the testicle. According to Larrey, on the return of the French Army from the Egyptian expedition the soldiers complained of atrophy and disappearance of the testicle, without any venereal affection. The testicle would lose its sensibility, become soft, and gradually diminish in size. One testicle at a time was attacked, and when both were involved the patient was deprived of the power of procreation, of which he was apprised by the lack of desire and laxity of the penis. In this peculiar condition the general health seemed to fail, and the subjects occasionally became mentally deranged. Atrophy of the testicles has been known to follow an attack of mumps.

In his description of the diseases of Barbadoes Hendy mentions several peculiar cases under his observation in which the scrotum sloughed, leaving the testicles denuded. Alix and Richter mention a singular modification of rheumatic inflammation of the testicle, in which the affection flitted from one testicle to the other, and alternated with rheumatic pains elsewhere.

There is a case of retraction of the testicle reported in a young soldier of twenty-one who, when first seen, complained of a swelling in the right groin. He stated that while riding bareback his horse suddenly plunged and threw him on the withers. He at once felt a sickening pain in the groin and became so ill that he had to dismount. On inspection an oval tumor was seen in the groin, tender to the touch and showing no impulse on coughing. The left testicle was in its usual position, but the right was absent. The patient stated positively that both testicles were in situ before the accident. An attempt at reduction was made, but the pain was so severe that manipulation could not be endured. A warm bath and laudanum were ordered, but unfortunately, as the patient at stool gave a sudden bend to the left, his testicle slipped up into the abdomen and was completely lost to palpation. Orchitis threatened, but the symptoms subsided; the patient was kept under observation for some weeks, and then as a tentative measure, discharged to duty. Shortly afterward he returned, saying that he was ill, and that while lifting a sack of corn his testicle came partly down, causing him great pain. At the time of report his left testicle was in position, but the right could not be felt. The scrotum on that side had retracted until it had almost disappeared; the right external ring was very patent, and the finger could be passed up in the inguinal canal; there was no impulse on coughing and no tendency to hernia.