Chapter XIV

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As a rule, spontaneous gangrene of the penis has its origin in some intense fever. Partridge describes a man of forty who had been the victim of typhus fever, and whose penis mortified and dried up, becoming black and like the empty finger of a cast-off glove; in a few days it dropped off. Boyer cites a case of edema of the prepuce, noticed on the fifteenth day of the fever, and which was followed by gangrene of the penis. Rostan mentions gangrene of the penis from small-pox. Intermittent fever has been cited as a cause. Koehler reports a fatal instance of gangrene of the penis, caused by a prostatic abscess following gonorrhea. In this case there was thrombosis of the pelvic veins. Hutchinson mentions a man who, thirty years before, after six days' exposure on a raft, had lost both legs by gangrene. At the age of sixty-six he was confined to bed by subacute bronchitis, and during this period his whole penis became gangrenous and sloughed off. This is quite unusual, as gangrene is usually associated with fever; it is more than likely that the gangrene of the leg was not connected with that of the penis, but that the latter was a distinct after-result. Possibly the prolonged exposure at the time he lost his legs produced permanent injury to the blood-vessels and nerves of the penis. There is a case on record in which, in a man of thirty-seven, gangrene of the penis followed delirium tremens, and was attributed to alcoholism. Quoted by Jacobson, Troisfontaines records a case of gangrene of the skin and body of the penis in a young man, and without any apparent cause. Schutz speaks of regeneration of the penis after gangrenous destruction.

Gangrene of the penis does not necessarily hinder the performance of marital functions. Chance mentions a man whose penis sloughed off, leaving only a nipple-like remnant. However, he married four years later, and always lived in harmony with his wife. At the time of his death he was the father of a child, subsequent to whose birth his wife had miscarried, and at the time of report she was daily expecting to be again confined.

Willett relates the instance of a horseman of thirty-three who, after using a combination of refuse oils to protect his horse from gnats, was prompted to urinate, and, in so doing, accidentally touched his penis with the mixture. Sloughing phagedena rapidly ensued, but under medical treatment he eventually recovered.

Priapism is sometimes seen as a curious symptom of lesion of the spinal cord. In such cases it is totally unconnected with any voluptuous sensation and is only found accompanied by motor paralysis. It may occur spontaneously immediately after accident involving the cord, and is then probably due to undue excitement of the portion of the cord below the lesion, which is deprived of the regulating influence of the brain. Priapism may also develop spontaneously at a later period, and is then due to central irritation from extravasation into the substance of the cord, or to some reflex cause. It may also occur from simple concussion, as shown by a case reported by Le Gros Clark. Pressure on the cerebellum is supposed to account for cases of priapism observed in executions and suicides by hanging. There is an instance recorded of an Italian "castrate" who said he provoked sexual pleasure by partially hanging himself. He accidentally ended his life in pursuance of this peculiar habit. The facts were elicited by testimony at the inquest.

There are, however, in literature, records of long continued priapism in which either the cause is due to excessive stimulation of the sexual center or in which the cause is obscure or unknown. There may or may not be accompanying voluptuous feelings. The older records contain instances of continued infantile priapism caused by the constant irritation of ascarides and also records of prolonged priapism associated with intense agony and spasmodic cramps. Zacutus Lusitanus speaks of a Viceroy of India who had a long attack of stubborn priapism without any voluptuous feeling. Gross refers to prolonged priapism, and remarks that the majority of cases seem to be due to excessive coitus.

Moore reports a case in a man of forty who had been married fifteen years, and who suffered spasmodic contractions of the muscles of the penis after an incomplete coitus. This pseudopriapism continued for twenty-three days, during which time he had unsuccessfully resorted to the application of cold, bleeding, and other treatment; but on the twenty-sixth day, after the use of bladders filled with cold water, there was a discharge from the urethra of a glairy mucus, similar in nature to that in seminal debility. There was then complete relaxation of the organ. During all this time the man slept very little, only occasionally dozing. Donne describes an athletic laborer of twenty-five who received a wound from a rifle-ball penetrating the cranial parietes immediately in the posterior superior angle of the parietal bone, and a few lines from the lambdoid suture. The ball did not make egress, but passed posteriorly downward. Reaction was established on the third day, but the inflammatory symptoms influenced the genitalia. Priapism began on the fifth day, at which time the patient became affected with a salacious appetite, and was rational upon every subject except that pertaining to venery. He grew worse on the sixth day, and his medical adviser was obliged to prohibit a female attendant. Priapism continued, but the man went into a soporose condition, with occasional intervals of satyriasis. In this condition he survived nine days; there was not the slightest abatement of the priapism until a few moments before his death. Tripe relates the history of a seaman of twenty-five, in perfect health, who, arriving from Calcutta on April 12, 1884, lodged with a female until the 26th. At this time he experienced an unusually fierce desire, with intense erection of the penis which, with pain, lasted throughout the night. Though coitus was frequently resorted to, these symptoms continued. He sought aid at the London Hospital, but the priapism was persistent, and when he left, on May 10th, the penis formed an acute angle with the pubes, and he again had free intercourse with the same female. At the time of leaving England the penis made an angle of about 45 degrees with the pubes, and this condition, he affirmed, lasted three months. On his return to England his penis was flaccid, and his symptoms had disappeared.

Salzer presents an interesting paper on priapism which was quoted in The Practitioner of London. Salzer describes one patient of forty-six who awoke one morning with a strong erection that could not be reduced by any means. Urine was voided by jerks and with difficulty, and only when the subject was placed in the knee and elbow position. Despite all treatment this condition continued for seven weeks. At this time the patient's spleen was noticed to be enormously enlarged. The man died about a year after the attack, but a necropsy was unfortunately refused. Salzer, in discussing the theories of priapism, mentions eight cases previously reported, and concludes, that such cases are attributable to leukemia. Kremine believes that continued priapism is produced by effusion of blood into the corpora cavernosa, which is impeded on its return. He thinks it corresponds to bleeding at the nose and rectum, which often occurs in perfectly healthy persons. Longuet regards the condition of the blood in leukemia as the cause of such priapism, and considers that the circulation of the blood is retarded in the smaller vessels, while, owing to the great increase in the number of white corpuscles, thrombi are formed. Neidhart and Matthias conclude that the origin of this condition might be sought for in the disturbance of the nerve-centers. After reviewing all these theories, Salzer states that in his case the patient was previously healthy and never had suffered the slightest hemorrhage in any part, and he therefore rejects the theory of extravasation. He is inclined to suppose that the priapism was due to the stimulation of the nervi erigentes, brought about either by anatomic change in the nerves themselves, or by pressure upon them by enlarged lumbar glands, an associate condition of leukemia.

Burchard reports a most interesting case of prolonged priapism in an English gentleman of fifty-three. When he was called to see the man on July 15th he found him suffering with intense pain in the penis, and in a state of extreme exhaustion after an erection which had lasted five hours uninterruptedly, during the whole of which time the organ was in a state of violent and continuous spasm. The paroxysm was controlled by 3/4 grain morphin and 1/50 grain atropin. Five hours later, after a troubled sleep, there was another erection, which was again relieved by hypodermic medication. During the day he had two other paroxysms, one lasting forty-five minutes; and another, three hours later, lasting eighteen minutes. Both these were controlled by morphin. There was no loss of semen, but after the paroxysms a small quantity of glairy mucus escaped from the meatus. The rigidity was remarkable, simulating the spasms of tetanus. No language could adequately describe the suffering of the patient. Burchard elicited the history that the man had suffered from nocturnal emissions and erotic dreams of the most lascivious nature, sometimes having three in one night. During the day he would have eight or ten erections, unaccompanied by any voluptuous emotions. In these there would rarely be any emission, but occasionally a small mucous discharge. This state of affairs had continued three years up to the time Burchard saw him, and, chagrined by pain and his malady, the patient had become despondent. After a course of careful treatment, in which diet, sponging, application of ice-bags, and ergot were features, this unfortunate man recovered.

Bruce mentions the case of an Irishman of fifty-five who, without apparent cause, was affected with a painful priapism which lasted six weeks, and did not subside even under chloroform. Booth mentions a case of priapism in a married seaman of fifty-five, due to local inflammation about the muscles, constricting the bulb of the penis. The affection lasted five weeks, and was extremely painful. There was a similar case of priapism which lasted for three weeks, and was associated with hydrocele in a man of forty-eight.

Injuries of the testicle and scrotum may be productive of most serious issue. It is a well-known surgical fact that a major degree of shock accompanies a contusion of this portion of the body. In fact, Chevers states that the sensitiveness of the testicles is so well known in India, that there are cases on record in which premeditated murder has been effected by Cossiah women, by violently squeezing the testicles of their husbands. He also mentions another case in which, in frustrating an attempt at rape, death was caused in a similar manner. Stalkartt describes the case of a young man who, after drinking to excess with his paramour, was either unable, or indifferent in gratifying her sexual desire. The woman became so enraged that she seized the scrotum and wrenched it from its attachments, exposing the testicles. The left testicle was completely denuded, and was hanging by the vas deferens and the spermatic vessels. There was little hemorrhage, and the wound was healed by granulation.

Avulsion of the male external genitalia is not always accompanied by serious consequences, and even in some cases the sexual power is preserved. Knoll described a case in 1781, occurring in a peasant of thirty-six who fell from a horse under the wheels of a carriage. He was first caught in the revolving wheels by his apron, which drew him up until his breeches were entangled, and finally his genitals were torn off. Not feeling much pain at the time, he mounted his horse and went to his house. On examination it was found that the injury was accompanied with considerable hemorrhage. The wound extended from the superior part of the pubes almost to the anus; the canal of the urethra was torn away, and the penis up to the neck of the bladder. There was no vestige of either the right scrotum or testicle. The left testicle was hanging by its cord, enveloped in its tunica vaginalis. The cord was swollen and resembled a penis stripped of its integument. The prostate was considerably contused. After two months of suffering the patient recovered, being able to evacuate his urine through a fistulous opening that had formed. In ten weeks cicatrization was perfect. In his "Memoirs of the Campaign of 1811," Larrey describes a soldier who, while standing with his legs apart, was struck from behind by a bullet. The margin of the sphincter and, the skin of the perineum, the bulbous portion of the urethra, some of the skin of the scrotum, and the right testicle were destroyed. The spermatic cord was divided close to the skin, and the skin of the penis and prepuce was torn. The soldier was left as dead on the field, but after four months' treatment he recovered.

Madden mentions a man of fifty who fell under the feet of a pair of horses, and suffered avulsion of the testicles through the scrotum. The organs were mangled, the spermatic cord was torn and hung over the anus, and the penis was lacerated from the frenum down. The man lost his testicles, but otherwise completely recovered. Brugh reports an instance of injury to the genitalia in a boy of eighteen who was caught in a threshing-machine. The skin of the penis and scrotum, and the tissue from the pubes and inguinal region were torn from the body. Cicatrization and recovery were complete. Brigham cites an analogous case in a youth of seventeen who was similarly caught in threshing machinery. The skin of the penis and the scrotum was entirely torn away; both sphincters of the anus were lacerated, and the perineum was divested of its skin for a space 2 1/2 inches wide. Recovery ensued, leaving a penis which measured, when flaccid, three inches long and 1 1/2 inches in diameter.

There is a case reported of a man who had his testicles caught in machinery while ginning cotton. The skin of the penis was stripped off to its root, the scrotum torn off from its base, and the testicles were contused and lacerated, and yet good recovery ensued. A peculiarity of this case was the persistent erection of the penis when cold was not applied.

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

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

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

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

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

## partly down, causing him great pain. At the time of report his left

testicle was in position, but the right could not be felt. The scrotum on that side had retracted until it had almost disappeared; the right external ring was very patent, and the finger could be passed up in the inguinal canal; there was no impulse on coughing and no tendency to hernia.

A unique case of ectopia of the testicle in a man of twenty-four is given by Popoff. The scrotum was normally developed, and the right testicle in situ. The left half of the scrotum was empty, and at the root of the penis 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 testicle, but softer in constituency. The patient claimed that this swelling had been present since childhood. His sexual 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 testicle.

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 penis. 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 testicle into the penis. 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.

Rupture of the spermatic arteries and veins has caused sudden death. Schleiser is accredited with describing an instance in which a healthy man was engaged in a fray in the dark, and, suddenly crying out, fell into convulsions and died in five minutes. On examination the only injury found was the rupture of both spermatic arteries at the internal ring, produced by a violent pull on the scrotum and testicles by one of his antagonists. Shock was evidently a strong factor in this case. Fabricius Hildanus gives a case of impotency due to lesions of the spermatic vessels following a burn. There is an old record of an aged man who, on marrying, found that he had erections but no ejaculations. He died of ague, and at the autopsy it was found that the verumontanum was hard and of the size of a walnut and that the ejaculatory ducts contained calculi about the size and shape of peas.

Hydrocele is a condition in which there is an abnormal quantity of fluid in the tunica vaginalis. It is generally caused by traumatism, violent muscular efforts, or straining, and is much more frequent in tropic countries than elsewhere. It sometimes attains an enormous size. Leigh mentions a hydrocele weighing 120 pounds, and there are records of hydroceles weighing 40 and 60 pounds. Larrey speaks of a sarcocele in the coverings of the testicle which weighed 100 pounds. Mursinna describes a hydrocele which measured 27 inches in its longest and 17 in its transverse axis.

Tedford gives a curious case of separation of the ovary in a woman of twenty-eight. After suffering from invagination of the bowel and inflammation of the ovarian tissue, an ovary was discharged through an opening in the sigmoid flexure, and thence expelled from the anus.

In discussing injuries of the vagina, the first to be mentioned will be a remarkable case reported by Curran. The subject was an Irish girl of twenty. While carrying a bundle of clothes that prevented her from seeing objects in front of her, she started to pass over a stile, just opposite to which a goat was lying. The woman wore no underclothing, and in the ascent her body was partially exposed, and, while in this enforced attitude, the goat, frightened by her approach, suddenly started up, and in so doing thrust his horn forcibly into her anus and about two or three inches up her rectum. The horn then passed through the bowel and its coverings, just above the hymen, and was then withdrawn as she flinched and fell back. The resultant wound included the lower part of the vagina and rectum, the sphincter and, the fourchet, and perineum. Hemorrhage was profuse, and the wound caused excruciating pain. The subject fainted on the spot from hemorrhage and shock. Her modesty forbade her summoning medical aid for three days, during which time the wound was undergoing most primitive treatment. After suturing, cicatrization followed without delay.

Trompert mentions a case of rupture of the vagina by the horn of a bull. There is a case recorded in the Pennsylvania Hospital Reports of a girl of nineteen who jumped out of a second-story window. On reaching the ground, her foot turned under her as she fell. The high heel of a French boot was driven through the perineum one inch from the median line, midway between the anus and the posterior commissure of the labia majora. The wound extended into the vagina above the external opening, in which the heel, now separated from the boot, projected, and whence it was removed without difficulty. This wound was the only injury sustained by the fall.

Beckett records a case of impalement in a woman of forty-five who, while attempting to obtain water from a hogshead, fell with one limb inside the cistern, striking a projecting stave three inches wide and 1/2 inch thick. The external labia were divided, the left crus of the clitoris separated, the nymphae lacerated, and the vaginal wall penetrated to the extent of five inches; the patient recovered by the fourth week.

Homans reports recovery from extensive wounds acquired by a negress who fell from a roof, striking astride an upright barrel. There was a wound of the perineum, and penetration of the posterior wall of the vagina, with complete separation of the soft parts from the symphysis pubis, and extrusion of the bladder.

Howe reports a case of impalement with recovery in a girl of fifteen who slid down a hay-stack, striking a hay-hook which penetrated her perineum and passed into her body, emerging two inches below the umbilicus and one inch to the right of the median line.

Injuries of the vagina may be so extensive as to allow protrusion of the intestines, and some horrible cases of this nature are recorded. In The Lancet for 1873 there is reported a murder or suicide of this description. The woman was found with a wound in the vagina, through which the intestines, with clean-cut ends, protruded. Over 7 1/2 feet of the intestines had been cut off in three pieces. The cuts were all clean and carefully separated from the mesentery. The woman survived her injuries a whole week, finally succumbing to loss of blood and peritonitis. Her husband was tried for murder, but was acquitted by a Glasgow jury. Taylor mentions similar cases of two women murdered in Edinburgh some years since, the wounds having been produced by razor slashes in the vagina. Taylor remarks that this crime seems to be quite common in Scotland. Starkey reports an instance in which the body of an old colored woman was found, with evidences of vomiting, and her clothing stained with blood that had evidently come from her vagina. A postmortem showed the abdominal cavity to be full of blood; at Douglas' culdesac there was a tear large enough to admit a man's hand, through which protruded a portion of the omentum; this was at first taken for the membranes of an abortion. There were distinct signs of acute peritonitis. After investigation it was proved that a drunken glass-blower had been seen leaving her house with his hand and arm stained with blood. In his drunken frenzy this man had thrust his hand into the vagina, and through the junction of its posterior wall with the uterus, up into the abdominal cavity, and grasped the uterus, trying to drag it out. Outside of obstetric practice the injury is quite a rare one.

There is a case of death from a ruptured clitoris reported by Gutteridge. The woman was kicked while in a stooping position and succumbed to a profuse hemorrhage, estimated to be between three and four pounds, and proceeding from a rupture of the clitoris.

Discharge of Vaginal Parietes.--Longhi describes the case of a woman of twenty-seven, an epileptic, with metritis and copious catamenia twice a month. She was immoderately addicted to drink and sexual indulgence, and in February, 1835, her menses ceased. On May 8th she was admitted to the hospital with a severe epileptic convulsion, and until the 18th remained in a febrile condition, with abdominal tenderness, etc. On the 21st, while straining as if to discharge the contents of the rectum, she felt a voluminous body pass through the vagina, and fancied it was the expected fetus. After washing this mass it was found to be a portion of the vaginal parietes and the fleshy body of the neck of the uterus. The woman believed she had miscarried, and still persisted in refusing medicine. Cicatrization was somewhat delayed; immediately on leaving the hospital she returned to her old habits, but the pain and hemorrhage attending copulation was so great that she had finally to desist. The vagina, however, gradually yielding, ceased to interfere with the gratification of her desires. Toward the end of June the menses reappeared and flowed with the greatest regularity. The portions discharged are preserved in the Milan Hospital.

The injuries received during coitus have been classified by Spaeth as follows: Deep tears of the hymen with profuse hemorrhage; tears of the clitoris and of the urethra (in cases of atresia hymenis); vesicovaginal fistula; laceration of the vaginal fornices, posteriorly or laterally; laceration of the septum of a duplex vagina; injuries following coitus after perineorrhaphy. In the last century Plazzoni reports a case of vaginal rupture occurring during coitus. Green of Boston; Mann of Buffalo; Sinclair and Munro of Boston, all mention lacerations occurring during coitus. There is an instance recorded of extensive laceration of the vagina in a woman, the result of coitus with a large dog. Haddon and Ross both mention cases of rupture of the vagina in coitus; and Martin reports a similar case resulting in a young girl's death. Spaeth speaks of a woman of thirty-one who, a few days after marriage, felt violent pain in coitus, and four days later she noticed that fecal matter escaped from the vagina during stool. Examination showed that the columns of the posterior wall were torn from their attachment, and that there was a rectovaginal fistula admitting the little finger. Hofmokl cites an instance in which a powerful young man, in coitus with a widow of fifty-eight, caused a tear of her fornix, followed by violent hemorrhage. In another case by the same author, coitus in a sitting posture produced a rupture of the posterior fornix, involving the peritoneum; although the patient lost much blood, she finally recovered. In a third instance, a young girl, whose lover had violent connection with her while she was in an exaggerated lithotomy position, suffered a large tear of the right vaginal wall. Hofmokl also describes the case of a young girl with an undeveloped vagina, absence of the uterus and adnexa, who during a forcible and unsuccessful attempt at coitus, had her left labium majus torn from the vaginal wall. The tear extended into the mons veneris and down to the rectum, and the finger could be introduced into the vaginal wound to the depth of two inches. The patient recovered in four weeks, but was still anemic from the loss of blood.

Crandall cites instances in which hemorrhage, immediately after coitus of the marriage-night, was so active as to almost cause death. One of his patients was married three weeks previously, and was rapidly becoming exhausted from a constant flowing which started immediately after her first coitus. Examination showed this to be a case of active intrauterine hemorrhage excited by coitus soon after the menstrual flow had ceased and while the uterus and ovaries were highly congested. In another case the patient commenced flooding while at the dinner table in the Metropolitan Hotel in New York, and from the same cause an almost fatal hemorrhage ensued. Hirst of Philadelphia has remarked that brides have been found on their marital beds completely covered with blood, and that the hemorrhage may have been so profuse as to soak through the bed and fall on the floor. Lacerations of the urethra from urethral coitus in instances of vaginal atresia or imperforate hymen may also excite serious hemorrhage.

Foreign Bodies in the Vagina.--The elasticity of the vagina allows the presence in this passage of the most voluminous foreign bodies. When we consider the passage of a fetal head through the vagina the ordinary foreign bodies, none of which ever approximate this size, seem quite reasonable. Goblets, hair-pins, needles, bottles, beer glasses, compasses, bobbins, pessaries, and many other articles have been found in the vagina. It is quite possible for a phosphatic incrustation to be found about a foreign body tolerated in this location for some time. Hubbauer speaks of a young girl of nineteen in whose vagina there was a glass fixed by incrustations which held it solidly in place. It had been there for six months and was only removed with great difficulty. Holmes cites a peculiar case in which the neck of a bottle was found in the vagina of a woman. One point of the glass had penetrated the bladder and a calculus had formed on this as well as on the vaginal end.

When a foreign body remains in the vagina for a long time and if it is composed of material other than glass, it becomes influenced by the corrosive action of the vaginal secretion. For instance, Cloquet removed a foreign body which was incrusted in the vagina, and found the cork pessary which had formed its nucleus completely rotted. A similar instrument found by Gosselin had remained in the vagina thirty-six years, and was incrustated with calcareous salts. Metal is always attacked by the vaginal secretions in the most marked manner. Cloquet mentions that at an autopsy of a woman who had a pewter goblet in her vagina, lead oxid was found in the gangrenous debris.

Long Retention of Pessaries, etc.--The length of time during which pessaries may remain in the vagina is sometimes astonishing. The accompanying illustration shows the phosphatic deposits and incrustations around a pessary after a long sojourn in the vagina. The specimen is in the Musee Dupoytren. Pinet mentions a pessary that remained in situ for twenty-five years. Gerould of Massilon, Ohio, reports a case in which a pessary had been worn by a German woman of eighty-four for more than fifty years. She had forgotten its existence until reminded of it by irritation some years before death. It was remarkable that when the pessary was removed it was found to have largely retained its original wax covering. Hurxthal mentions the removal of a pessary which had been in the pelvis for forty-one years. Jackson speaks of a glove-pessary remaining in the vagina thirty-five years. Mackey reports the removal of a glass pessary after fifty-five years' incarceration.

There is an account of a young girl addicted to onanism who died from the presence of a pewter cup in her vagina; it had been there fourteen months. Shame had led her to conceal her condition for all the period during which she suffered pain in the hypogastrium, and diarrhea. She had steadily refused examination. Bazzanella of Innsbruck removed a drinking glass from the vagina by means of a pair of small obstetric forceps. The glass had been placed there ten years previously by the woman's husband. Szigethy reports the case of a woman of seventy-five who, some thirty years before, introduced into her vagina a ball of string previously dipped in wax. The ball was effectual in relieving a prolapsed uterus, and was worn with so little discomfort that she entirely forgot it until it was forced out of place by a violent effort. The ball was seven inches in circumference, and covered with mucus, but otherwise unchanged. Breisky is accredited with the report of a case of a woman suffering with dysmenorrhea, in whose vagina was found a cotton reel which had been introduced seven years before. The woman made a good recovery. Pearse mentions a woman of thirty-six who had suffered menorrhagia for ten days, and was in a state of great prostration and suffering from strong colicky pains. On examination he found a silk-bobbin about an inch from the entrance, which the patient had introduced fourteen years before. She had already had attacks of peritonitis and hemorrhage, and a urethrovaginal fistula was found. The bobbin itself was black. This patient had been married twice, and had been cared for by physicians, but the existence of a body 3/4 inch long had never been noticed. Poulet quotes two curious cases: in one a pregnant woman was examined by a doctor who diagnosticated carcinomatous degeneration of the neck of the uterus. Capuron, who was consulted relative to the case, did not believe that the state of the woman's health warranted the diagnosis, and on further examination the growth was found to have been a sponge which had previously been introduced by the woman into the vagina. The other case, reported by Guyon, exemplified another error in diagnosis. The patient was a woman who suffered from continuous vaginal hemorrhage, and had been given extensive treatment without success. Finally, when the woman was in extreme exhaustion, an injection of vinegar-water was ordered, the use of which was followed by the expulsion from the vagina of a live leech of a species very abundant in the country. The hemorrhage immediately ceased and health returned.

There is a record of a woman of twenty-eight who was suddenly surprised by some one entering her chamber at the moment she was introducing a cedar pencil into her vagina. With the purpose of covering up her act and dissembling the woman sat down, and the shank of the wood was pushed through the posterior wall of the vagina into the peritoneal cavity. The intestine was, without doubt, pierced in two of its curves, which was demonstrated later by an autopsy. A plastic exudation had evidently agglutinated the intestine at the points of penetration, and prevented an immediate fatal issue. Erichsen practiced extraction eight months after the accident, and a pencil 5 1/2 inches long, having a strong fecal odor, was brought out. The patient died the fourth day after the operation, from peritonitis, and an autopsy showed the perforation and agglutination of the two intestinal curvatures. Getchell relates the description of a calculus in the vagina, formed about a hair-pin as a nucleus. It is reported that a country girl came to the Hotel-Dieu to consult Dupoytren, and stated that several years before she had been violated by some soldiers, who had introduced an unknown foreign body into her vagina, which she never could extract. Dupuytren found this to be a small metallic pot, two inches in diameter, with its concavity toward the uterus. It contained a solid black substance of a most fetid odor.

Foreign bodies are generally introduced in the uterus either accidentally in vaginal applications, or for the purpose of producing abortion. Zuhmeister describes a case of a woman who shortly after the first manifestations of pregnancy used a twig of a tree to penetrate the matrix. She thrust it so strongly into the uterus that the wall was perforated, and the twig became planted in the region of the kidneys. Although six inches long and of the volume of a goose feather, this branch remained five months in the pelvis without causing any

## particular inconvenience, and was finally discharged by the rectum.

Brignatelli mentions the case of a woman who, in culpable practices, introduced the stalk of a reed into her uterus. She suffered no inconvenience until the next menstrual epoch which was accompanied by violent pains. She presented the appearance of one in the pains of labor. The matrix had augmented in volume, and the orifice of the uterine cervix was closed, but there was hypertrophy as if in the second or third month of pregnancy. After examination a piece of reed three cm. long was extracted from the uterus, its external face being incrusted with hard calcareous material. Meschede of Schwetz, Germany, mentions death from a hair-pin in the uterine cavity.

Crouzit was called to see a young girl who had attempted criminal abortion by a darning-needle. When he arrived a fetus of about three months had already been expelled, and had been wounded by the instrument. It was impossible to remove the needle, and the placenta was not expelled for two days. Eleven days afterward the girl commenced to have pains in the inguinal region, and by the thirty-fifth day an elevation was formed, and the pains increased in violence. On the seventy-ninth day a needle six inches long was expelled from the swelling in the groin, and the patient recovered. Lisfranc extracted from the uterus of a woman who supposed herself to be pregnant at the third month, a fragment of a large gum-elastic sound which during illicit maneuvers had broken off within five cm. of its extremity, and penetrated the organ. Lisfranc found there was not the slightest sign of pregnancy, despite the woman's belief that she was with child.

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