be united. The bladder may be herniated without exstrophy.
Symptoms Produced by Epispadias. — The most annoying, and a very
common, symptom is incontinence of urine, complete or partial. The deformity
Fig. 216. — Epispadias.
(New York Hospital, service of Dr. Frank Hartley.)
CONGENITAL Ml E< l B OF THE [JRETHKA 641
also involves impotentia generandi, amj Dearly always impotentia coeundi. The
diagnosis, from whal has been 3tated, needs no further comment.
Hypospadias.- Much the most common deformity of the urethra is in-
complete union along its ventral Burfaci — hypospadias. The urine then escapes
through the abnormal opening. In all cases the defect is confined t" thai por-
tion of the urethra in fronl of the triangular ligament, bo that the sphincter
mechanism is nol interfered with, and these patients have norma] control over
the bladder. The deformity is to Bome extent hereditary, several examples
having been observed in the Bame family. The deformity exists in three de-
grees: (1) Glandular or balanitic hypospadias; (2) peno-scrotal or penile
hypospadias; (3) scrotal, or perineo-scrotal, or perineal hypospadias.
1. Glandular Hypospadias. — In the first degree the urethral opening is
usually situated at the point where the frenum normally joins the glans, or
just behind that point. In some cases there is a pit or gi ve in the glans al
the site <>t* the normal meatus, in other cases none. This is the mosl frequent
form. It is not usually attended by any very annoying symptoms; sometimes
the individual i- unconscious of any deformity. In other cases there is slight
dribbling at the end of urination, or a slighl curvature of the glans downward
during erection. Neither potentia cceundi nor potent ia generandi are inter-
fered with. In other cases the ahnormal orifice may be strictured, or the glans
may be deformed or twisted; the urine is delivered in a crooked or twi
stream, so that the individual wets his thighs or clothing. In some ci - -.
combined with tins grade of hypospadias, a membranous layer of skin joins
the site of the frenum to the scrotum; erection may then be seriously inter-
fered with ( virga palmata ).
2. Penoscrotal or Penile Hypospadias. — The second degree — peno-scrotal
or penile hypospadias — is much more rare than the first. In these cases the
urethral orifice may be situated anywhere along the ventral surface of the
penis as far hack as the peno-scrotal angle (peno-scrotal hypospadias). The
anterior portion of the urethra may be represented by a groove, by a blind
canal closed either anteriorly or posteriorly, or no trace of the canal may be
present The penis is nearly always small, often deformed, bent downward,
and adherent to the scrotum. The deformity and disability increase at pu-
herty. liotli satisfactory coitus and impregnation may be impossible. Urina-
tion is uncomfortable, and must be performed in the sitting or squatting pos-
ture, in order to avoid wetting the clothing and thighs. The urethral orifice
may be strictured.
3. Scrotal, Perineoscrotal, Perineal Hypospadias. — The third and most
distressing form of hypospadias. In these cases the urethral opening i- in
the scrotum, or farther hack in the perineum. The scrotum is divided into two
lateral halves, between which is a funnel-shaped depression, lined with a red
muco-cutaneous membrane, at the bottom of which is the urethral orifice. The
penis is small and undeveloped, heiit downward, and adherent to the symphysis.
The whole apparatus resembles a vulva, with a large clitoris. Ordinarily a
642 THE URETHRA
testis is present in either half of the divided scrotum. If cryptorchism exists,
the sex of the individual may be doubtful, notably if the general make-up is
not of a distinctively masculine type. These are the only cases where difficulty
exists in the diagnosis. Normal sexual relations are impossible. Urination
is performed after the manner of women. In some cases other abnormalities
exist at birth — atresia ani, or the formation of a common cloacal opening.
(See also Congenital Defects of the Penis.)
I knew a man who had this degree of hypospadias, and in spite of the fact
that he had two good-sized testes, he had been brought up as a girl and became a
trained nurse in one of the large hospitals in this city. He apparently had had
no idea that he was a man until he became ill and was examined by the surgeons
of the hospital. His sex being made known to him, he gave up nursing, dressed
as a man, learned to smoke, shaved, grew a heavy mustache, and entered a busi-
ness career. He came under my observation on account of an inguinal hernia. He
was very sensitive about his deformity, and very unhappy because he could not
have sexual relations. He refused operation.
INJURIES OF THE URETHRA
Injuries of the urethra may be incised, punctured, or contused and lacer-
ated wounds ; the last are usually subcutaneous. Injuries of the corpora caver-
nosa will be considered in another place. The incised wounds occur for the
most part in the penile urethra. They are rather rare injuries. An important
distinction is to be drawn between wounds parallel to the urethra and those
which are transverse or oblique. The former heal without difficulty, leaving
no stricture behind. The latter are inevitably followed by stricture, if not
united by sutures, and in many cases even when such sutures are applied. The
immediate dangers of incised wounds of the urethra are urinary infiltration
and peri-urethral cellulitis, or gangrene. The remote results in cases which
do not heal per primam are urethral fistuke and stricture. The diagnosis pre-
sents no difficulties. It is to be made by inspection of the wound, by the escape
of urine from the wound during urination, and the appearance of blood at
the urinary meatus. Urinary infiltration is indicated by a rapidly spreading,
red, boggy swelling of the penis and scrotum, cellulitis and gangrene, and by
the general symptoms of septicemia. Wounds penetrating the urethra through
the scrotum are certain to be followed by urinary infiltration unless appropriate
surgical treatment is at once applied. When the urethra is completely divided
the proximal end retracts deeply, and a careful search and dissection may be
necessary in order to find it.
Subcutaneous Injuries of the Urethra. — Far more frequent than open wounds
are the subcutaneous ruptures and lacerations of the urethra. The injuries
occur from blows and falls upon the perineum. The bulbous and membranous
portions are the parts injured. The prostatic portion is rarely involved, and
then only in cases of fracture of the pelvis, or where extreme direct violence
INJURIES OF THE tJRETHKA 643
is applied to the perineum, as in cased of impalement, [n juries of the penile
urethra from Muni violence occur :ilin«>-i always during erection, as during
coitus, when the rigid organ is suddenly and forcibly bent, or in breakii
chordee. The immediate consequences are rarely serious, though stricture may
follow. A case has. however, recently been reported in which the erecl penis was
actually torn completely away from tin- body by the band of a woman. It was
demonstrated by experiments on the cadaver thai this was possible only when the
penis was erect. The vessels were suitably injected to produce 'hi- condition.
The typical injuries of the perineum associated with contusion or rupture
of the urethra occur from falls astride of some linn, narrow object — the rail
of ;i fence, the pommel of ; i saddle, the rear wheel of a bicycle, etc. — or by
direel violence, as from the kick of a horse or man on tin- perineum. Ruptures
of the urethra may also lie produced by fall- or crushing injuries, < -;i 1 1 - i i i^r
fractures of the pelvis. The parts injured, the mode of production, and the
nature of the lesions vary in different cases. When the blow or fall exercises
pressure from before backward, the l>nll> i- crushed againsl the anterior surface
of the pubes, and the membranous portion is often torn as well. The urethra
may simply be contused without actual rupture, or a considerable portion of the
urethra may he irretrievably crushed, or the wall of the canal may be simply
torn across. When the force is exerted from behind forward, as from a kick
or blow just in front of the amis, the membranous portion alone is apt to be
torn. When the pelvis is fractured the urethra may be directly crushed be-
tween the hony fragments of the pubes or penetrated by a sharp fragment, or
the displacement of hone may tear the urethra at the junction of the membran-
ous with the prostatic portion. Tn this lasl group of cases the prognosis is very
serious. I recall a case of this kind upon which I operated some year- ago:
A large muscular man fell into the hold of a ship, striking a beam in such a way
a- to fracture the horizontal and descending rami of the pubes upon cither side. When
brought to the hospital soon afterwards he was bleeding from the urinary meatus.
He was unable to urinate and rapidly developed a hematoma in the perineum
and scrotum. The pubic symphysis and the horizontal rami upon cither side con-
stituted a central, movable bony fragment. A catheter passed deeply into the
perineum, hut could not he made to enter the Madder. Perineal section was done
at once. The membranous urethra was found torn away from the apex of the
prostate. The tissues of the perineum were so torn and infiltrated with blood
that the orifice of the prostatic urethra could not he found. A suprapubic in-
cision of the bladder was made and retrocatheterization, in order to furnish
perineal drainage. The patient made a slow and tedious convalescence. A stricture
requiring the frequent passage of sounds formed in his perineum.
For purposes of description the subcutaneous injuries of the deep urethra
may he classified as i 1 ) contusions of the urethra, with or without tearing of
the mucous membrane; C2) rupture of the urethra— (a) partial, {!>) complete
( Kaufmann). The two cardinal symptoms of rupture of the urethra are the
escape of blood from the meatus and retention of urine. Tn the cases of mere
644 THE URETHRA
contusion both these symptoms may be absent. In these a painful, tender
swelling will be formed in the perineum. A little blood may appear at the
meatus, or the urine may be slightly blood-stained. The urine may continue
to be passed normally, or, when the hematoma in the perineum reaches such
a size as to compress the urethra, there may be difficult urination or retention.
Catheterization is possible. In the cases where the urethra is wholly or partly
torn across 'the amount of bleeding is considerable; a painful, tender swelling
is formed in the perineum in a few hours, and soon spreads to the scrotum.
Ecchymosis may also appear in the groins and upon the lower abdomen. Bleed-
ing from the meatus may be profuse or slight. When the urethra is com-
pletely torn across, the distal end of the canal may be plugged with a clot, and
little or no blood may escape from the meatus. In these cases there is invari-
ably retention of urine. Catheterization is impossible. It is important to
bear in mind that the amount of bleeding from the meatus is no criterion of
the severity of the injury to the urethra. In cases of severe contusion to the
urethra the early symptoms may be trifling, whereas the subsequent sloughing
of the contused urethra may, after a number of days, put the patient in the
gravest peril from extravasation of urine.
Course and Diagnosis of Subcutaneous Injueies of the Urethra. —
The course of simple contusions is usually favorable. Not so those complicated
by complete or partial rupture of the urethra. In these extravasation of urine
inevitably occurs, unless immediate perineal section is made and adequate
drainage provided for the urine. The phenomena of infiltration of urine ob-
served in these cases are as follows : The patient holds his water as long as he
can, but sooner or later attempts to urinate. If the urethra is nearly or wholly
ruptured, little or no urine escapes from the meatus. The urine enters the
loose connective tissues of the perineum, finds its way into the scrotum, beneath
the integument of the penis, then into the subcutaneous tissues of the abdomen
and thighs. Rapid decomposition occurs, with an intense septic and putrid
infection of the infiltrated tissues. The skin is brawny, swollen, and dusky
red; the scrotum may attain the 'size of a child's head. The subcutaneous
tissues rapidly slough, the skin becomes gangrenous and greenish-black in color,
over areas of variable size ; sometimes the whole scrotum and perineum slough.
Incision evacuates thin, stinking, greenish or brownish pus, mixed with foul
urine, shreds of necrotic tissue, sometimes gas. The patient rapidly develops
a mixed sapremic and pyogenic infection, with great prostration. Stupor, de-
lirium, and coma end the scene in a few days, sometimes in forty-eight hours.
In the cases which survive, either by spontaneous perforation or after incision,
considerable loss of substance occurs. I have seen the testicles and spermatic
cords entirely denuded up to the inguinal canals. In other cases several per-
forations occur here and there, from which urine, pus, and sloughs are dis-
charged. If the patient survives, urinary fistula?, opening in the perineum,
through the scrotum, or upon the thighs, remain, through which most of the
urine escapes. A tight stricture or actual obliteration of a portion of the canal
FOREIGN BODIES IN THE MALE URETHRA 645
will be found ;it the site of the injury. Rupture of the urethra may be <-"H
Pounded with rupture of the bladder. (Sec Rupture of the Bladder; also
lions on I leinat nri;i. )
FOREIGN BODIES IN THE MALE URETHRA
Foreign bodies gain â– M-rc>< to the urethra through the meatus or through
the bladder in the largesl proportion of cases. Rarely calculi are formed in
the urethra itself, in pouches, or diverticula, or upon ulcerated surfaces, or
in abscess cavities. If we exclude those cases in which portions of catheters
introduced by the patienl himself or by a physician or nurse are broken oil' in
the canal, the patients are chiefly lunatics, or persons who have soughl to obtain
sexual satisfaction in an abnormal way. Among the article-; introduced for
this latter purpose may lie mentioned needle- ami pin- of all kinds, pipestems,
twigs and sticks, frnil stones, beads, chewing gum, a leather thong, a safely pin.
etc., to the end of a very long category. Pieces of catheter, or of bougies, or
entire soft instruments, may lie lost in the urethra. There appears to he a
strong tendency for such objects to .-lip hack into the bladder, favored by un-
successful efforts at extraction. Round, smooth bodies tend to rest in the fossa
navicularis, or in the bulbous portion, or to be stopped by an existent stricture.
Sharp and irregular hodies tend to become impacted, ami yet it is astonishing
to observe the irregularity in form of certain bodies which reach the bladder.
(See Vesical ( lalculus.)
The fate of foreign bodies in the urethra, when not evacuated upon urina-
tion or extracted, may be: (1) They pass into the bladder and form the nucleus
of a stone. (2) They remain in the urethra and form the nucleus of an ure-
thral calculus. (?>) They cause pressure ulceration and perforate the urethra
with the formation of an ahscess, or the perforation i- followed by urinary
infiltration. Under either condition a urinary urethral fistula and stricture of
the urethra may result.
Symptoms and Diagnosis. — When a portion of a catheter or a whole catheter
is left in the urethra, the history may he readily obtainable ; hut if the patients
are lunatics or children, or if the body has been introduced from a perverted
sexual instinct, the history of its presence is apt to be wanting. Even after
the body ha- been extracted, all knowledge of bow it gol into the urethra will
usually he denied. When the body consists of a calculus descended from the
kidney, there will usually he a history of more or less typical renal colic, yet
such a history is often absent. Either the attack has not been severe and has
been forgotten, or the previous symptoms may have been referred to the blad-
der — namely, painful and frequent urination, with or without changes in the
urine. In some cases there will he a history of difficult and obstructed urina-
tion. I saw a case of this kind some years ago:
The patient was a healthy man aged thirty years, lie was suddenly seized
with a violent pain during urination. The stream suddenly ceased and he could
646 THE UEETHEA
not empty his bladder. Under the influence of a hot bath and an opiate he was
able with pain and straining to urinate in a feeble stream. The urine contained
a little blood, and was otherwise normal. Upon introducing a sound, an ob-
struction was felt in the membranous urethra. The point of the instrument struck
a hard substance, and a grating sensation was transmitted to the hand. The stone
was pushed back into the bladder, crushed and evacuated. The fragments weighed
forty grains. They consisted of urates with oxalate of lime. The patient left
the hospital two days later quite well.
In another case the patient had a similar history but the retention of urine
was complete. The stone had lodged in the fossa navicularis. I extracted it with
forceps after enlarging the meatus.
When a stone or other foreign body becomes impacted behind a stricture the
latter must be cut before the stone can be removed. It is always undesirable to
incise the penile or scrotal urethra from without, lest a fistula remain. Perineal
section will be necessary in certain cases. There are numerous ingenious forceps
and other instruments intended to aid in the extraction of catheters, stones, and
other foreign bodies from the urethra.
When a foreign body has been introduced from without, the symptoms will
vary according to the shape and size of the body, and other physical qualities.
Rough, large, and sharp bodies will produce symptoms at once— namely, dysu-
ria, or retention of urine. In some cases dysuria will be followed by retention,
owing to the swelling and inflammation of the urethral wall caused by pressure.
When the body remains in front of the bulb, palpation of the urethra will
usually permit the surgeon to detect its presence. If it lies in the membranous
portion it may sometimes be felt by rectal palpation. If a body remains in
the anterior urethra, its exact character and often the best means of extracting
it may be determined by inspection through an endoscopic tube. If the body
is still movable the surgeon should be careful not to let it get away from him
and slip into the bladder. A finger should be kept constantly pressed upon
the urethra behind the body during the efforts at extraction. In some cases the
escape of the body into the bladder has been prevented when it was soft by
transfixing the urethra and the body with a needle. Smooth foreign bodies,
if not large, may produce but slight symptoms for the time, and the same may
be true of calculi which have formed in the urethra itself. The patients may
notice nothing but slight obstruction to urination, with some muco-purulent ure-
thral discharge. After a time pressure ulceration will cause increased pain
and dysuria. Retention will finally occur, or perforation of the urethra with
abscess formation, resulting in urinary fistula or in infiltration.
Urethral calculi, whether they have come from the bladder or have orig-
inated in the urethra itself or have formed about a foreign body, may reach
a considerable size. This is notably true of calculi formed in urethral pouches
or diverticula ; when so situated they do not necessarily produce any marked
symptoms. Multiple calculi in the urethra have been observed. In certain cases
the diagnosis of foreign bodies in the urethra is aided by the use of the X-rays.
CHAPTEK XXXII]
DISEASES OF THE (III Till: \
GONORRHEA AND ITS COMPLICATIONS
Acute Gonorrhea — Acute Specific Urethritis. — Acute gonorrhea, the most
common of all venereal infections, is an acute purulent inflammation produced
by infection with the specific micro-organism of gonorrhea — the gonococcus of
Neisser. The disease is usually acquired during sexual intercourse with a
woman afflicted with ;t gonorrheal discharge. Other sources of infection are
possible; among such may be mentioned infection from the scats of infi
water-closets, from infected towels and other linen, from infected urethral in-
struments. The epidemics of gonorrhea among both male and female children
in hospitals, asylums, etc., demonstrate that mediate contagion is not only pos-
sible, but very frequent.
( For the microscopic characters of the gonococcus, see Bacteria Concerned
in Surgical Infections; also Urethral Shreds.)
Method of Enfection. — Mere undisturbed contact of pus containing gono-
cocci, with the healthy mucous membrane of the urethra, is all that is necessary
to insure infection. Immunity from gonococcus invasion is, so far as I am
aware, unknown. The flat epithelium of the fossa naviculars appears to be
resistent to the gonococcus, yet the aspirating action of the urethra, produced
by the to-and-fro movements of the penis during coitus, is usually sufficient to
bring the gonococci-bearing discharge into contact with the cylindrical epi-
thelium of the penile urethra, where they find a favorable soil.
Period of [ncubation. — The first symptoms appear after a period of in-
cubation, which seems to vary within rather wide limits. One to fourteen days
;ire the limits usually given; on the average six days. An incubation of less
than four days has been rare in my experience. In those cases where a dis-
charge has appeared less than forty-eight hours after exposure, 1 have assumed
that the disease was an outbreak of a former uncured, though latent, attack, or
that the infection occurred in a urethra already the seat of chronic gonorrheal
inflammation.
Symptoms of Acute Gonorrhea. — The symptoms of acute gonorrhea are
unfortunately so well known thai they scarcely require description; briefly they
are as follows; A \'cw days after exposure the patient notices an itching 0T
burning sensation at the meatus urinarius; upon inspection, the lips <d* the
meatus are found glued together, and slightly swollen. A few hours later a
647
648 DISEASES OF THE URETHRA
little sticky, opalescent discharge may be seen in the orifice. A slight burning
sensation is felt during urination. The following day the discharge becomes
more profuse and distinctly purulent. The lips of the meatus are swollen,
puffy, and reddened. Pain on urination becomes more marked, until an in-
tense burning sensation accompanies the act. As one patient described it to
me, he felt as though he were urinating fish-hooks. After three or four days
the disease is fully developed. The discharge is profuse, thick, and creamy
yellow ; later on it often assumes a greenish tinge from the presence of blood,
or is even distinctly blood-stained. Painful erections occur at night. The
patient sleeps badly ; no sooner does he get warm in bed and fall asleep than
he is awakened by the pain of a new erection. Actual chordee with bending
of the penis occurs in a large proportion of cases. The corpus spongiosum
becomes infiltrated with inflammatory material ; its elasticity is lost ; it cannot
stretch sufficiently during erection, and thus acts like the string of a bow to
cause a bending of the erect corpora cavernosa. The pain accompanying
chordee is intense. Efforts on the part of the patient to straighten the organ
may cause rupture of the infiltrated tissues of the corpus spongiosum with
sharp bleeding, often followed by stricture. During the early days of the
disease there may be a slight rise of temperature, loss of appetite, and mod-
erate prostration. The urinary stream is diminished in size, and may be
forked or twisted. Frequency does not occur until the posterior urethra is
involved. When stricture of the urethra exists, retention may occur. There
are subjective sensations of pain and tenderness along the penile urethra, and
reflex pains in the groins, inner surface of the thighs, in the lumbar region,
and the testes. If the foreskin be long and tight, retention of the purulent
discharge may cause balanoposthitis, with swelling and inflammation of the
foreskin and general integument of the penis. Phimosis is common, and para-
phimosis may occur.
Frequent and very painful nocturnal emissions may occur during the acute