CHAPTER LVI
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THE MALE GENITAL ORGANS.
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.)
[Illustration: FIG. 667
Diagrammatic sections showing different varieties of hypospadias: 1, hypospadias with imperforate glans; 2, hypospadias with blind canal in glans; 3, with barrier placed between penile urethra and balanitic groove; 4, typical case of hypospadias; 5, hypospadias with normal meatus; 6, penile urethra opening below glans; 7, absence of the whole inferior part of the penile urethra; 8, hypospadias with absence of urethra through glans; 9, case of d’Arnaud; 10, case of Lacroix; 11, case of Lippert with normal meatus. (Kauffmann.)]
[Illustration: FIG. 668
Hypospadias. Liberation of anterior urethra and tunnelling the glans. (Hartmann.)]
[Illustration: FIG. 669
Hypospadias. Drawing the liberated urethra through the tunnel in the glans. (Hartmann.)]
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.
[Illustration: FIG. 670
Perineal section for deep rupture of urethra. Posterior opening is identified and catheter, which has been introduced from the meatus, is guided through it into the bladder. (Lejars.)]
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