_Perineal section_ for exploration, drainage, or stricture is

practically accomplished as follows: The patient is first placed in

the so-called lithotomy position, _i. e._, upon the back with the

limbs flexed and knees parted, the feet or legs being held either by

assistants or in suitable leg holders upon the operating table. This is

the position in which nearly all perineal operations in both sexes are

made.

A grooved staff, with large curve and long beak, is introduced into the

bladder, and not only held in the vertical position by an assistant,

but in such a manner as to make its curve bulge the perineum as much

as possible toward the operator. The rectum, which should have been

previously thoroughly cleaned, may be utilized for identification or

for necessary assistance during the operation. The scrotum is held up

out of the way by the assistant who holds the staff. The perineum being

thus put upon the stretch may be most quickly opened by a straight,

sharp-pointed bistoury, which is inserted a little posteriorly to the

scrotal junction, its point driven through the tissues and made to

engage in the groove of the staff, from which it should not escape

until finally withdrawn. As the instrument is pushed backward the

handle is depressed; a triangular-shaped opening is thereby effected,

whose apex is in the membranous urethra and whose base occupies the

raphé of the perineum, to the extent of perhaps one and a half inches.

The entire incision may be made with one effort. Its effect is to open

the membranous urethra. Into the groove of the staff, the knife being

withdrawn, may be introduced either a species of grooved director or

the finger-nail of the index finger, which may be passed backward

and made to enter the prostatic urethra, while at the same time the

staff is withdrawn. If the prostatic urethra be constricted it will

be difficult to enter the bladder with the finger, otherwise it will

readily yield to pressure, and it is thus possible to enter the bladder

within a few seconds after the first incision is begun (Fig. 655).

It is preferable in all these cases to have first washed out the

bladder, and then to have filled it with a mild antiseptic solution.

This will escape instantly an outlet is made from below. If there is a

small calculus within the bladder the effect of the stream will be to

carry it toward this outlet, where it is identified by the finger.

The prostatic urethra will bear a considerable amount of gradual

dilatation, which will make it more than easily accommodate an ordinary

finger. In this way a sufficient channel is made, through which forceps

may be introduced and calculi of small or medium size withdrawn. They

should be seized as carefully as possible within the proper grasp of

these instruments, so that a minimum of laceration may be effected as

they are extracted. A small calculus will be easily removed; a large

and soft one may crumble in consequence of the pressure made upon it

during its extraction. In this event the fragments should be separately

removed, the bladder then repeatedly washed out, and the finger finally

used to make sure that no particles remain.

Whether one stone or several be present the opportunities for the

purpose of their extraction afforded by this median operation are the

same. The bladder having been emptied and washed out a self-retaining

drainage tube, or a hard rubber or metal perineal tube should be

inserted, with such gauze packing around it as may be necessary for

its retention and for the checking of hemorrhage. The intent of the

tube is a double one, it being intended to serve for easy drainage and

for gentle pressure. Sometimes the prostate is more or less torn in the

process of dilatation, and in this case will bleed more freely than is

comfortable. Such oozing may be checked by plugging gauze around the

drainage tube.

_Lateral lithotomy_ may be combined with median section, by

deliberately passing a blunt bistoury into the prostatic urethra, and

making with it an incision in the prostatic substance, the cut being

directed toward a point midway between the anus and the ischiatic

tuberosity, and carried to a depth of one-half or three-quarters of

an inch. This affords a much larger opening through which to remove

larger calculi. Obviously it will bleed more freely and will usually

require packing. The _old lateral method_ was to begin the external

incision at a point, in the middle line, a little behind the scrotum,

and direct it for one and a half or two inches backward and outward

to a point between the tuberosity and the anus. The incision was then

deepened through the perineal fascia until the index finger-nail of

the left hand could identify the staff within the urethra, after

which the urethra was opened at this point (_i. e._, just behind the

bulb), when the knife was again introduced and made to divide the

prostate obliquely as above. In this way the membranous urethra and

lateral aspect of the prostate were divided to the requisite depth. If

such incision be extended too far backward and outward the internal

pudic artery might be divided, which would at least be awkward and

necessitate ligature, and this would be somewhat difficult because it

would require further division of tissues.

[Illustration: FIG. 655

Second stage of lithotomy. (Erichsen.)]

The same management is required after lateral as after median

operation. Except only when a long and seriously inflamed bladder

requires almost permanent drainage the perineal tube should be removed

within forty-eight hours, and the external opening allowed to close as

rapidly as possible.

TUMORS OF THE BLADDER.

The most common benign tumor of the bladder is _papilloma_, which here

assumes almost invariably the villous form and grows even luxuriantly.

It may be solitary or multiple. In the beginning it is usually more

or less pedunculated, but may grow in great numbers, as in the mouth.

A class of denser tumors are the _fibromas_, which are covered by

a more or less thickened mucous membrane. _Myxomas_ grow mainly in

children. _Adenomas_ have been described, but are rare. _Dermoid cysts_

in or about the walls of the bladder have also been described. The

malignant tumors of the bladder are mainly of the epithelial type,

usually _adenocarcinoma_, of a somewhat peculiar type, due to malignant

degeneration of an original papilloma, an unfortunately common event

(Fig. 656).

[Illustration: FIG. 656

Villous tumor (papilloma) of bladder. (Musée Dupuytren.)]

[Illustration: FIG. 657

Tumor of bladder as seen with cystoscope. (Nitze.)]

=Symptoms.=--The symptoms due to tumor in the bladder do not differ

much from those of calculus, except that there is at first less

pain. In nearly all cases there will be _hemorrhage_, occurring

independently of exciting causes, as during sleep, not only abundant

but often frequent. In the early stages pain is rarely severe. In

cancer it is largely proportionate to involvement of the bladder wall

and the adjacent organs, and is more common in cases of basal tumors.

It is both local and referred. With a bladder filled or filling up

with a tumor mass there will be reduction of capacity and frequency

of urination, while in nearly all instances the essential features

of cystitis are superadded. The actual evidences of tumor are its

detection by the cystoscope, its discovery by vaginal or rectal

palpation, or its recognition by fragments discovered in the urine.

When the cystoscope is used in these cases it usually reveals the

location, size, vascularity, arrangement, and character of the tumor.

Its use, however, is often difficult or impossible, because the

manipulation by which the bladder is so distended as to permit its use

causes hemorrhage and obscurement of the field of vision (Figs. 657 and

658).

With the cystoscope has been recognized also an early condition of

_leukoplakia_, corresponding to that seen in the mouth and on the

tongue, which may be regarded as a precancerous condition.

=Treatment.=--The only treatment which can be made effective is

complete _operative removal_. There is no reason why any benign tumor

of the bladder should not be attacked, the most unpromising cases being

those of general papillomatous involvement, where only small areas of

the bladder mucosa are left uninvolved. Such a villous condition as

this is serious, and may later justify an effort at extirpation of the

bladder. _Palliative treatment_ will include the arrest of hemorrhage

(for which a few drops of turpentine oil are often effective), with

gentle lavage of the bladder and removal of clots, securing their

disintegration by injecting an emulsion of pepsin or of papain; while

tenesmus, irritability, and pain are to be controlled by cannabis,

suppositories, morphine, or whatever may be needed. In inoperable cases

cystotomy for drainage purposes may be the final measure for relief

purposes.

Radical measures include _opening of the bladder_, either above or

below the pubis, as the cystoscope may indicate; or the former,

when the cystoscope cannot be used, as it affords better means for

exploration. Through this opening, which may be made larger than for

mere exploratory or lithotomy purposes, and aided by artificial light

(small electric lights introduced by suitable mechanism, as within a

test-tube), there may be removed with scissors or curette, or even with

the finger-nail, by enucleation, such growths as are met, while in

nearly every instance it will be an advisable precaution to cauterize

their bases with the actual cautery. Through more extensive incisions,

with the patient in the Trendelenburg position and the prevesical space

widely opened, the bladder mucosa may be excised, and ample drainage

provided both by retention of a catheter and insertion of a siphon tube

through the lower part of the opening. The suprapubic route affords

better opportunities for thorough work than does the perineal, the

latter being suitable only for a limited class of cases.

[Illustration: FIG. 658

Illumination of anterior vesical wall by Nitze’s cystoscope.]

Finally comes the question of _extirpation_ or a _complete cystectomy_.

This radical and difficult measure has been added to the list of

possible surgical procedures. In a case of general papillomatous

disease it might be successful, but it is questionable whether any case

of cancer which would call for such a measure can be cured by it. The

operation has been done much oftener in women than in men, and usually

by a combined procedure of suprapubic opening, which may be vertical

or transverse, with attack from the vagina. If the vaginal wall be

involved it may also be cut away. The ureters should be isolated and

preserved, when, the affected tissues being removed, it becomes a

question of what to do with them. They may either be left to drain into

the vagina, which is thus utilized simply as a conduit, and which may

be closed later and the urethra thus utilized, a urinal being worn, or

they may be immediately or by a secondary operation turned into the

rectum. The latter procedure introduces fresh complications, though,

if successful, it would minimize the unpleasant features of such a

case.[69]

[69] Symphysiotomy may, when required, be combined with suprapubic

operation as in the case of young children, for removal of very large

stones or tumors, as has been recently demonstrated by Palmer, of

Persia.

It is thus possible to successfully extirpate the entire bladder

proper, conserving the ureteral orifices or not, as well as the

urethra, although the resultant condition can hardly be considered

brilliantly satisfactory.[70]

[70] In a recent case I have been able to more easily effect this

procedure by raising a flap, including the tissues of the mons,

exsecting a portion of the symphysis containing the insertion of the

recti, by oblique division, in such a way that when replaced the bone

could not be easily displaced, and in this way uncovering the space

of Retzius so that, by combined manipulation, it was easier to detach

the bladder wall from its surroundings.

THE PROSTATE.

The prostate, with the duct extremities of the seminal vesicles, are

enclosed in a fibrous sheath or _capsule_, of more or less density,

which has been called by Belfield the broad ligament of the male.

In structure this body is composed of a mixture of adenomatous and

muscular (involuntary) fibers, with considerable connective tissue, so

that in many respects it is the homologue of the uterus. It not only

serves as the portal of the bladder, but through it pass the prostatic

urethra and the seminal ducts. Infection proceeding from either

direction may, therefore, travel along either one of several paths,

spreading disaster and causing a variety of troubles. Such infection

may be tuberculous, gonorrheal, or of the ordinary septic type. There

will ensue in consequence various forms of _prostatitis_: the _acute_,

which may lead to abscess, and the _chronic_, which will always lead to

hypertrophy.

ACUTE PROSTATITIS.

Acute prostatitis is generally the result of gonorrheal infection, the

consequence of extension from the urethra into the mucous follicles and

the prostatic structure. _Primary tuberculous_ disease in this location

is rare. _Septic infection_ comes either from the use of unclean

instruments, from the presence of infected urine, or from the extension

of cellulitis from some adjacent structure. It is not infrequently seen

in connection with deep and tight strictures and accompanying cystitis,

or in connection with the presence of small concretions, _i. e._,

prostatic calculi.

Acute prostatitis is an exceedingly painful affection, made so

particularly by inelasticity of the capsule, which affords no

accommodation for the swelling due to the inflammation. In addition

to the inevitable pain and tenderness the swelling will sometimes

practically close the urethra in such a manner that urination becomes

almost impossible. To nearly every case will be added some of the

symptoms of acute cystitis, which may have preceded the prostatitis.

Prostatic inflammation can be made known by the exquisite tenderness of

the organ, discoverable by digital examination through the rectum. This

feature, with tenderness in the deep perineum, and the above symptoms

make diagnosis easy.

According to the intensity of the lesion will be the liability to

suppuration. _Prostatic abscess_ is a frequent result, and its

presence is evidenced by accentuated pain and tenderness, with perhaps

considerable febrile disturbance. In some cases fluctuation can be

detected through the rectum. Such cases sometimes evacuate themselves

spontaneously, although often in an undesirable way, when left

untreated, or unrecognized, discharge taking place usually into the

rectum, but perhaps into the bladder or into the urethra. Should pus

burrow into the pelvis there will arise a deep pelvic cellulitis, with

probable disastrous consequences.

When _a prostatic abscess is suspected_ the patient should be

anesthetized, the sphincter dilated, the exploring needle used if

necessary, and any collection of pus, no matter how detected, should be

either completely emptied with the aspirator or by free incision.

CHRONIC PROSTATITIS.

Chronic prostatitis may be the residue of an acute lesion or the

gradual production of a mild but more or less constant septic

infection. It leads always to more or less enlargement, is often the

basis for the classic prostatic hypertrophy, and causes dull pain,

referred in various directions, often to the sacrum and the back,

with frequency of urination and escape of a viscid mucus, the natural

prostatic mucus in excess, which the patient will usually consider

semen, but which is really the product of the overworked prostatic

glands.

This last phenomenon is spoken of as _prostatorrhea_, and deserves

consideration not alone from the alarm with which patients often regard

it, but because it indicates a significant condition. A prostate whose

glandular structures have been unduly active will, in consequence,

enlarge; such a prostate is compressed with the passage of every hard

stool, the consequence being the expulsion of some of this fluid with

each act of defecation, a feature interpreted by too many patients

as _spermatorrhea_. The two conditions are to be differentiated in

clinical study, the former being common, the latter quite rare.

_Acute prostatorrhea_ is also frequently the consequence of more or

less prolonged sexual excitement. It corresponds essentially to a

chronic nasal catarrh, which is accentuated by exposure to cold or to

irritation of any kind, and is only the overflow of a natural fluid

under morbid conditions. With chronic prostatitis, furthermore, the

sexual appetite is often decreased, while sensations are more or less

disturbed, ejaculation being perhaps premature; the patient is often

made thereby despondent, and the case regarded by himself, or by

the quack whom he is led to consult, as at least incipient, perhaps

hopeless, impotence.

The physical _evidences of chronic prostatitis_ are enlargement, with

tenderness not only of the prostate itself, but of the seminal vesicles

above it, and often the appearance of a few drops of prostatic mucus

at the meatus after pressure or stroking of the prostate itself has

expelled them.

=Treatment.=--Removal of the cause is the secret of success; if this

be a stricture it may be divided and dilated; if cystitis, it must

be combated; if chronic constipation, it should be overcome; while

excesses, either alcoholic or sexual, should be controlled. Some one

or nearly all of these conditions will be seen in nearly every case of

this character. To other manipulative features may be advantageously

added a certain massage or “milking” of the prostate, at intervals of

five or six days, by which it is emptied of its accumulated secretion.

Equally beneficial is the occasional passage of a large sound through

the prostatic urethra and into the bladder. Its effect also is to

make pressure, while at the same time it stimulates and does good in

a way perhaps difficult of explanation. Irritation in the prostatic

urethra should also be controlled by occasional injections, with a

deep urethral syringe, of a drop or two of a ¹⁄₂ per cent. solution

of silver nitrate. Improvement in other respects may be expected from

constitutional, dietetic, and hygienic measures.

PROSTATIC HYPERTROPHY.

Many theories have been advanced as to the etiology of prostatic

enlargement. Those worthy of any consideration may be summarized as

follows:

1. That it is of inflammatory origin;

2. That it is due to senile and sclerotic changes;

3. That it is produced by sexual excess;

4. That it is due to ungratified sexual desire;

5. That it is a secondary and degenerative change following disease

of the bladder;

6. That it is due to some perverted testicular secretion;

7. That it is to be regarded as a normal senile change;

8. That it is of catarrhal or septic origin secondary to bladder

disease;

9. That it is to be regarded as an adenoma.

Inasmuch as the prostate is to be regarded as essentially a sexual

gland, many cases of hypertrophy are the result of bad sexual habits

which produce continued congestion. Nevertheless the importance of

previous infections, _e. g._, gonorrheal, by which hypertrophy of

glandular and cell elements may be produced, cannot be overlooked.

Prostatic enlargement assumes one of three principal types:

(_a_) True hypertrophy of gland elements, without interstitial

participation;

(_b_) The development of more or less distinctly encapsulated

myomatous and adenomatous masses; and

(_c_) A mixed condition involving both of these features.

In consequence the ensuing enlargement assumes one of the three

following clinical types:

(_a_) An enlarged soft prostate;

(_b_) A small contracted and sclerotic prostate;

(_c_) A mixed type.

These types do not necessarily merge into each other, but may remain

distinct. There may be atrophy of glandular elements as a result of

hypertrophy of the muscle and fibrous elements, or _vice versa_.

Much confusion has arisen regarding the so-called _third lobe_, in

spite of the fact that the prostate is essentially a bilobed organ.

Whence has arisen the tendency to speak of the “third lobe,” or is

there such a thing? The explanation is that median enlargement is

a common expression of prostatic hypertrophy, occurring toward the

interior of the bladder at a point where the prostate has no capsule,

and where growth occurs in the direction of least resistance. That

morbid specimens show an apparent “third lobe” is true, but that such a

condition exists normally is a mistake. It should, therefore, be spoken

of as a _median enlargement_ (Fig. 659).

[Illustration: FIG. 659

General prostatic enlargement, with formation of a median overgrowth

and posterior pocket or sac. Illustrating how residual urine may be

retained, as well as the difficulties of all kinds of instrumentation,

_i. e._, an argument, therefore, for radical treatment. (Socin and

Burckhardt.)]

In addition to the more innocent and purely hypertrophic forms of

prostatic enlargement, it has been recently shown, especially by

Young, that the element of _cancer_ is present in a proportion of

cases hitherto quite unsuspected. It may begin as a small indurated

nodule, in one or both lobes, and while developing remains confined

for a relatively long period by the strong prostatic capsule. When it

extends, its line of invasion is upward toward the vesicles rather

than into the bladder. When the latter has become involved, if a

radical operation is to be practised, extirpation must include not

only the entire prostate, with its capsule, the urethra, the vesicles,

but the adjacent portion of the base of the bladder. Early diagnosis

in these cases is difficult, since it may occur at any age after

fifty years, and, being connected with hypertrophy, produces symptoms

masked by it, only the element of pain being more prominent. As the

condition develops pain becomes rather disproportionate, spreads to the

suprapubic region, and is intensified as the bladder fills. When pain

is referred also to the rectum and lower extremities it is a suspicious

symptom. The condition does not necessarily, at least at first, cause

enormous enlargement. Therefore the obstructive features vary. If the

portions involved can be left they will be found more dense and hard

than the surrounding tissue. One peculiarity of prostatic cancer is

that metastases occur more often in the bones than in the lymphatics.

Consequently the pelvic nodes are not so often affected. Ulceration and

intravesical tumor are rare.

=Diagnosis.=--Early diagnosis is based on rapidity of growth,

disproportionate pain, indurated contraction of the prostatic urethra

near its apex, and absence of intravesical enlargement, as shown by

the cystoscope. When there is much residual urine, without enlargement

of intravesical lobes, suspicion is strengthened. If after removal

of such prostate it should be shown to be more or loss dotted with

“seed calculi,” as is possible, instead of with cancer, the benefit

and relief to the patient would be none the less marked, while the

prognosis would be all the better.

Prostatic hypertrophy leads to a collection of phenomena spoken of as

_prostatism_. These include mechanical impediment to urination, with

consequent obstruction, sometimes with complete retention, and to the

consequences of the same in the direction of infection and cystitis,

with added features of pain, tenesmus, and pyuria. _Prostatism is a

matter of gradual development._ Its earliest symptoms are frequent

urination with occasionally some difficulty or slowness in the act.

From this as a beginning cases become gradually aggravated, until death

finally ensues from retention, rupture of the bladder, pyelonephritis,

or exhaustion in consequence of the pain and suffering entailed.

Prostatism may be imitated in persons whose prostates are not

perceptibly enlarged, in whom the difficulty and obstruction are due

to sclerosis and contracture of the vesical neck. This condition is

especially common in elderly men, subjects of arterial sclerosis. This

will account for instances of prostates which, on removal, are found

hard and sclerosed, and yet not enlarged enough to be obstructive.

If such a prostate could be divided by the cautery, benefit, even

permanent relief, might ensue. Therefore, such a condition might be

well attacked when diagnosticated (either by suprapubic operation

or by perineal section), with the use of the Bottini galvanocaustic

instrument, especially through a perineal opening.

Prostatic enlargement produces distortion of the prostatic urethra,

which becomes longer, smaller, and sometimes deviated, with elevation

of the level of the vesico-urethral orifice, and causes, by pressure

on veins, more or less disturbance of the return circulation.

Enlargement with impediment produces dilatation of the bladder, with

possible involvement of the ureters or the kidneys, and thickening of

the vesical walls, often with sacculation of its mucosa between its

disturbed muscle fibers.

Finally come the consequences of septic infection with ammoniacal

putrefaction of urine, pyuria, and perhaps pyelonephritis with uremia,

which will be terminal. While the condition is generally regarded as

belonging to the late years of life it may begin by natural processes

at the forty-fifth year, although uncommon before the fifty-fifth.

[Illustration: FIG. 660

Enormous prostatic hypertrophy, necessitating suprapubic cystotomy

because of impossibility of catheterization from below. (Socin and

Burckhardt.)]

=Symptoms.=--When a man past the middle years of life, previously

free from urinary difficulties, is aroused to urinate more frequently

than usual, especially at night, while the desire to urinate and the

natural feeling of relief at the conclusion of the act are more or

less perverted, the beginning of prostatism may be suspected. If in

addition to these features the urine shows fermentative changes, or

the presence of mucus or pus, the more or less disastrous consequences

of obstruction have begun. Symptoms similar to these may be caused by

the presence of calculus. It is therefore necessary to differentiate

between this and prostatic enlargement. This is first done by a careful

digital examination of the empty rectum, the index finger being gently

introduced and made to so completely palpate the prostate, through

the anterior wall of the rectum, that an accurate estimate of its

relative size, as well as of any marked irregularity, may be made.

If the prostate be enlarged the explanation is at once afforded.

If there be but little apparent change noted by this method the

surgeon should introduce a stone searcher. Manipulation with this,

in a bladder distended with fluid, should reveal the presence of a

calculus, or should indicate a lengthening of the prostatic urethra,

with such distortion, as might make the introduction of the instrument

difficult, while by further manipulation, its beak being gently

revolved, he learns whether behind the prostate there is a pocket

in which residual urine may be retained. The question of calculus

being settled the patient should now empty the bladder naturally and

as usual, after which a catheter should be introduced, in order to

withdraw such residual urine as may be retained, whose amount should

then be noted. This is a measure of the size of the postprostatic

pocket which the patient fails to empty, and in which decomposition

and pathological changes are especially likely to occur. Should such

a pocket be found in a case without noticeable other enlargement (as

detected through the rectum) it will indicate _intravesical growth_

and the formation of the so-called “third lobe” or “median bar,” as it

was formerly called (_i. e._, an outgrowth at the posterior end of the

prostatic urethra, projecting upward into the bladder, impeding alike

the exit of urine and the introduction of an ordinary instrument).

Those expert with its use may gain still further information of value

by use of the cystoscope.

=Treatment.=--The diagnosis thus established, the question of treatment

is raised. Views concerning what is best have been largely modified by

the operative methods recently introduced, and the advice given a few

years ago is now frequently modified. So long as surgical treatment

was unsatisfactory and incomplete it was to be postponed as long as

possible. Under those circumstances patients were taught to use the

catheter and established the “catheter habit.” Almost invariably they

became careless, and the catheter habit led invariably to cystitis.

Nevertheless circumstances may arise which make this good advice even

today, as in the presence of other and serious disease, or of anything

which makes radical operation inexpedient. Under such circumstances the

patient must be impressed as profoundly as possible with the necessity

for care and caution. If such a case has progressed to the stage of

almost complete retention then the catheter should be used at regular

intervals. If it be simply necessary to draw off residual urine once

a day, then it may be used at night, at which time it would be well

also to gently and carefully wash the bladder. It is possible in this

way to temporize for a variable length of time, and until more serious

conditions supervene.

When, however, the prostate has enlarged so conspicuously as to be not

only a constant impediment but a constant menace to the comfort and

even life of the patient, one is brought to seriously consider which

of the various mechanical methods for relief should be instituted.

The choice must now be governed by the physical condition and the

surroundings of the patient, as age, degree and character of the

obstruction, and the extent of septic infection. One has again to

choose between the most radical and usually the most satisfactory

method of _extirpation_ (_prostatectomy_), or one of the less radical

and palliative operations, such as the _Bottini operation with the

galvanocautery_.

A few years ago White and others laid great stress on the fact that

after removal of the testicles there was notable atrophy of the

prostate, and suggested the expedient of _double castration_ or

_orchidectomy_ for this purpose. The method proved disappointing,

although doubtless more or less effective in some cases, and so

objectionable to many patients, for obvious reasons, that it has been

practically abandoned. The less mutilating substitute of division and

exsection of a portion of each vas deferens (_vasectomy_) has for the

same reason been discarded.

When radical measures become necessary the choice should be made

between the _galvanocautery_ (_i. e._, canalization of the base of

the prostate and its median bar by means of the instrument devised

by Bottini) and the bolder and more radical method of _extirpation_

(prostatectomy). This _prostatectomy_ is done by either the

_suprapubic_ or the _perineal_ route. As between them there is often

room for choice, for reasons mentioned below. Each method has its

advocates and its opponents.[71]

[71] The question of credit and priority for these operations has

been of late much discussed. To McGill, of Leeds, and Goodfellow, of

San Francisco, should be given most of the credit for the earliest

perineal operations, while Fuller, of New York, who first performed

the suprapubic operation in 1894, should probably be given credit

for the latter, although it has been evidently unjustly claimed for

Freyer, of London. Belfield, of Chicago, was also one of the earliest

advocates of extirpation of the enlarged prostate.

=Suprapubic Prostatectomy.=--It is of assistance in this method to have

the empty rectum somewhat distended, and held up by the introduction

of a rubber bag, which may be later distended with water or with

air. By this means the prostate and floor of the bladder are pushed

upward toward the operator’s finger. This is, however, by no means

necessary, but simply advantageous. The first part of the operation is

essentially that described as suprapubic cystotomy. The bladder being

thus opened and the prostate carried upward by a sound, which should

have been inserted in the urethra, the finger first accurately notes

its dimensions and the direction of its enlargement. Blunt scissors are

now used, or the sharp finger-nail, for making an opening through the

mucosa and prostatic covering, _through the capsule_ of the latter,

down upon that body. This opening is preferably made near the urethral

entrance. The balance of the operation consists in blunt dissection

by the end of the finger, _i. e._, _enucleation_ of the prostate from

within its enclosing capsule and surrounding tissues (Fig. 661). More

or less disturbance of the basal structures is necessitated, but as

the surgeon becomes expert the amount of this disturbance becomes

relatively surprisingly small. In most instances it is possible also to

practically strip off the prostatic tissue from the urethra, so that

it is rarely necessary to tear or to cut across it in order to lift

the prostate out of its bed. In the average case it is possible in

this way to enucleate the prostate in a single piece, and to remove it

as an _entire organ_. If, however, it should prove too large for the

bladder opening which has permitted the procedure it would be better

to morcellate it, or so far divide it with scissors as to permit its

extraction piecemeal. Its removal leaves a bleeding cavity at the base

of the bladder, with torn and separated tissues, and a pocket where

the prostate used to lie, into which urine will be poured from above,

while it cannot ordinarily be at first easily emptied from the more or

less injured urethra connected with it. From this surface there will

be at first considerable oozing, mostly venous. Should this be serious

and prolonged a quantity of gauze may be packed into it through the

opening, and pressure thus made. Such packing should only be retained

for a few hours. Ordinarily it is sufficient to provide at once for

_drainage_. My own preference is to make double provision for this by

the passage of a catheter through the urethra, and by the insertion of

a drainage tube from above, whose lower end rests within the pocket. It

is a great desideratum to drain the urine as fast as it accumulates,

and, at the same time, to keep the patient dry. This is best effected

by a method described later, of complete _bladder siphonage_, which can

be resorted to in either form of operation. It is again advisable to

get the patient into the sitting posture, which should be done within

a day or two, or as soon as his strength will permit, in order that

gravity may assist in drainage. (See p. 1003.)

[Illustration: FIG. 661

Suprapubic prostatectomy. Process of enucleation by finger-tip of one

hand in the bladder, the other hand making pressure in the perineum.

(Hartmann.)]

When difficulty is met in enucleation assistance is derived by the

introduction of one or two fingers of the disengaged hand into the

rectum, by which certain manipulation can be effected from below that

will be of material help. Pressure in the perineum or manipulation of a

sound may also be of assistance.

So soon as satisfactory drainage through the urethra can be effected

the suprapubic tube should be removed, and the wound thus encouraged to

close.

=Perineal Prostatectomy.=--Perineal prostatectomy constitutes a

similar attempt at enucleation, effected from a different direction.

The patient now being in the lithotomy position, with the rectum not

only emptied but sterilized, the perineum is widely opened. While the

removal may be accomplished through a median incision it is better to

have ample room, therefore by a semilunar flap a sort of trap-door

should be raised, its apex downward, through which easy access to the

deep perineum is afforded. It is only necessary to divide the central

tendon of the recto-urethral muscles before the operator arrives at

the apex of the prostate and the membranous urethra. The latter, being

exposed at this point, is usually divided upon a grooved staff. Here,

at its junction, the capsule is usually divided by a free opening,

through which the finger-tip is insinuated and made to strip the

capsule from the prostate itself. By different operators instruments

have been devised which facilitate much of the subsequent work. Perhaps

the best of these is the double-blade retractor of Young, which, shaped

like a sound, can be opened after introduction, and made to serve

excellent purpose by traction upon its handles. If, now, the perineal

route have been large enough, and retracted sufficiently, the prostate

can be so pulled down into the wound as to be exposed to sight as well

as to touch. The effort is sometimes made to enucleate the prostate

entire and withdraw it whole, but usually to separate each lateral

mass by itself. It is advisable to seize with strong tenaculum forceps

and pull down the loosened portions of the organ, in order that it

may be more easily separated at its upper part; but it has now been

found unnecessary to either open the bladder above the pubis, or even

to expose it by an opening through the skin so that it may be pressed

down, traction from below taking the place of suprapubic pressure,

whatever is needed in the latter direction being effected through the

uninjured abdominal wall (Figs. 662, 663 and 664).

[Illustration: FIG. 662

First exposure of prostate after introduction of sound through opening

just in front of it. (Proust.)]

[Illustration: FIG. 663

Enucleation of a portion or all of the prostate by use of the index

finger. (Proust.)]

[Illustration: FIG. 664

Hemisection of prostate, each half being secured within the bite of

vulsellum forceps. (Proust.)]

The balance of the procedure must depend on the size and character

of the growth. To strip off a naturally adherent capsule is quite

easy, but to detach one which has become firmly adherent through

old inflammation or cancerous infiltration is sometimes extremely

difficult. Thus enucleation may sometimes be effected in two or three

minutes. The stripping and enucleating process should be carried around

the prostatic enlargement and into the bladder, and the effort should

be to make the smallest possible rent in the vesical mucosa, as well

as to separate prostatic tissue from around the urethra rather than

to tear or mutilate the latter. Experience and patience will permit

the accomplishment of this to a surprising degree. Morcellation may be

an aid in removing large masses, and no hesitation should be felt in

dividing a mass of tissue which does not come out easily through the

wound (Fig. 665).

[Illustration: FIG. 665

Prostate removed by the perineal route: _A_, lateral lobes; _B_,

intravesical growth particularly obstructing urethral entrance.

(Proust.)]

The organ once enucleated, there results a bleeding cavity, at the base

of the bladder, which, however, is now opened below and should drain

itself easily. If the surgeon’s finger and his instruments have been

kept, as they should have been constantly, within the prostatic capsule

there is no possibility of harm to the rectum, which, however, may be

utilized for assistance in the manipulation should it be required.

There remain, therefore, after enucleation the checking of hemorrhage,

provision for drainage, and suitable narrowing of the wound. The first

and second of these are usually combined by the insertion of a tube,

of sufficient rigidity to permit a gauze packing to be placed around

it. This should be connected exteriorly with a suitable drainage

tube, and bladder siphonage be provided. The wound around the tube is

closed by two or three deep sutures, usually of silkworm-gut, since it

tends naturally to close by pressure and requires but little further

attention.

The greatest harm likely to be done in this operation is _injury to the

seminal vesicles_, above the prostate, between which and the prostate

itself the surgeon may not distinguish, with _unnecessary mutilation

of the posterior urethra_. Occasionally, in spite of great care,

the rectum will be slightly lacerated. Injury or destruction of the

vesicles might lead to impotence, while mutilation of the urethra would

be followed by delay in repair, with uncertainty of subsequent bladder

action and control.

Subsequent treatment consists in removing both gauze and tube at the

earliest possible date, which should not be later than the fourth day;

after this irrigation may be given once or twice a day, with the least

possible use of instruments.

In either of these methods of prostatectomy the greatest reliance is to

be placed upon natural processes of repair. In some way, which seems

almost inscrutable, torn bladder and more or less mutilated urethra

come naturally together and connection is reëstablished.

After this brief description of operative methods there remains only

to contrast them. The especial advantages of the suprapubic method

are the total avoidance of perineal fistula, of disturbance of the

deep urethra, of the perineal structures, of the seminal vesicles,

and a minimum of disturbance of the entire basal portion of the

bladder, with a greater theoretical possibility of speedy restoration

of its function. It is the method of choice with certain operators

of large experience. It seems especially indicated in cases of

pronounced intravesical enlargement, but may be made difficult in obese

individuals.

In behalf of the perineal route must be alleged the advantage of

seeing much of what one is doing, of being really nearer to the field

of activity, and of more perfect control of the mass which is to be

removed, as well as the fact that the prostate is not an intravesical

organ.

Whichever method be adopted the patient should be encouraged to be up

and about as soon as possible. Subsequent bladder control comes with

varying rapidity to different patients. Urinary fistulas are not likely

to persist in patients who have not worn drainage tubes too long. After

two or three weeks it is advisable to pass a sound occasionally, in

order to maintain proper direction of the urethral canal and prevent

formation of stricture. Bladders in which there has been a serious

complication of cystitis should be irrigated through the openings so

long as they are maintained.

The operation of itself is not a very serious nor difficult measure. It

is too often performed on feeble or septic patients, as a last resort,

when it is too late.

The _galvanocaustic operation_ is done with an instrument devised by

Bottini, shaped like a lithotrite, with a movable platinum blade, which

can be heated to the desired degree by the electric current. This

instrument is introduced into the deep urethra until its beak enters

the bladder, after which the latter is turned half around; then the

electric current is turned on, the movable caustic blade gradually

withdrawn by a screw mechanism in the handle, and made to traverse a

distance of one inch to one inch and a half, previously measured, and

in such a way as to burn a channel through the floor of the prostatic

urethra, and through any median bar or obstruction which may exist.

This is the principle of its use. At one time it was popular, although

of late prostatectomy seems to have supplanted nearly every other

method. Nevertheless in certain cases it will be found of advantage.

I have preferred to combine it, in most cases, with a small perineal

opening, introducing the instrument after opening the membranous

urethra, and having it in this way much more completely under control.

Through the opening thus made subsequent bladder drainage can be

effected if desired. It permits also of more perfect exploration of the

bladder with the finger.

CANCER OF THE PROSTATE.

Extensive _cancerous involvement of the prostate_ puts a case beyond

the pale of operative surgery, except for palliative purposes, though

either perineal or suprapubic drainage may be made for final and

temporary relief, the case admitting of nothing else. As mentioned

above many apparently ordinarily enlarged prostates prove to contain

cancerous elements. It has been found that, when not too extensively

involved, prostatectomy in these cases gives as good results as in the

absolutely non-malignant.

[Illustration: FIG. 666

Siphon drainage of bladder, with Cathcart’s S-tube (its essential

feature). May be applied equally well to perineal or urethral tubes, or

to drainage of other cavities.]

BLADDER SIPHONAGE.

A matter of great importance and comfort for the patient is an

effective _siphonage of the bladder_ after it has been opened. This

has usually been accomplished by the use of a Y-shaped tube, one of

the branches connecting with a suitable reservoir for water, hung

above the level of the body, the other with a tube connecting with

the bladder, while from the lower end another tube connects with a

suitable reservoir on the floor. This is rarely effective, and can only

be made so by inserting the S-shaped tube devised by Cathcart in the

lower drainage tube. With this, and a suitable regulation of the flow,

the water can be made to escape, drop by drop, and make an effective

suction that completely fails without the use of Cathcart’s tube. The

device is illustrated in Fig. 666.

CHAPTER LVI.

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 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.

[Illustration: FIG. 671

Bulbous sound.]

_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.

[Illustration: FIG. 672

Otis’ urethrometer.]

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]

[72] Van Hook has recommended the following excellent expedient for

the discovery of the urethral canal when apparently lost in the

depths of a dense, deep stricture: He gives a dose of potassium

iodide two or three hours before the operation. During the latter,

and when seeking the proximal end of the urethra, he drops a little

acetate of lead solution at the point where the urine is expected to

appear. The formation of the bright-yellow lead iodide will mark the

actual appearance of the urine and indicate its source.

[Illustration: FIG. 673

Otis’ dilating urethrotome.]

_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]

[73] In the pathological museum of the University of Buffalo I

deposited specimens illustrating this fact, one testicle forming

a tumor as large as the patient’s head, the other as large as a

cocoanut. These were both successfully removed from an adult, and

without the patient developing any subsequent evidence of malignant

infection. It is thus important in every case of intrapelvic tumor in

the male to examine the scrotum and be sure that both testicles are

in their proper position.

=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.

[Illustration: FIG. 674

Varicocele. (Hartmann.)]

SPERMATOCELE.

Spermatocele implies a cystic tumor in whose contained fluid, no matter

what its source, are found spermatozoa, which may be seen alive under

the microscope if examined immediately after removal. Spermatoceles are

usually found at the lower end of the cord and in close connection with

the testicle. Their occurrence is not uncommon, but somewhat difficult

to explain, for it implies connection, at least at some time, between

the structures of the cord and a more or less displaced seminiferous

tubule. Spermatoceles are rarely diagnosticated as such until

aspiration or evacuation and examination of their fluid contents, which

usually are of a milky appearance. In general they are to be treated

like any other cysts, and by the same methods.

VARICOCELE.

This exceedingly prevalent affection is the result of a varicose

condition of the pampiniform plexuses and of the spermatic veins. It

occurs in perhaps 10 or 12 per cent. of adult males, rarely before

puberty, and almost invariably upon the left side, varicocele upon the

right side being as rare as 1 in 500 cases. Its confinement to the left

side is explained partly by compression of the left spermatic veins

beneath an overloaded and distended sigmoid, and by the disadvantage at

which the blood current from the left spermatic vein empties into the

vena cava, this being on the left side at a right angle, while on the

right the angle is oblique. It has occasionally to do with accident or

injury, as well as with occupation or habit. It occurs more frequently

in those who are long in the saddle and in those who ride the bicycle

to excess. (See Fig. 674.)

Varicocele is usually of slow development, and discovered finally by

accident or by attention being drawn to these parts through quack

advertisements or misleading statements. The effect is to produce an

elongated mass of varicose veins, often described as feeling like a

“bag of angle worms,” occupying the lower portion of the cord and

extending down upon the back of the testicle. In the more advanced

cases the condition can be traced almost to the external ring, but

is always more marked low down than higher up. Sometimes it is so

extreme that the entire group of veins corresponds in bulk to a hen’s

egg; ordinarily it is but a fraction of this size. The consequence is

increase of weight and production of dragging sensation upon the cord,

often referred to the back, and displacement downward of the testicle,

with consequent elongation of the scrotum, which may so greatly relax

that it appears to be twice its normal length and contains this

varicose mass at its lower extremity. Such a condition will naturally

produce a certain degree of discomfort and annoyance, but _beyond this

it is innocent_, save that it is made to cause much mental anxiety,

mainly through ignorance, and has led thousands of victims to quacks,

for treatment for conditions dishonestly represented and treated as

both distressing and extreme. It is true that a large mass of enlarged

veins may in time produce some atrophy of the testicle; it is likewise

true, also, that virility or masculine potency may be to a trifling

extent limited in this way. It is not true, however, that impotence can

be so produced, because the affection is limited to but one organ, so

that the impotency of which many men complain is mainly of psychical

origin. Such individuals need explanations and advice as much as

treatment, although it is difficult to elevate many of them from the

condition of sexual hypochondria into which they gradually fall.

[Illustration: FIG. 675

FIG. 676

Resection of scrotum for varicocele. (Hartmann.)]

=Treatment.=--Treatment of varicocele may be _palliative_, _i. e._,

it may consist of suspension of the overloaded testicle and somewhat

relaxed scrotum within a well-fitting _suspensory bandage_, and this

suffices for most mild cases in normally minded individuals. When,

however, the condition preys deeply upon the mind or upon the body, or

when it is actually and anatomically advanced, then _radical operation_

is legitimate and humane. Of the many operations recommended in time

past only two will be described here, for it seems to me that all

subcutaneous and blind methods are bad in theory as in practise.

_Excision of the varicose veins_ is easily performed under local

cocaine anesthesia. It is done by incision below the external ring,

over the course of the cord, the cord itself being exposed for two to

three inches. Here the enlarged veins appear usually in a group (the

pampiniform plexus), and as such can be isolated and separated from the

balance of the cord, it being essential to _carefully exclude the vas_,

as injury to or division of this canal would naturally be followed by

impotence of that testicle. The veins involved being isolated to an

extent of two inches, are ligated above and below, the intervening

portion being then exsected, after which it is my custom to utilize the

catgut with which this ligation is effected, threading it on each side

into a needle, using each as a suture, thus providing two sutures, by

which the divided ends are approximated and tied together, the effect

being to bring the testicle up and make a more effective suspensory of

the cord itself.

=Shortening of the Scrotum.=--To the above procedure, when the scrotum

is much elongated and relaxed, may be added its _shortening by a

species of amputation_. The entire procedure may be practised as

follows: The scrotum being stretched downward is shortened by removing

one and a half to three inches from the lower end of the scrotal pouch

of skin and the contained connective tissue, including the septum.

In this way the tunical sacs and lower ends of the testicle will be

immediately exposed. The left testicle can now be drawn down, and the

operation, described above, of exsection of a portion of its veins, may

then be practised. This being completed the scrotal wound is closed

with sutures, with or without catgut drainage. The effect is to not

only remove the varicose veins, but to reduce the size of the scrotum,

and to make it, as it were, a suspensory of living tissue (Figs. 675

and 676).

THE SEMINAL VESICLES.

The lower ends of the vasa and the seminal vesicles themselves suffer

most commonly from the consequences of _tuberculous_ or of _gonorrheal

infection_, travelling in either direction, they being easily invaded

from the prostatic urethra along the seminal ducts. The consequence

is _seminal vesiculitis_, which produces a more or less tender

swelling, with discomfort referred to the lower end of the rectum,

and discoverable by digital examination above the prostate. When the

vesicles are distended or infiltrated they may be felt with the finger

in the rectum. In addition there may be on pressure more or less

discharge of fluid into the prostatic urethra, while the semen when

emitted may be more or less mixed with blood.

It is necessary usually to differentiate between prostatitis or

prostatic hypertrophy and vesiculitis.

Chronic involvement of the seminal vesicles may be best treated by a

species of massage or “milking,” by which retained contents are coaxed

along the ducts and into the urethra. Its local treatment is almost

impossible. When the conditions resulting from infection of either type

have become chronic and intractable we may take advantage of recent

advances and decide upon _removal of the vesicles_ by operation. Fuller

suggested that this be done by putting the patient in the knee-chest

position or a modified Sims position. While it is not difficult to

reach the vesicles through the rectum, the method has its disadvantages

and the perineal route is much the better. The operation is then

effected, much as is prostatectomy, by perineal opening and blunt

dissection between the rectum and the prostate, carried upward until

the vesicles themselves are reached, after which they may be curetted

or extirpated by a process of enucleation.[74]

[74] In the treatment of infections of the seminal vesicles,

particularly those of gonorrheal origin, Belfield has advised

irrigation and drainage of the same through the vas deferens. He

brings this up against the skin of the scrotum, where it is easily

identified, and then, through a one to two-inch incision, made under

local anesthesia, exposes the vas, into which the blunted end of a

hypodermic-syringe needle may be introduced, by means of which a

solution of any desired agent may be injected. This being thrown in

the direction of the seminal current passes up through the vas and

into the vesicle. He has even recommended in certain cases to attach

the vas to the skin by a fine silkworm suture, and in this way to

make a minute fistula, which can be used for the purpose as long as

may be necessary. He considers the method invaluable in the treatment

of chronic gonorrheal vesiculitis or the chronic infections of the

seminal canal in the elderly, which are often mistaken for enlarged

prostate, as well as in cases of recurrent epididymitis resulting

from repeated invasion from behind. Thus he has seen benefit follow,

in tuberculosis of the epididymis, from irrigation with carbolic

solution. The amount injected into the vesicle should never exceed 2

Cc.

SPERMATORRHEA.

Accurately defined this term refers to the escape of semen under

abnormal and involuntary conditions, an occurrence which is of great

rarity. Most cases of so-called spermatorrhea are, in effect, but

the escape of excessive or superfluous amounts of _prostatic mucus

(prostatorrhea)_, the fluid, whether it appear drop by drop or in

considerable quantity, being mistaken by the patient for semen. Thus

with the extrusion of a hard fecal mass there may be sufficient

pressure upon the prostate to express from it 1 Cc. or more of

this fluid. True spermatorrhea, on the other hand, rarely occurs

except in connection with disease of the vesicles or prostate, and

will then be recognized rather by the detection of spermatozoa in

the urine than from any phenomenon noticeable by the patient. All

statements, therefore, made by patients to the effect that they suffer

from involuntary escape of semen should be taken with the greatest

allowance, and will usually be found to be misleading.

All of this might lead up to a considerable discussion of matters

included within the domain of sexual physiology and hygiene, topics

which, however, cannot be afforded space in the present work; all

that can be said being that many patients are in need of accurate

information who suffer acutely in mind, and sometimes slightly in body,

for lack of it, and who are tempted by motives of delicacy to consult

quacks and charlatans rather than their family physician.

CASTRATION.

The only operation of importance upon the external genitals not yet

described is that of _castration_, _i. e._, removal of the testicle.

This is ordinarily a simple procedure, requiring, first, incision of

sufficient length. If the disease condition include the slightest

infiltration or involvement of the overlying skin a little or the

greater portion of it, as required, should be included in an oval

incision, in order that it may be totally removed. The testicle

and its coverings, being now exposed, are to be loosened from all

their surroundings, the organ pulled down, and the cord brought into

sight. If there be no reason for following up the spermatic cord it

is sufficient to surround it with a ligature (chromic gut), at a

convenient height above the testicle, after which the cord is divided

below it and the mass removed. In most instances, however, the disease

which calls for so much operating will require to be followed up along

the cord, and perhaps through the inguinal canal down into the pelvis.

This is done by continuing the incision in the proper direction,

isolating the cord, ligating bleeding vessels, and finally dividing the

cord itself at a point of election decided to be above the disease.

Previous generations were hesitant about including the entire cord in a

ligature, for fear of tetanus, but we now know that if the technique be

carefully carried out there need be no fear on this score. The diseased

mass being removed the wound is closed, with or without catgut drainage

at one or more points, as may be indicated.

CHAPTER LVII.

AMPUTATIONS.

Amputations are performed for (_a_) _the results of injury_, (_b_) _the

results of disease_, and (_c_) _removal of deformity or mutilation_, or

the possible results of congenital defects. While generally they are

measures of necessity, made such by traumatism or by actively advancing

disease, there are occasional instances where an individual decides

that an artificial limb will be more useful or that he will be freed

from an intolerable annoyance by the sacrifice. The principal diseases

which may require such mutilation are the exceedingly acute, _e. g._,

osteomyelitis, the slower destructive forms of ulcer, tuberculosis or

of sepsis, the gangrene caused by vascular or diabetic conditions, or

the slow involvement of tumors, usually malignant, but sometimes benign.

When a serious and mutilating injury has been received, if there have

been complete crushing of a limb or avulsion, of course no doubt exists

as to the necessity. Amputation is not now made for compound fractures

nearly as often as in former times, for if only the vascular supply

be good much may be done by resection of bone ends, wiring, or other

expedients; and the attempt should always be made to save a limb unless

it appear that even should the effort succeed the limb itself would be

too useless to justify the attempt. With the possibilities of modern

asepsis, and with immediate attention to the injury, the question of

what should be done with an injured limb is largely a question of

its blood supply. Extensive contusions with lacerations do not of

themselves necessitate amputation, neither does injury to the skin

unless it be most extensive.

It is unfortunate when vacillation or any misguided effort at

conservatism call for great delay. While this may sometimes be

advantageous, at other times the favorable moment has passed before

permission to amputate may be obtained. Should delay seem advisable the

surgeon should use his best endeavor to effect suitable antisepsis,

to provide physiological rest, and to preserve the circulation, all

of which require a thorough antiseptic technique, which will include

the removal of blood clot, of fragments, and of all tissue which

evidently cannot live, and suitable splinting or its equivalent, and

of everything that can be done by local warmth and general stimulation

to maintain the vigor of the circulation. When once infection has

occurred, and especially been allowed to spread, the possibility of

recovery inheres only in immediate amputation.