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.
Fig. 670
