Couper reports a fatal case of stab-wound of the b.u.t.tocks, in which the knife pa.s.sed 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 b.u.t.tocks with a long sailor's knife, with resultant symptoms of peritonitis which proved fatal. At the autopsy it was found that the knife had pa.s.sed through the gluteal muscles and divided part of the great sacrosciatic ligament. It then pa.s.sed 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 b.u.t.tocks 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 p.a.w.nee Indians, and was wounded in a fight near Fort Larned, Kansas. Being mounted and leaning over his horse, a p.a.w.nee, on foot and within a few paces, drove an arrow deep into his right b.u.t.tock. The stick was withdrawn by his companions, but the iron point remained in his body. He pa.s.sed b.l.o.o.d.y 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 circ.u.mstances it was apparent that the arrow-head had pa.s.sed 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 un.o.bstructed 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 pa.s.sing 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 pa.s.s 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 a.s.sumed 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 a.s.sured 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, pa.s.sed through the bladder and r.e.c.t.u.m, 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 pa.s.sed 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 pa.s.sed several small pieces of bone by the r.e.c.t.u.m. 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 pa.s.sing excrement through the urethra, in others, urine by the a.n.u.s. 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 Lusita.n.u.s, and others speak of excrement pa.s.sing through the p.e.n.i.s; and there are many cases of v.a.g.i.n.al a.n.u.s recorded. Langlet cites an instance in which the intestine terminated in the bladder. Arand mentions recovery after atresia of the a.n.u.s with pa.s.sage of excrement from the v.u.l.v.a. Bartholinus, the Ephemerides, Fothergill, de la Croix, Riedlin, Weber, and Zacutus Lusita.n.u.s mention instances in which gas was pa.s.sed by the p.e.n.i.s and urethra. Camper records such a case from ulcer of the neighboring or connecting intestine; Frank, from cohesion and suppuration of the r.e.c.t.u.m; Marcellus Donatus, from penetrating ulcer of the r.e.c.t.u.m; and Pet.i.t, from communication of the r.e.c.t.u.m and bladder in which a cure was effected by the continued use of the catheter for the evacuation of urine.

Flatus through the v.a.g.i.n.a, v.u.l.v.a, and from the uterus is mentioned by Bartholinus, the Ephemerides, Meckel, Mauriceau, Paullini, Riedlin, Trnka, and many others in the older literature. d.i.c.kinson mentions a Burmese male child, four years old, who had an imperforate a.n.u.s and urethra, but who pa.s.sed feces and urine successfully through an opening at the base of the glans p.e.n.i.s. d.i.c.kinson 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 pa.s.sing 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 pa.s.sed 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-gra.s.s. During the night she urinated freely, and claimed that she had pa.s.sed 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 pa.s.sed by the bowel. A rectov.a.g.i.n.al 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 pa.s.sing 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 pa.s.sages, 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 cl.u.s.ter 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 ca.n.a.l, and then pa.s.sed 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 pa.s.sed 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 a.n.u.s, and the patient recovered. Wheeler reports the case of a man of twenty-one who pa.s.sed a b.u.t.ton-hook into his a.n.u.s, from whence it escaped into his bladder. The hook, which was subsequently spontaneously pa.s.sed, 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 b.r.e.a.s.t.s 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, alb.u.minous, 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 ill.u.s.tration. 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 p.e.n.i.s into her urethra.

It was removed by an incision into this ca.n.a.l, 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 circ.u.mstance 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 ca.n.a.l 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 pa.s.sing 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 r.e.c.t.u.m and v.a.g.i.n.a for sixteen years, and spontaneously discharged. Barwell mentions a case in which a gum elastic catheter that had been pa.s.sed into the v.a.g.i.n.a 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 p.e.n.i.s to the extent of five pounds. Colles mentions a man of thirty-eight, p.r.o.ne to obesity, and who had been married two months, who said that in s.e.xual congress he had hurt himself by pushing his p.e.n.i.s 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 p.e.n.i.s 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 p.e.n.i.s 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 p.e.n.i.s.--A peculiar accident to the p.e.n.i.s 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 p.e.n.i.s 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 p.u.b.es, 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 p.e.n.i.s was erect it was bent in the form of a semicircular bow.

The Transactions of the South Carolina Medical a.s.sociation 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 p.e.n.i.s was seven inches in circ.u.mference around the glans, and but little less near the s.c.r.o.t.u.m. 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 p.e.n.i.s.--Fabricius Hilda.n.u.s mentions a curious case of paraphimosis caused by violent coitus with a virgin who had an extremely narrow v.a.g.i.n.a. 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 p.e.n.i.s 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 circ.u.mcise 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 p.e.n.i.s 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 p.e.n.i.s 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 p.e.n.i.s by an infuriated horse, and the two crura were pulled out entire.

Amputation of the p.e.n.i.s is not always followed by loss of the s.e.xual 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 p.e.n.i.s, beside inflicting a wound in the abdomen through which the intestines protruded. After recovery there was a distinct increase of s.e.xual desire and frequent nocturnal emissions. In the same report there is recorded the history of a man who had entirely lost his p.e.n.i.s, 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 p.e.n.i.s while it was partly erect. The wound was acquired at the second battle of Fredericksburg. The ball entered near the center of the glans p.e.n.i.s, and taking a slightly oblique direction, it pa.s.sed out of the right side of the p.e.n.i.s 1 1/2 inches beyond the glans; it then entered the s.c.r.o.t.u.m, and after striking the pelvis near the symphysis, glanced off around the innominate bone, and finally made its exit two inches above the a.n.u.s. The after-effects of this injury were incontinence of urine, and inability to a.s.sume 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 b.u.t.tock and came out of the groin, only to penetrate the dorsum of the p.e.n.i.s 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 t.e.s.t.i.c.l.es were found to be uninjured, but the p.e.n.i.s was doubled out of sight and embedded in the s.c.r.o.t.u.m, from whence it was restored to its natural position and the man recovered.

Nelaton describes a case of luxation of the p.e.n.i.s in a lad of six who fell from a cart. Nelaton found the missing member in the s.c.r.o.t.u.m, 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 pa.s.sing over his body close to the abdomen. The glans p.e.n.i.s could not be recognized, since the p.e.n.i.s 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 p.e.n.i.s, which had been driven into the perineum.

Raven mentions a case of spontaneous retraction of the p.e.n.i.s in a man of twenty-seven. While in bed he felt a sensation of coldness in the p.e.n.i.s, and on examination he found the organ (a normal-sized one) rapidly retracting or shrinking. He hastily summoned a physician, who found that the p.e.n.i.s 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 p.e.n.i.s 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 a.s.sured of its constancy, he tied a string about it above the glans.

Injuries of the p.e.n.i.s and t.e.s.t.i.c.l.es self-inflicted are grouped together and discussed in Chapter XIV.

As a rule, spontaneous gangrene of the p.e.n.i.s has its origin in some intense fever. Partridge describes a man of forty who had been the victim of typhus fever, and whose p.e.n.i.s 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 p.e.n.i.s. Rostan mentions gangrene of the p.e.n.i.s from small-pox. Intermittent fever has been cited as a cause. Koehler reports a fatal instance of gangrene of the p.e.n.i.s, 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 p.e.n.i.s became gangrenous and sloughed off. This is quite unusual, as gangrene is usually a.s.sociated with fever; it is more than likely that the gangrene of the leg was not connected with that of the p.e.n.i.s, 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 p.e.n.i.s. There is a case on record in which, in a man of thirty-seven, gangrene of the p.e.n.i.s followed delirium tremens, and was attributed to alcoholism. Quoted by Jacobson, Troisfontaines records a case of gangrene of the skin and body of the p.e.n.i.s in a young man, and without any apparent cause. Schutz speaks of regeneration of the p.e.n.i.s after gangrenous destruction.

Gangrene of the p.e.n.i.s does not necessarily hinder the performance of marital functions. Chance mentions a man whose p.e.n.i.s 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 p.e.n.i.s 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 s.e.xual 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 s.e.xual 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 a.s.sociated with intense agony and spasmodic cramps. Zacutus Lusita.n.u.s 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 p.e.n.i.s 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 pa.s.sed 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 appet.i.te, 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 p.e.n.i.s 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 p.e.n.i.s formed an acute angle with the p.u.b.es, and he again had free intercourse with the same female. At the time of leaving England the p.e.n.i.s made an angle of about 45 degrees with the p.u.b.es, and this condition, he affirmed, lasted three months. On his return to England his p.e.n.i.s was flaccid, and his symptoms had disappeared.

Salzer presents an interesting paper on priapism which was quoted in The Pract.i.tioner 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 r.e.c.t.u.m, 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 r.e.t.a.r.ded 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 a.s.sociate 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 p.e.n.i.s, 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 s.e.m.e.n, but after the paroxysms a small quant.i.ty of glairy mucus escaped from the meatus. The rigidity was remarkable, simulating the spasms of teta.n.u.s. 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 p.e.n.i.s. The affection lasted five weeks, and was extremely painful. There was a similar case of priapism which lasted for three weeks, and was a.s.sociated with hydrocele in a man of forty-eight.

Injuries of the t.e.s.t.i.c.l.e and s.c.r.o.t.u.m 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 t.e.s.t.i.c.l.es 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 t.e.s.t.i.c.l.es 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 s.e.xual desire. The woman became so enraged that she seized the s.c.r.o.t.u.m and wrenched it from its attachments, exposing the t.e.s.t.i.c.l.es. The left t.e.s.t.i.c.l.e 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 s.e.xual 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 ap.r.o.n, 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 p.u.b.es almost to the a.n.u.s; the ca.n.a.l of the urethra was torn away, and the p.e.n.i.s up to the neck of the bladder. There was no vestige of either the right s.c.r.o.t.u.m or t.e.s.t.i.c.l.e. The left t.e.s.t.i.c.l.e was hanging by its cord, enveloped in its tunica v.a.g.i.n.alis. The cord was swollen and resembled a p.e.n.i.s 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 s.c.r.o.t.u.m, and the right t.e.s.t.i.c.l.e were destroyed. The spermatic cord was divided close to the skin, and the skin of the p.e.n.i.s 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 t.e.s.t.i.c.l.es through the s.c.r.o.t.u.m. The organs were mangled, the spermatic cord was torn and hung over the a.n.u.s, and the p.e.n.i.s was lacerated from the frenum down. The man lost his t.e.s.t.i.c.l.es, 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 p.e.n.i.s and s.c.r.o.t.u.m, and the tissue from the p.u.b.es and inguinal region were torn from the body.

Cicatrization and recovery were complete. Brigham cites an a.n.a.logous case in a youth of seventeen who was similarly caught in threshing machinery. The skin of the p.e.n.i.s and the s.c.r.o.t.u.m was entirely torn away; both sphincters of the a.n.u.s were lacerated, and the perineum was divested of its skin for a s.p.a.ce 2 1/2 inches wide. Recovery ensued, leaving a p.e.n.i.s 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 t.e.s.t.i.c.l.es caught in machinery while ginning cotton. The skin of the p.e.n.i.s was stripped off to its root, the s.c.r.o.t.u.m torn off from its base, and the t.e.s.t.i.c.l.es were contused and lacerated, and yet good recovery ensued. A peculiarity of this case was the persistent erection of the p.e.n.i.s when cold was not applied.

Gibbs mentions a case in which the entire s.c.r.o.t.u.m and the perineum, together with an entire t.e.s.t.i.c.l.e and its cord attached, and nearly all the integument of the p.e.n.i.s were torn off, yet the patient recovered with preservation of s.e.xual powers. The patient was a negro of twenty-two who, while adjusting a belt, had his coat (closely b.u.t.toned) caught in the shafting, and his clothes and external genitals torn off.

On examination it was found that the whole s.c.r.o.t.u.m was wrenched off, and also the skin and cellular tissue, from 2 1/2 inches above the spine of the p.u.b.es down to the edge of the sphincter ani, including all the breadth of the perineum, together with the left t.e.s.t.i.c.l.e with five inches of its cord attached, and all the integument and cellular covering of the p.e.n.i.s except a rim nearly half an inch wide at the extremity and continuous with the mucous membrane of the prepuce. The right t.e.s.t.i.c.l.e was hanging by its denuded cord, and was apparently covered only by the tunica v.a.g.i.n.alis 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 s.e.xual powers. Other cases of injuries to the external genital organs (self-inflicted) will be found in the next chapter.

The preservation of the s.e.xual power after injuries of this kind is not uncommon. There is a case reported of a man whose t.e.s.t.i.c.l.es 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 s.e.xual desire nor power of satisfaction. Robbins mentions a man of thirty-eight who, in 1874, had his left t.e.s.t.i.c.l.e removed. In the following year his right t.e.s.t.i.c.l.e became affected and was also removed. The patient stated that since the removal of the second gland he had regular s.e.xual 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 t.e.s.t.i.c.l.e 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 t.e.s.t.i.c.l.e. According to Larrey, on the return of the French Army from the Egyptian expedition the soldiers complained of atrophy and disappearance of the t.e.s.t.i.c.l.e, without any venereal affection. The t.e.s.t.i.c.l.e would lose its sensibility, become soft, and gradually diminish in size. One t.e.s.t.i.c.l.e 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 p.e.n.i.s. In this peculiar condition the general health seemed to fail, and the subjects occasionally became mentally deranged.

Atrophy of the t.e.s.t.i.c.l.es 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 s.c.r.o.t.u.m sloughed, leaving the t.e.s.t.i.c.l.es denuded. Alix and Richter mention a singular modification of rheumatic inflammation of the t.e.s.t.i.c.l.e, in which the affection flitted from one t.e.s.t.i.c.l.e to the other, and alternated with rheumatic pains elsewhere.

There is a case of retraction of the t.e.s.t.i.c.l.e 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 t.e.s.t.i.c.l.e was in its usual position, but the right was absent. The patient stated positively that both t.e.s.t.i.c.l.es 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 t.e.s.t.i.c.l.e 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 t.e.s.t.i.c.l.e came partly down, causing him great pain. At the time of report his left t.e.s.t.i.c.l.e was in position, but the right could not be felt. The s.c.r.o.t.u.m on that side had retracted until it had almost disappeared; the right external ring was very patent, and the finger could be pa.s.sed up in the inguinal ca.n.a.l; there was no impulse on coughing and no tendency to hernia.

A unique case of ectopia of the t.e.s.t.i.c.l.e in a man of twenty-four is given by Popoff. The s.c.r.o.t.u.m was normally developed, and the right t.e.s.t.i.c.l.e in situ. The left half of the s.c.r.o.t.u.m was empty, and at the root of the p.e.n.i.s there was a swelling the size of a walnut, covered with normal skin, and containing an oval body about four-fifths the size of the t.e.s.t.i.c.l.e, but softer in const.i.tuency. The patient claimed that this swelling had been present since childhood. His s.e.xual power had been normal, but for the past six months he had been impotent. In childhood the patient had a small inguinal hernia, and Popoff thought this caused the displacement of the t.e.s.t.i.c.l.e.

A somewhat similar case occurred in the Hotel-Dieu, Paris. Through the agency of compression one of the testes was forced along the corpus cavernosum under the skin as far as the glans p.e.n.i.s. It was easily reduced, and at a subsequent autopsy it was found that it had not been separated from the cord. Gluiteras a cites a parallel case of dislocation of the t.e.s.t.i.c.l.e into the p.e.n.i.s. It was the result of traumatism--a fall upon the wheel of a cart. It was reduced under anesthesia, after two incisions had been made, the adhesions broken up, and the shrunken sac enlarged by stretching.