The principles and practice of modern surgery

THE PENIS AND URETHRA.

The most common congenital defects of the penis are connected with elongation of the prepuce or with abnormality in the construction of the urethra. Aside from these, however, rare congenital abnormalities have been met with, as, for instance, a double or bifid penis, or its almost complete absence. The former is perhaps to be regarded as an atavistic condition, having its prototype in the kangaroo. Misplacement of the organ is usually apparent rather than real.

PHIMOSIS.

Except as produced in consequence of disease, i. e., by edema or inflammation with swelling, phimosis indicates a congenital condition, either of elongation or constriction of the prepuce, usually with adhesions to the glans. A considerable proportion of male children are born with more or less complete conditions of this kind. These are not so abnormal anatomically, but they lead to serious complications later in life. An extremely tight prepuce is often complicated with stenosis of the meatus, the combined result being a practical stricture at the end of the urethra, through which the infant has to strain with each act of urination. This is a common predisposing cause of hernia. Whether the prepuce be adherent, or so constricted as to make it a retentive sac, there will accumulate between it and the sensitive mucous surface of the glans more or less smegma which, as it decomposes in the course of time, becomes excessively irritating, and a fertile source of reflex disorders, involving even distant parts of the body. Thus in young boys especially, convulsions, chorea, epilepsy, and various other neuroses are produced, while, in addition, its perpetuation produces a condition of unnatural excitability which leads again to habits of masturbation or to sexual irritability and unnatural excitability.

Every newborn male infant should be carefully examined in order that the above condition, if present, may be remedied. This remedy will consist, in mild cases, of forcible retraction of the elongated prepuce, with separation of any adhesions uniting it to the glans. Preputial stenosis may be overcome in some cases by simply slitting up the dorsum, which, if not too long, may be thus released and not require circumcision. On the other hand a much elongated and contracted prepuce should be sufficient justification for prompt circumcision. At the same time any unnatural contraction of the meatus may be overcome by trifling incision. If every boy baby were thus carefully inspected and relieved, if necessary, there would be fewer reflex disorders in young children.

Incidentally it may be said that, in lesser degree, the same thing may apply to girl infants, in whom the clitoris, although small, should nevertheless be freely uncovered by retraction of its miniature hood or prepuce. When this is not easily possible it should be made so. Disorders of the same general character as easily arise in girls, from this same general cause, as in boys, nocturnal incontinence being a frequent expression thereof. In my opinion the teaching of obstetrics should not be considered complete without unmistakable reference to these matters.

Phimosis in the adult may be brought about by disease, especially in connection with a prepuce already retentive, or elongated and difficult of retraction. Retained secretion beneath such a prepuce is a fertile source of danger of all kinds, as well of venereal infection as of cancerous growth. Surgeons in the Orient have described calculi, even of considerable size, found in this location as the result of retention of matter which should not have been at all retained, this condition being noted most often among the Chinese.

Infection, usually gonorrheal, of the concealed surface of the prepuce, which has a distinctly mucous character, is known as posthitis; that of the covering of the glans as balanitis; while, in effect, whatever appears in this location will essentially be a balanoposthitis. If such a condition do not easily subside by irrigation, with a small nozzle introduced beneath the margin of the prepuce, it will then be necessary to slit up the dorsum, or make a complete circumcision, in order that the affected surfaces may be made accessible. The same is true in cases of chancroid and even in cases of chancre; incision or circumcision being justifiable whenever indicated.

PARAPHIMOSIS.

Paraphimosis implies an opposite condition, where the prepuce, having been retracted, is caught behind the margin of the glans and cannot be released nor brought forward. This may be the result of undue effort to retract a very tight but otherwise normal prepuce, or is frequently the result of an acute inflammation, where edema and solid exudate so solidify the tissues as to make them inflexible and almost immovable. In mild cases of paraphimosis cold applications, or pressure with patient manipulation, may be sufficient to restore the proper condition. An extreme degree of such constriction would threaten the nutrition of the glans, to the extent even of possible gangrene, and sloughing of some portion of the end of the penis is not an infrequent result of a neglected condition of this kind. Under these circumstances constriction must be released, it being usually sufficient to apply or inject cocaine, and then with scissors or blunt bistoury nick or incise the constricting ring, to a degree sufficient to release it and permit the desired result; in one way or another this must be attained, else more or less sloughing is sure to follow.

Other rare malformations of the urethra include its more or less complete obliteration, in some portion at least, or, more often, its sacculation or dilatation in certain areas, the result being the formation of pockets or pouches. Such abnormality may persist to adult life, and finally contain a considerable amount of retained urine.

EPISPADIAS AND HYPOSPADIAS.

Epispadias and hypospadias constitute defects in the urethral construction, so that urine escapes at some point much nearer the body than normally intended. A complete degree of epispadias nearly always accompanies extroversion of the bladder, already described. Milder conditions may be met in any degree. In these cases the urethra becomes a canal open above, and the glans is more or less defective. Cases of epispadias may be divided into the balanic, where the urethra terminates on the upper portion of the glans, and the penile, where it terminates between the glans and the pubis; while cases of hypospadias may be divided into balanic and penile, similar to the above, the penoscrotal, where the urethra opens at the junction, and the perineoscrotal, where both the perineum and scrotum are involved. While all of these defects are more or less mutilating and unphysiological, none of them menace life. The physiological requirements of either case demand conditions permitting normal urination, and coitus to a degree permitting fecundation. (See Fig. 667.)

Most cases of hypospadias are accompanied by other defects on the inferior surface of the penis and the scrotum, which, more or less, bind them down and interfere with the normal method of urination as well as of insemination. The indications, then, in such cases are to straighten the penis and to restore the continuity of the urethra. The former may be accomplished by transverse incisions through the bands which cause the curvature, or, if necessary, division of the intracavernous septum, or even of the sheaths of or the cavernous bodies themselves. Wedge-shaped pieces of cavernosa have often been successfully excised. The restoration of the urethra is a much more difficult matter, especially in an extensive case, to make it sufficient for insemination. The methods may be grouped under simple canalization or approximation and the construction of flaps. Nearly all of these methods are more or less simple in theory but difficult in practice, and frequently unpromising because of the difficulties in securing final union of tissues, no matter how neatly united, where the same may be interfered with by the presence of urine or the occurrence of erections. The former may be prevented by a perineal section, with drainage of the bladder, and this is probably the best method to adopt in nearly all of these cases. The latter is to some extent overcome by drugs, but is sometimes produced by the local irritation of the operation and the dressings. To describe all these methods would require a long chapter. They have included efforts at tunnelling the glans, by the passage of a trocar, maintaining the channel by keeping within it some bougie or foreign body until its interior has healed, then connecting this up with the balance of the urethra (Figs. 668 and 669). The urethral passage-way is rarely sufficiently wide to permit of approximation of freshened edges by stitches, and these will almost surely pull out. Therefore some more plastic method of formation of flaps must be devised. Many ingenious expedients have been suggested, among them the utilization of a strip of skin, dissected up on one side, whose external surface is turned in and made to vicariate as mucous membrane, while its raw surface, now faced outward, is covered with another flap, raised either from the penis itself or from the scrotum. It is the operations based on this general plan which have given the best results in well-marked cases, and yet they have to be conducted with great care. American surgeons, among them particularly Beck, of New York, have done a great deal to advance the plastic surgery of these parts and for these purposes. He, for instance, has especially exploited the movability of the urethra, and shown how by dissecting it out it may be drawn forward and made much more available. Beck has suggested a similar method of displacement and reëmployment of the urethra for epispadias.

Epispadias is far more uncommon than hypospadias, occurring in proportion of 1 to 150 cases of the latter, and is rarely seen except in connection with vesical extroversion, except in minor degree, in which the defect is simply a little grooving of the upper surface of the glans. The best method of dealing with the urethra, in epispadias, is to displace it, as suggested by Beck, separating the cavernous bodies and dropping it down to its normal situation beneath them, and uniting with this procedure more or less of the transplantation suggested by him. It is surprising how much can be accomplished by this method, even in extreme cases. The glans, if necessary, may be tunnelled, and the anterior end of the urethra may even be given a hypospadiac termination.

HERMAPHRODISM.

Hermaphrodism, spurious and actual, implies the existence of sexual organs of both sexes in the same individual. It is a condition actually existent in many of the lower forms of life, but its occurrence in the human being is a matter of extreme rarity. There are numerous malformations which, by the laity, are often mistaken for indications of this condition, but the actual co-existence of both testicle and ovary—e. g., which may perhaps be assumed as the true test—is one of the rarest of all phenomena in human anatomy. External malformations which more or less simulate the appearance of the organs of one sex in those of the other include such conditions in the male, for instance, as atrophy of the penis, hypospadias, a more or less complete division of the scrotum into halves, retained testicles with atrophy of the external organs, and similar conditions by which the external genitalia are made to appear divided or relatively too small. In the female, on the contrary, may be seen occasionally an hypertrophy of the clitoris, which causes it to assume almost the proportions and even the erectibility of the male organ, while other deformities of the vulva simulate more or less the scrotum. Again in the female one meets occasional congenital absence of the uterus or of the ovaries, or congenital atresia, or almost complete absence of the vagina, or vulvas which are almost impassable by virtue of exceedingly dense hymens, where the natural appearances are so perverted as to mislead the ignorant. These are, however, cases of pseudohermaphrodism, although in many of them there are certain general changes in appearance, as of the breast, the figure, speech, and even in manner, which are regarded as evidences of effeminacy in a male individual, or of masculinity in a female.

Strange mistakes and errors have thus arisen, and children about whose sex ignorant parents have been in doubt have been mistakenly brought up, even to a point in life when it was sociologically almost too late to remedy the error. Such cases require careful study for the actual determination of sex, especially in young infants.

True hermaphrodism is not to be denied, as certain historical cases have proved, and as has been demonstrated in certain individuals who travel from city to city, exposing themselves for a consideration for scientific examination. In general it is sufficient to say here that true hermaphrodism is a rare possibility, while spurious or pseudohermaphrodism is a condition not uncommonly met.

INJURIES TO PENIS AND URETHRA.

The great vascularity of the penis makes it peculiarly liable to obstinate hemorrhage in cases of incision or laceration. For the same reason when strangulated, as may occur in some drunken orgy or otherwise, it may swell enormously and quickly become gangrenous. An actual fracture of the cavernosa has occurred, through violence in the erected condition. Subcutaneous lacerations or contusions may lead to extensive hemorrhages, possibly with gangrene as the result. Any injury by which the urethra is lacerated, especially torn across, will be followed by much hemorrhage, probably with urinary extravasation, and perhaps great difficulty in establishing the continuity of the channel. Under any circumstances urinary infiltration of any part, deep or superficial, is likely to be followed by abscess and sloughing. An absolute dislocation of the penis is not unknown, it having been displaced beneath the integument of the perineum, abdomen, or thigh, especially in extremely obese individuals.

Urethral injuries are not all accidental. Some of them are the result of design, or of the introduction of foreign bodies which cannot be removed by the patient himself. Such articles may also be introduced, during a drunken orgy, by another individual, or under conditions of sexual perversion by the man himself; and such bodies as pencils, slate-pencils, twigs, and almost every imaginable small object have been found within the urethra. Again it has been seriously injured and even punctured by the careless use of sounds, or by the wire stillette of the old-fashioned linen catheter. Both the anterior and deep urethra may be seriously injured by such accidents as falls upon the external genitals, or upon the perineum, and serious deep lacerations, with complete severance of the membranous urethra, and the infliction of even greater damage, are by no means unknown in such cases.

The first determination should be as to the presence of any foreign body. This being eliminated an effort should be made to check the hemorrhage, and to make sure that there is no such obstruction of the urethra as to interfere with the freedom of the urinary stream. The constant discharge of blood from the meatus, or the admixture of blood with the urine, is always suggestive and should lead to careful investigation. This should include not merely the gentle passage of a sound or catheter, or at least attempt thereat, but perhaps an inspection of the site of injury through the endoscope. When the injury is compound, in the sense of being an external laceration, the deep conditions are more easily ascertained. If with gentleness and yet with difficulty a catheter can be passed through the injured portion of the urethra it would be well to leave it in situ, at least for several hours, perhaps for three or four days, in order that it may act as a splint and the parts more kindly heal around it. If the urethra be so lacerated as to not permit the passage of an instrument, the safer course is an external perineal section, for the purpose of temporary bladder drainage, or to find a deep tear, while a retrograde catheterization may perhaps be practised, and an instrument introduced and carried through in the reverse of the ordinary direction; this may be possible even when ordinary methods fail. Extravasation of blood may be extensive and serious, but extravasation of urine is always followed by disastrous consequences, which should be prevented by external urethrotomy and bladder drainage.

These cases may not be seen until the dangers have already occurred. If it should so happen, an effort should be made, by deep incision and free dissection, to open up all pockets containing urine or blood and to afford free outlet from the bladder. Under some of these circumstances, especially when attempted at night with poor light, the performance of an external perineal urethrotomy is by no means an easy matter, since the torn urethra may be lost in ragged and infiltrated tissues, and may sometimes be found only after long and tedious search.

What to do with a torn urethra, under these circumstances, is sometimes a problem. If it be ragged and more or less torn away it may sometimes be resected, and the ends re-united by sutures, if necessary with a certain amount of dislocation of the urethra by dissecting around it. Pringle and others have resorted to the fresh urethra of the ox, for grafting into cases of recent or old defect, as in instances of extensive deep rupture; as well as in cases of hypospadias, with defect in the floor of the urethra throughout its entire penile portion.

The removal of foreign bodies from the urethra is not easy when these have passed into its deeper portion. With special instruments it is sometimes possible to grasp and extract them, although a pointed extremity may interfere with the ease of removal. More harm will come from leaving them than from removing them. Therefore when their extraction is impracticable there need be no hesitation in button-holing the membranous or the deep urethra, and by pushing the object down toward the opening, there effecting its removal.

The urethral walls will take fine sutures, with every prospect of repair, providing their vascular supply be not too seriously disturbed. Therefore lateral or end-to-end suture may be attempted whenever it appears promising, but in such cases it would be well either to leave a catheter for a few days or to make bladder drainage back of the injury.

Cavernitis refers to an acute or chronic inflammation of the corpus cavernosum on one or both sides. It may be the result of the exudate connected with an injury or with the process of repair. It may ensue in consequence of a local gonorrheal inflammation, or it may be an induration due to chronic syphilis. The condition is one which causes local tenderness rather than pain, while the induration causes a perceptible lump or tumor, and infiltration of vascular tissue interferes with symmetry during erection. Again pressure may cause some ureteral obstruction. Cases of syphilitic origin are to be treated by local inunctions of mercurial ointment, perhaps with ichthyol, which are of benefit in any instance, while the internal administration of the iodides is of more or less assistance. The non-specific cases yield only to time and to massage.

Gummas of the penis may assume the above type, but usually occur in more distinct form, either in the cavernous bodies or between them. An abruptly limited nodule in any such locality will always naturally arouse suspicion of specific disease and lead to its appropriate treatment.

Upon the glans and the prepuce, especially, herpetic vesicles frequently appear, constituting an annoying local lesion, corresponding minutely to the ordinary “cold-sore” upon the lip. This is known as herpes preputialis. It is the result usually of uncleanly habits or local irritation. It is of no consequence, save that in some individuals it occurs frequently, with considerable local irritation. The broken surface thus produced is liable to chancroidal or septic infection, which constitutes its greatest danger, while such a sore, irritated by caustics or injudicious applications, is sometimes mistaken for a specific lesion. A chronic herpes may frequently prove a precancerous lesion.

The papillomas, or warty growths, are frequently noted about the glans and prepuce, being expressions of local irritation, while, under the conditions of local warmth and moisture which prevail, they luxuriate and may develop into condylomatous masses, known as “strawberry” or “mulberry” growths, which may attain large size. In the female they occur on all parts of the vulva and anal region; in the male they rarely appear except as above.

All that such papillomatous growths require is complete excision or extirpation (i. e. destruction), with cauterization of their bases and subsequent local cleanliness. They are not infrequently referred to as venereal warts, which, in effect, they usually are. The other benign tumors of the penis are rare. Occasionally some dermoid cyst or small fatty or fibrous growth may be seen. Sarcoma of the penis is also rare, while epithelioma is not uncommon, constituting the ordinary cancer of the penis.

Epithelioma in this region has its origin around some portion of the mucous surface of the glans, spreading in time to the prepuce, more or less involving the entire organ, while by its rich lymphatic supply involvement of the inguinal and other nodes happens early, whereby the situation is sadly complicated. Epithelial cancer here evinces the same local tendencies toward extension and destructive ulceration as elsewhere, made more rapid by exposure to surface irritation. Its base is indurated, even if sometimes everted; it grows irregularly, but destroys everything with which it comes in contact.

Epithelioma of the penis should be recognized and extirpated early to offer any prospect of success. It is usually as unpromising a condition as epithelioma of the tongue, because of the early lymphatic involvement. A lesion of limited area may justify local excision, but a distinctly marked lesion can only be successfully treated by amputation, at least of the anterior portion of the organ, perhaps of the entire structure of the penis, and thus ensure complete eradication.

Amputation of the penis is easily effected with a circular sweep of the knife, or by an abrupt cross-section, there being but little choice of method, the intent being only to save sufficient of the organ so that cleanliness during and after the act of urination may be maintained. When any portion of the pendulous organ is preserved the margin of the divided skin should be attached to that of the urethra by a series, say, of four sutures, placed at equal intervals, after hemorrhage, which will be somewhat difficult of control, both from the larger vessels and from the cavernosa, has been subdued. It may require buried sutures through the divided cavernosa in order to permit of such control.

If, however, it seem necessary to remove the organ close to the pubis it will probably be found more desirable to make a more complete dissection, taking out the corpora cavernosa entirely, and then making a median incision in the perineum, dissecting out the urethra, bringing it out through the wound, shortening it to the proper extent, and fastening its termination to the skin margin, thus making, as it were, a vulvar outlet, which will not interfere with urinary control, but will permit urination to be satisfactorily accomplished, though only in the sitting posture. This is usually known as Demarquay’s operation.

CIRCUMCISION.

In children this requires a general anesthetic; in adults it can almost always be satisfactorily performed under local cocaine anesthesia; the intent being to remove the redundant foreskin. A circular incision is necessary, which may be made with knife or scissors. The parts being prepared for operation, the prepuce is drawn forward, being caught either with forceps or fingers of an assistant, and the little circular amputation is made just in front of the corona of the glans. The first incision extends through the skin, after which there remains a cuff of mucous membrane, which is sometimes adherent to the glans, as in children, or may be infiltrated with exudate, as by a concealed chancroid or chancre beneath. Ordinarily this cuff is split in the middle line of the dorsum and removed in halves, in order to avoid any possible injury to the glans itself. The cut is made somewhat obliquely from above downward and forward, the intent being to divide it at the frenum, sufficiently far from the meatus in order to not distort the latter by subsequent cicatricial contraction. These tissues are sometimes inordinately vascular, and bleeding points need to be quite carefully secured. In one case known to me an infant bled to death from an unsecured vessel near the frenum, the operator having neglected it at the time and having left the patient. In a clean case, the vessels having been secured, a running suture of fine catgut should unite the cut edges of the mucosa and of the skin. It is not necessary to apply sutures in a venereally infected case, for raw surfaces will also become infected, and would be best protected by immediate cauterization, in which case primary union would be prevented.

The little procedure may be modified in various ways to meet individual needs. After its performance there will occur considerable local swelling and edema, which can be best kept under subjection by a dressing moistened with cold saturated boric acid solution or its equivalent. If the sutures have been too tightly applied there may be a species of paraphimosis, with too much constriction, which would require their division.

THE URETHRA.

In Chapter XII, on Gonorrhea, were described the usual specific forms of urethritis, with their complications and results. To this chapter the reader is referred for all data regarding gonorrhea as it involves this passage-way, with its complications. Such lesions as ulcers may persist for some time, while the papillomatous outgrowths, polypi, etc., connected with gonorrhea and gleet, which are not discoverable from without, are now easily examined and estimated with the endoscope. Specific ulcers of the syphilitic type, and virulent ulcers even of the chancroidal type, also occur, usually within the first inch of the urethra, causing more or less discharge, with local soreness, and leading, unless promptly recognized, to cicatricial stricture formation.

STRICTURES OF THE URETHRA.

Strictures of the urethra may be of traumatic origin, as when produced by external accident, with or without laceration, or by the introduction of foreign bodies, or the minor injuries inflicted during their extraction. Deep traumatic stricture is the result of serious injuries to the perineum. The common type of urethral stricture is the consequence of one or more attacks of gonorrhea, which, not having been promptly cured, has merged into so-called gleet, and this into these inevitable consequences, with more or less infiltration of the peri-urethral tissues, and subsequent encroachment upon the caliber of the urethra, either by irregular new tissue formations or well-marked annular constriction. In addition to the above conditions there is also known a spasmodic stricture, due to involuntary contraction of the muscular fibers encircling the urethra, and of the deeper perineal muscles which concern it. Otis held that such urethral spasm is a frequent accompaniment of a contracted meatus, and taught that the best method to deal with it is by first enlarging the meatus, as may be easily done with a simple bistoury, under local cocaine anesthesia (meatotomy), and the subsequent passage of instruments of proper size.

To persistent and well-marked contraction of the urethra is given the term organic stricture, and such a stricture is generally the consequence of injury or disease, whereas purely spasmodic stricture, mentioned above, is a not infrequent occurrence in perfectly chaste individuals.

Organic stricture may be single or multiple, of large or small caliber, or even impassable and impermeable—that is, from before backward—so that even while urine may leak through, drop by drop, from behind it seems impossible to introduce an instrument from the front. In aggravated cases three or four inches of the urethral canal may be involved in lesions of this kind, which constitute a formidable condition for satisfactory treatment. The ordinary non-traumatic organic strictures are all in front of the prostate and more common near the meatus. The size of a stricture is determined either by the urethrometer devised by Otis, or, more simply, by determining the diameter of the bulbous bougie which may be made to easily slip through it, the latter being the common method. These instruments are indicated by numbers, which refer to the millimeters in circumference of the bulb; thus No. 27 implies that the bulb has a circumference of 27 Mm. The bulbous instrument is far better for examination than the sound, since it indicates the exact depth as well as the length of the strictured passage, and gives a better idea of its density or resilience. (See Figs. 671 and 672.)

The indications of stricture are difficulty in micturition, even to the degree of impossibility, persistence of gleety discharge, and slowness or impossibility of ejaculation, while sometimes cicatricial tissue can be felt from the outside.

The strictured urethral canal should be restored to normal dimensions at the earliest practicable moment. This may be effected through gradual dilatation with a conical steel sound, passed at intervals of two or three days, or rapidly, by the improved instrument of Otis known as the dilating urethrotome, which, being passed through the stricture, has its blades expanded by a mechanism at the handle, while the stricture when it is stretched is divided by the working of a concealed blade. The Otis instrument is illustrated in Fig. 673.

A meatus too small to admit a suitable instrument should be incised to the necessary degree.

Gradual dilatation may be employed in the milder cases, and has been combined with a method of electrolysis, in which I have little faith. No matter which method be adopted, the patient should be impressed with the force of the old adage, “Once a stricture always a stricture,” and should be warned that the occasional passage of an instrument is necessary for a long period, and that while he may be taught the procedure he should not neglect it. This is true alike of every method of treatment.

Divulsion was a method employed during the past generation of rupturing a stricture by forcible separation of the blades of a divided instrument, tearing it instead of neatly cutting it, thus inflicting a maximum instead of a minimum of local damage. Every divulsion thus led to a subsequent stricture formation. The procedure has been abandoned. Now by the employment of the Otis instrument, or one of its substitutes, the stricture is first found, then penetrated with the instrument, and divided to an extent easily regulated, thus permitting exact work, which is preferable to the older methods of drawing a large blade along the urethral tract.

In tight strictures the operator proceeds at first with small filiform bougies made of whalebone, with which, sometimes after considerable effort with a bundle of them in the urethra, trying one after another, he may succeed in passing one and causing it to enter the bladder. The others are then withdrawn. It may now be possible to thread over the whalebone a perforated tip made for the urethrotome, and thus to slip the latter down into the depths over the fine bougie as a guide, and then to push it farther, using now more force because it must necessarily follow the urethral canal. When, however, what seems to be judicious manipulation by this method is unsuccessful the metal instrument should be withdrawn, the whalebone bougie remaining in situ, and thus serving as a guide for that which is now made necessary, namely, external urethrotomy.[72]

External urethrotomy is essentially a median perineal section, carried down at least to the urethra. It is done preferably with a guide, usually a fine bougie. With it the urethral channel may be easily identified; without a guide, in aggravated cases, it is often a difficult matter to identify and dissect out the urethra, and then to find its tortuous passage-way and follow it into the bladder. Patience and a knowledge of the anatomy of the perineum will lead to success. Sometimes extensive dissections are necessary, and the perineal wound needs to be widely retracted in order to better expose the deep tissue. Once the urethra is identified it may be followed in each direction, and the case should not be left until the entire canal has been restored to its normal caliber. In these cases it is best to leave a self-retaining catheter in the perineal wound for at least a day, after which it is sometimes of benefit to introduce a catheter through the meatus, and leave it in the urethra for two or three days. Such a urethra is an infected channel, and must be so cared for that no retention or infection of fresh wounds occurs.

PERINEAL ABSCESS.

Perineal abscess is the not infrequent consequence of a very tight and deep stricture, having its beginnings as a folliculitis, with subsequent extension and perforation, with escape of urine, and sometimes with the formation of acute, diffuse phlegmon, which may even extend into the scrotum or to the abdominal wall. Ordinarily it constitutes a circumscribed collection of pus. Such a phlegmon when neglected may be followed by extensive burrowing of pus, or local sloughing, with gangrene, and partial or complete destruction of the external genitals. When such a phlegmon occurs above the triangular ligament there will be swelling about the prostate, with edema of the anterior rectal wall, while the prostate itself may become later involved. Such a collection may terminate as an ischiorectal abscess, associated with perineal fistulas.

The inevitable results of such conditions have two or three disastrous tendencies, such as burrowing of pus and the formation of urinary fistulas, sometimes at considerable distance from the urinary channels. The same is true in traumatic cases, for in such cases there may be the expression of an old and neglected stricture. To the chronic condition may be added that of tuberculous infection.

Treatment.

—The treatment of such abscesses and fistulas is based upon the principles of evacuation of pus and restoration of the urinary canal to its proper size. This may be an easy or a difficult task, but it should be accomplished by whatever method will permit it with the least damage to tissues. When urinary infiltration threatens gangrene extensive incisions should be made. When the scrotum is swollen, as it may be to enormous dimensions, free opening should be made into it to permit escape of serum and pus if present. Even the surrounding tissues, including the penis, may be enormously edematous. This swelling will rapidly subside when pressure upon the deep veins has been relieved, but pus, no matter where present, must be evacuated.

URINARY FEVER.

Instrumentation of any kind within the urethra may, in some individuals, be followed by what has been called urethral or urinary fever, including chill, pyrexia, with sometimes the development of an acute inflammatory affection, either of the urethra or even of the kidney, with not only retention but actual suppression of urine. These manifestations are ordinarily regarded as due to toxemia, but are sometimes difficult to explain, because their violence seems so disproportionate to the amount of intervention. Thus I have known an individual to die, of apparently acute uremia, within four days after the painless passage of a sound for dilatation of an old stricture, the same not being followed by any blood or local disturbance.

These accidents were more prone to occur before the introduction of antiseptic methods in all urethral instrumentation. At present they are much rarer than in former days. Nevertheless the passage of any instrument, even for legitimate examination, as for stone, may be followed by unpleasant consequences. These are preventable to some degree as well as curable, by antiseptic local measures, as well as by the administration of quinine or urotropin, especially the latter, with sitz baths and perhaps general antifebrile measures, while any local disturbance thus set up is to be treated on general principles.

THE TESTICLES, THE CORD, AND THE VESICLES.

The testicle is originally formed by differentiation from the Wolffian bodies, at a level above the pelvis. Its migration from its original location into the pouch where it normally belongs is known as the descent of the testicle. When it fails to appear at the external ring it is spoken of as retained testicle, and when detained outside the ring above its proper level the condition is referred to as incomplete descent, these being purely arbitrary terms. The reasons for incompleteness of the descent are as little understood as those for its completion, and have but little reference to clinical surgery.

The surgical anatomy of the testicle may be only briefly considered here. Each is essentially a double organ, consisting of the testis proper, the secreting portion, with its more or less complete double peritoneal covering (originally peritoneum), and the epididymis, or conducting portion, variable in size, and corresponding to the parovarium in the ovary in respect that it is subject to cystic degeneration. The pathway made by the testicle as it passes from the abdominal wall should be completely obliterated. When unobliterated it facilitates the occurrence of hernia, while when partially obliterated cystic dilatations of the enclosed portions (hydroceles of the cord) occur. The lowermost portion of the accompanying peritoneal pouch is normally left as a closed sac, which constitutes the cavity of the tunica vaginalis testis. In the ordinary standing posture the epididymis occupies toward the testis proper the same relative position that the heel does toward the anterior part of the foot, i. e., it lies to its posterior and inner sides. While both portions of the organ may be involved in acute or chronic diseases, each of them may be by itself involved with a minimum of disturbance of the other.

RETAINED TESTICLE, OR CRYPTORCHIDISM.

As above indicated failure in descent varies in degree from complete absence from sight and touch to a presentation of the testicle at a point where it can be both seen and felt but still at too high a level. Ordinarily the condition is symptomless, its only signs being those above rehearsed. Strange to say the condition sometimes passes unrecognized until adult life is reached. Commonly it is early discovered. Pain is felt only when friction or traumatism lead to the same unpleasant sensations which would be produced by pressure upon a normal organ. Thus a testicle retained at the external ring may be irritated by the clothing, and has been many a time mistaken for an incomplete hernia, upon which a truss pad has been applied with inevitably resulting suffering. While accompanying malformations in other parts of the body may be found it does not follow that the individual may not be otherwise perfectly developed.

It is usually held that an incompletely descended testicle is more or less functionless; often it is at least more or less atrophied. Its functional capacity varies. It is usually more or less surrounded by a cavity formed from the peritoneum. While the condition is ordinarily one of minor importance, it has been established by numerous observations that retained testicles are relatively prone to undergo malignant degeneration.[73]

Treatment.

—The proper early treatment of cryptorchidism has been a matter of dispute, some advising to leave the condition entirely untouched so long as it be not troublesome; others that early intervention should be practised. If the organ be simply displaced and not otherwise diseased, whatever be done may be limited to freeing it from its abnormal surroundings and restoring it as nearly as possible to the position where it belongs. If it be actually diseased it should be removed. What may be accomplished will depend much upon its movability and its blood supply.

Thus Keetley would liberate the testicle, when retained within the inguinal canal, by division of the latter and lengthening of the cord by blunt dissection, with division also of the lateral portions of the gubernaculum near the pillars of the external ring and as far as possible from the testicle. By traction upon this it is then often practicable to bring the testicle down, without undue tension, to the lower part of a new scrotal pouch, which is formed by making for it a nest, as it were, with the finger, with an opening at its lower extremity, through which forceps are thrust, passed upward and made to seize the end of the gubernaculum, or through which a suture may be passed for the same purpose. By means of this device the testicle is now drawn downward into the scrotal pouch, where, being once present, it is held by sutures, both direct and those which close the pouch above it. It is then advisable to close the inguinal canal, as after a hernia operation. In order to prevent upward traction on the scrotum it is necessary to attach its lower end to the skin of the thigh, by a suture which should remain for several days. If this be done on both sides the limbs should be snugly bandaged together and movement of all kinds prevented. Complete separation of the scrotum from the thighs should not be permitted for several weeks, unless unavoidable.

Beck recommends an incision from the external ring three inches downward along the cord, after which he opens the pouch of the testicle, lifts it from its bed, pulls it down, carefully dividing all bands of connective tissue or peritoneum which tend to immobilize it. It is then deposited in a scrotal pocket, in which it is held by a flap dissected from the outer margin of the inguinal ring, and turned downward in such a way that it can be attached to the opposite layer in semilunar shape. Thus a band of aponeurotic tissue is made to surround the testicle “like a necktie,” the organ being retained as in a buttonhole, the length of the flap being determined by the extensibility of the cord. The inguinal canal is then closed as after any other procedure.

Other abnormalities of the testicle include congenital atrophy or absence, while in a few cases a third testicle has been found, it lying in contact with one or the other of the naturally separated normal pair.

INJURIES TO THE TESTICLE.

Injuries to the testicle are of common occurrence, on account of their exposed position, yet less common than would otherwise occur were it not for their extreme movability. Aside from the lacerated, incised, or punctured wounds which may be inflicted the testicle suffers most often from contusions, always with resulting swelling, and sometimes with considerable effusion, of which a large amount may be accommodated in a distended tunica vaginalis.

HEMATOMA OF THE TESTICLE.

Hematomas of the testicle are also thus frequently produced. When of a limited degree of severity spontaneous absorption of blood may be expected, and should be favored by physiological rest, i. e., confinement in bed, with elevation of the scrotum and the application of water dressings. Large extravasations of blood, when fresh, may be withdrawn by the trocar, but when clotted will require incision and evacuation of clots, which should always be practised, as it leads to great saving of time. Extravasation is usually followed by induration, and more or less permanent enlargement, which will be slow to disappear; absorption may be encouraged by the use of a weak mercurial ointment.

TUBERCULOSIS OF THE TESTICLE.

Tuberculosis of the testicle simulates very closely that occurring in the lungs, in that one may see a disseminated miliary process, with subsequent coalescence and formation of caseous nodules, subsequently breaking down into abscess cavities, while at the same time the surrounding membranes, i. e., the tunica vaginalis, are involved, and effusion (hydrocele) occurs just as in the pleural cavity. In other words every appearance of pulmonary consumption may be imitated within the small extent of the testicles and the epididymis. Of these two parts the latter suffers much more frequently. Here are caused irregular nodules, which may later unite, giving to the entire epididymis a much enlarged, irregular shape, with induration, frequently extending upward along the cord, and always tending so to extend unless the disease be early seen and recognized. Too often adhesions to the skin occur, with ulceration and formation of fistulas, and perhaps more or less extensive ulcers, while in many instances the entire length of the vas becomes infected, and frequently even the prostate and corresponding vesicle become involved. By this time there will be more or less involvement of the inguinal lymphatics, and the patient may be already showing evidences of general tuberculous infection, at least those of some serious constitutional impression made by the local disease. One has to differentiate as between tuberculosis, syphilis, and cancer, which may be difficult in the early stages; but when the disease has extended beyond the epididymis itself it is rarely difficult to recognize, unless entirely masked by distention of the tunica vaginalis with fluid.

Treatment.

—The treatment for tuberculosis of the testicle is extirpation, i. e., castration, which includes the removal not only of the diseased organ, but of all the tissues, including the skin, to which it may be abnormally adherent, and of the spermatic cord, which, if necessary, should be followed into the pelvis by a long incision extending up along the inguinal canal. To remove a tuberculous testis and leave a tuberculous cord is to accomplish very little, while the latter, being an extraperitoneal tissue, may be followed with relative safety, even to the depths of the pelvis. Local applications in these cases give little relief. This teaching is at variance with that of some writers, but is justified by experience.

SYPHILIS OF THE TESTICLE.

Syphilis occurs in secondary and tertiary manifestations, usually first in the testis, sometimes in the epididymis, but always in the testicle before the cord. It produces nodules which may be mistaken for those of tuberculous trouble, but which often attain much larger size. They are usually painless. Nevertheless a syphilitic testicle is sometimes tender, and constantly so, to a degree causing no little annoyance. The occurrence of nodules in the epididymis, in connection with other evidences of syphilis, is regarded by some as pathognomonic. In this location the condition yields readily to properly directed treatment.

CYSTS OF THE TESTICLE.

Cysts are frequently found along the course of the epididymis. Some of them are expansions of the natural tubes of the paradidymis, while others are distinctly new. Dermoids are occasionally met, and either of these may attain considerable size. Cyst of the epididymis proper is to be distinguished from encysted hydrocele of the cord. All of these purely cystic conditions are essentially innocent, and need similar treatment. They may be evacuated and injected with an irritant like pure carbolic acid, which is sometimes an effective way, or they are better treated by open incision with extirpation of the cyst, which is, in the end, far the more satisfactory course to pursue.

EPIDIDYMITIS AND ORCHITIS.

Each of the separate portions of the testis may have its own nearly self-limited inflammations and infections, or both may participate in a common lesion. The most frequent cause of an acute epididymitis is gonorrhea, the infection travelling from the urethra along the vas, and causing acute and well-marked swelling of the epididymis, which becomes tender and painful in proportion to the amount of exudate. It may come on early or late, during the course of the urethritis. The condition is known to the laity as “swelled testicle.” It has been frequently called orchitis, which is an error, since however much the testis may later participate the primary trouble is in the epididymis. It may be easily distinguished by palpation, the enlarged and hardened epididymis, often very tender, being prominent behind the testis proper. The condition may, however, be masked by the acute effusion likely to occur in the tunica vaginalis, constituting a mild degree of acute hydrocele. This may be expected in nearly all severe cases, and serves to increase the size of the entire mass. A testicle thus affected may assume much more than normal dimensions, and, becoming thereby much heavier, drag upon the cord, which is its normal support. More or less fever and malaise accompany the condition, part of which may be due to the toxemia of gonorrheal infection. Usually but one side is involved. Both are rarely affected simultaneously, but one may follow the other.

The acute stage of gonorrheal epididymitis persists for a week or ten days, even under the best of treatment, and is followed by gradual subsidence, characterized by amelioration of symptoms and decrease in size.

Treatment.

—This improvement is to be induced, first, by rest in bed, with elevation of the scrotum, and the ordinary eliminative treatment suitable for any febrile condition. Local relief may come from the application either of heat or of ice-bags, the latter being preferable, but will be made more effective by the application over the scrotum of a mixture of two parts of olive oil with one part of methyl salicylate, or of guaiacol reduced with equal parts of oil or glycerin. The anointed surface should be covered with some impervious material, and the dressing be changed every few hours. Later, as the acute merges into the chronic condition, absorption may be stimulated by the ordinary mercurial ichthyol ointment.

In some exceedingly acute cases suppuration ensues, the consequences being a collection of pus in the epididymis, which will give the ordinary signs and call for the usual evacuation which every collection of pus demands. Epididymitis, more or less acute, has been known to follow the introduction of the catheter or sound, even in cases so far as known not previously infected. It is difficult to explain, but requires the same treatment as above.

Orchitis, or Inflammation of the Testis Proper.

—This condition is rare except as an occasional complication of mumps, or, much more rarely, of one of the other exanthems. Why after acute parotiditis there should be a tendency to inflammation of the testis or the ovary has never been fully explained. Nevertheless it is sufficiently frequent to be well known to the laity, and is occasionally so pronounced as to lead to actual atrophy, with loss of function of the testis involved. In any true orchitis there will be considerable pain and tenderness, because the testis proper is so tightly confined within its tunica albuginea, i. e., a firm, inelastic membrane. By proximity there will also be set up more or less involvement of the tunica vaginalis, with effusion, so that some degree of acute hydrocele may be looked for in every such instance.

Treatment.

—The treatment of the condition above described consists essentially in rest, with local soothing applications, of which perhaps nothing will be more satisfactory than guaiacol, which, however, should always be used with caution.

TUMORS OF THE TESTICLE.

Dermoid cysts and tumors and teratomas, i. e., those of mixed type, are frequently met in this region. Their explanation is doubtless afforded by the extreme complexity of the elements which help to make up the part, while in the embryonic condition, and the confusion of tissue elements which may then and there arise. These growths of embryonic origin vary from single cysts to a mass of cystic tumors, which may replace the organ, or constitute neoplasms of large size, while some of the teratomas have features causing them to resemble the mixed growths occasionally found within or about the ovary. In this way is to be explained the occurrence in such masses of hair, teeth, and other epiblastic elements, as well as of cartilage or bone or other mesoblastic elements. Taken together these growths constitute an interesting group for the pathologist to study. For the surgeon, however, they require essentially the same class of treatment, namely, extirpation, or, if this be impossible, complete removal of the organ, i. e., castration. There should be no hesitation in performing this upon any such growth, as no testicle thus affected is likely to be functionable, and the individual suffers no possible deprivation of potency by its removal.

The other benign and simple tumors, especially fibromas and chondromas, are occasionally met, and I have described one rare case of large lipoma within the limits of the testicle proper.

Cancer of the Testicle.

—This includes, usually, sarcoma, developing from the mesoblastic elements, although adenocarcinoma may be met here, but as an extension from some growth occurring first in the skin or in the immediate neighborhood. Deep cancer in this region is difficult to at first distinguish from the induration produced by tuberculosis or syphilis. In doubtful cases the therapeutic test may be tried in order to differentiate it from the latter. From the former it is usually separated by its more consistent and regular (i. e., its less nodular) character. In all three cases the lymphatics of the groin may be early involved, or perhaps not until late. As a rule cancer is met in the later years of life, while the other conditions are more frequently seen in the first half. In the more rapid cases there will be considerable pain, with dilatation of the scrotal veins, and evidences of constitutional involvement. Sarcoma may grow rapidly and metastasis is almost invariably to the lungs.

Of tumors in the testicle, as of those in the breast, it may be said that any new-growth which tends to enlarge, become more dense or adherent, to spread, or to be accompanied by lymphatic involvement should be removed; no mistake will be made in applying this rule in these cases, especially if by the therapeutic test or otherwise syphilis can be excluded. Malignant disease sometimes travels rapidly up the cord, and the main fear is not so much of local recurrence as of deep involvement within the pelvis. Cases of cancerous growth of the testicle should be not only thoroughly extirpated from the scrotum, but the inguinal canal should be opened, and the cord followed as far as possible and completely removed.

Cases may arise where amputation of the scrotum may be justifiable for the purpose of temporary relief, in order to avoid discomfort, hemorrhage, or offensive ulceration.

HYDROCELE.

Strictly speaking the term hydrocele means accumulation of watery fluid in any pre-existing cavity. By universal consent, unless some other cavity be specified, the tunica vaginalis is understood. The consequence is a more or less distended sac of serous fluid, which first occupies a position in front, but finally is spread around the lateral portion of the testicle, and may form a tumor the size even of the individual’s head. It is an innocent collection of serum, but the walls of such a sac will be thickened in proportion to its age and size, and may in the course of time undergo such degenerations as the calcareous, for instance, by which it becomes more or less infiltrated or encrusted with calcareous material. Thus I have in my possession a tumor of this kind, nearly the size and almost as hard as an ostrich egg, the old tunic being converted practically into a shell.

Acute hydrocele occurs, as above mentioned, in connection with the acute infections, but is then ordinarily a matter of but a few days or weeks.

Hydrocele, as usually implied by the term, is an exceedingly chronic and almost painless affection, which may follow injury, but which comes often without any known cause. Many theories have been advanced to account for it, but none are generally satisfactory. These cases, however, occur usually after the fortieth year of life, but may be seen in the young. Their greatest unpleasantness is that produced by the weight of the mass as it drags upon the cord and the scrotum.

The tumor is pear-shaped, and abruptly circumscribed at its upper limit, below the external ring (unless there be also involvement of the cord), and gives no impulse when the individual coughs. By these features it is distinguished from hernia, for which it is often inexcusably mistaken. A hernia is a distinct prolongation from above, whereas a hydrocele terminates below the hernial outlet, and by its smaller extremity. The distended sac will fluctuate, and will return clear fluid upon puncture with a hypodermic needle, and is so translucent that light may be transmitted through it when it is interposed between a candle-flame and the surgeon’s eye. (Serious thickening of the sac may interfere with the value of this test.) A congenital form of hydrocele is also known, due to failure of obliteration of the canal of Nuck, and it might be possible in some such cases to get a slight impulse on coughing, as when the sac connects with the abdominal cavity, in which case it should be possible to gently press its contained fluid back into the abdomen above. In most congenital cases there is a tendency to spontaneous cure, at least to obliteration of the canal.

Occasionally both sides are involved, or the sacculation may be multilocular, or accompanied by cystic extensions along the cord.

Treatment.

—In regard to methods of treatment, but two will be considered here, aspiration with injection of carbolic acid, and extirpation. The former consists in the insertion of an ordinary (small) trocar, which is thrust in from below upward, care being taken that its point avoid the testicle, which is always found to the posterior and inner side of the sac. Through this trocar the contained fluid should be completely evacuated, so that the sac is practically dry. Into it is now injected with some force from 2 to 6 Cc. of absolutely pure carbolic acid, after which the trocar is instantly withdrawn, pressure made upon the opening, and massage made upon the scrotum and the contained testicle, in order to distribute the acid freely over the serous surface. Its effect is to completely sear the entire surface so that the mouths of all the absorbents are closed. In this way danger of carbolic poisoning is quite avoided, a danger which would be imminent were the acid reduced in strength. But little pain is caused by the procedure. Its immediate effect is to produce exudate, with some recurrence of swelling, which ordinarily rapidly absorbs, while the exudate, coagulating, serves to produce obliteration of the cavity of the sac. This is the carbolic method of Levis, who introduced the acid as a substitute for the iodine formerly employed, upon which it was a great improvement. For cases of moderate age, whose sacs are not too thick, it often proves satisfactory. Having failed, or the case being considered not adapted to it, the other method is that by open incision and extirpation.

This open method consists in making an incision through the skin, down upon and into the sac, which, being thus instantly evacuated, will collapse. It is now possible to make a more or less complete enucleation of the sac wall, stripping it from the external tissues to which it adheres, as it is not necessary to separate it from the testicle itself. It has been found that when the major portion is thus removed the condition is effectually combated. The cavity may be drained with silkworm strands or with a small tube, but only for a short time, if the technique have been correct.

THE SPERMATIC CORD.

The cord participates essentially by its contained vas deferens and lymphatics in the consequences of acute and chronic infections, travelling in either direction, and thus it may be involved in tuberculous, syphilitic, or malignant disease. These expressions, however, are secondary and the conditions have been described above. Encysted hydrocele of the cord implies simple dilatation of an incompletely obliterated canal of Nuck, by which there may be formed along the cord one or more cystic expansions, causing tumors rarely attaining a size greater than a pigeon’s egg, which are innocent collections of fluid, corresponding to the ordinary hydroceles that may occur below. They are ordinarily not difficult of recognition, and are the most common form of neoplasms occurring in this region. They are amenable to the same treatment as that described for hydrocele.