SUBLUXATION By NORMAN
OF THE PENIS
RAINIER, m.f.c.p.,
d.p.h.
(Camb.),
MAJOR, I.M.S.
This injury appears to be so rare that I think the two cases that have come under my observation to be worthy of record, more especially as the clinical condition recorded in Treves' work, judging by my own and the cases I have collected, is apt to mislead. ^ f Of the five books I have been able to refer to Erichsen and Rose and Carless do not appear to mention the injury, Spencer and Gask merely mention it, while Treves' is the only work that gives any details, Neal's Medical Digest refers to five cases, of which through the courtesy of the Librarian of the Royal College of Surgeons, I have been able to obtain summaries. 1. My first case was a Gond boy, 14 years, admitted 11th April 1907 with a history of & gore in the perineum by a bullock. On admission my assistant found a ragged wound of the scrotal lacerated raphe and prolapse of both testicles. These after cleaning he replaced and sutured the wound, he also passed a catheter and drew off 8 ounces of bloody urine. I was asked to see the boy three days later as he had pain on passing water. The penis appeared normal, but on palpation was found to consist only of the sheath, the wound had partly given way and urine was passed both by the sheath and the wound.
118
THE INDIAN MEDIOAL GAZETTE.
on enlarging the wound the observed lying above and glans behind the testicles, it was drawn through the sheath with sinus forceps, the sheath circumcised and the torn preputial fold trimmed and stitched to the skin, healing was uneventful. I traced the boy two months ago, the penis appeared perfectly normal and power of erection complete. 2. The second was a young Hindoo, 1G years,
Under chloroform
penis
to
brought
was
me
later,
curiously
enough
some
two
as
Of the Collected In
Cases.
Nelaton saw ahoy aged G fall from a cart with urine issuing from a wound near the left buttock. On taking hold of the penis he was astonished to find it destitute of substance. The penis was found in the scrotum and replaced, but evidently complicated by a ruptured urethra as no urine was passed at the time of report by the natural 3.
years
9
1851, \T. days, after
a
passage. In 4.
1875, Moldenlianer reported a case of a 57, drunk, who fell from a cart and received severe injuries in the pubic region from the wheel. The scrotum was distended with blood and urine, glans penis could not be recognised nor a catheter passed, the sheath being full of clot (" a bloody
man
mass").
1911.
I cog-wheels, with extensive laceration of the pre1 puce and scroto-penile sheath the penis subluxating through the scrotal wound. Restitution was not attempted till four months later, and then only for sexual purposes. The glans penis emerged from the left scrotum and
his inability to have erections jeopardised the consummation of his marriage. His history also was that a bullock gored him (through the foreskin) and his penis disappeared, this is almost too extraordinary to be credible as a pure accident especially, as boys of his age wear a loin cloth, from one's knowledge of the East I quite believe the history, but I take the bullock to be a dissenting passive agent. On examination the penis again appeared perfectly normal, but on palpation the sheath was empty as far as the scrotal junction where a firm body was felt. Under chloroform the penis was easily seized and drawn through the sheath and fixed by strapping where it quickly became adherent in its old position. f have not been able to trace this case. months
[Nov.,
Several attempts including perineal incisions to find the urethra failed. A fortnight later an abscess formed opposite the iliac spine, and on opening it urine escaped, and on enlarging it down to the scrotal wound the penis was found buried in the abdominal fat and densely adherent except the glans. The patient objected to a free-ing operation
the sheath covered it like an apron. The sheath was then impermeable and undilatable by tents, but a plastic operation was performed with excellent results as regards the power of erection but with some shortening. The penile sheath was not then sufficient to form the entire covering of the replaced penis, scrotal tissue being also used. In 1895, Lieutenant-Colonel 6. Fischer, i.M.S., reported a case in the Lancet in full detail. A boy, aged 5 years, suffering from extravasation of urine due to a cart injury. Penis appeared normal at the time. Cock's operation performed with free incisions. Seen by Fischer six months later with a urinary fistula above and to the left of pubis, the penis appeared normal but shrivelled, and a catheter could only be passed a certain distance. The fistula was slit up and penis found firmly fixed at the base of the apparent penis. In this case the sheath was slit and sutured round the freed penis with excellent results. 7. In 1895, Reid reported in the Lancet a case of subluxation into the pubic region due to a horse rearing and falling on his rider. The case was seen within half hour of the accident. The empty sheath was at once diagnosed, and the organ reclaimed and refixed with a perfect result. Of these 7 cases 3 were due to cart-wheel injuries in the pubic region, one to machinery, two to bullock gores, and one to a horse falling on his rider. Only one case can strictly be called a direct dislocation by force applied to the penis in its sheath, the others appear to be indirect due to a vis a tergo applied to the perineum, scrotum or pubic skin lifting the sheath away from the penis, as in no case is the external surface of the sheath described as torn or bruised, even in case 4 very completely described in the original, the sheath is full of a bloody mass but not itself
injured. I
wish to lay stress on the appearempty sheath. In cases 4 and 7 only was a surgeon in immediate attendance and in neither was the condition diagnosed by sight, as Treves' description would lead us to expect " lookand, though painless erections occurred, was ing like blown out gold beater's skin." content with the penis in its new bed. The In case 4, the bloody mass was taken to be finding of the entire penis and not the ruptured the crushed glans and a catheter was inserted to urethra was a matter of the greatest surprise relieve tention from a ruptured urethra. to the surgeon. In case 7, it is not actually described but no 5. In 1898, Malinovski reported the case of one would attempt to pass a catheter knowingly a man whose trousers were caught between two into an empty sheath. ance
particularly of the
Nov., 1911.j
IDENTIFICATION OF SNAKES.
In case 5 only did the penile slieatli appear otherwise than normal, in this case the penis was protruding through the scrotum. In case G the penis appeared normal though
shrivilled. It
matter of great surprise in every case ; apparently to find on palpation or catheterism the penis to be absent except in case 4 where it was not even diagnosed until actually exposed by incision and case 5 where it was an obvious fact. The condition is unmistakeable, on palpation looking normal but feeling exactly like a rather thickened piece of the small bowel. As to treatment it is simple in recent cases, replacement either with or without incision secures a penis efficient in all its functions unless complicated by a ruptured urethra. In old cases a plastic operation may be necessary with an almost equally good result. was a
j
419
OF THE PENIS
RAINIER, m.f.c.p.,
d.p.h.
(Camb.),
MAJOR, I.M.S.
This injury appears to be so rare that I think the two cases that have come under my observation to be worthy of record, more especially as the clinical condition recorded in Treves' work, judging by my own and the cases I have collected, is apt to mislead. ^ f Of the five books I have been able to refer to Erichsen and Rose and Carless do not appear to mention the injury, Spencer and Gask merely mention it, while Treves' is the only work that gives any details, Neal's Medical Digest refers to five cases, of which through the courtesy of the Librarian of the Royal College of Surgeons, I have been able to obtain summaries. 1. My first case was a Gond boy, 14 years, admitted 11th April 1907 with a history of & gore in the perineum by a bullock. On admission my assistant found a ragged wound of the scrotal lacerated raphe and prolapse of both testicles. These after cleaning he replaced and sutured the wound, he also passed a catheter and drew off 8 ounces of bloody urine. I was asked to see the boy three days later as he had pain on passing water. The penis appeared normal, but on palpation was found to consist only of the sheath, the wound had partly given way and urine was passed both by the sheath and the wound.
118
THE INDIAN MEDIOAL GAZETTE.
on enlarging the wound the observed lying above and glans behind the testicles, it was drawn through the sheath with sinus forceps, the sheath circumcised and the torn preputial fold trimmed and stitched to the skin, healing was uneventful. I traced the boy two months ago, the penis appeared perfectly normal and power of erection complete. 2. The second was a young Hindoo, 1G years,
Under chloroform
penis
to
brought
was
me
later,
curiously
enough
some
two
as
Of the Collected In
Cases.
Nelaton saw ahoy aged G fall from a cart with urine issuing from a wound near the left buttock. On taking hold of the penis he was astonished to find it destitute of substance. The penis was found in the scrotum and replaced, but evidently complicated by a ruptured urethra as no urine was passed at the time of report by the natural 3.
years
9
1851, \T. days, after
a
passage. In 4.
1875, Moldenlianer reported a case of a 57, drunk, who fell from a cart and received severe injuries in the pubic region from the wheel. The scrotum was distended with blood and urine, glans penis could not be recognised nor a catheter passed, the sheath being full of clot (" a bloody
man
mass").
1911.
I cog-wheels, with extensive laceration of the pre1 puce and scroto-penile sheath the penis subluxating through the scrotal wound. Restitution was not attempted till four months later, and then only for sexual purposes. The glans penis emerged from the left scrotum and
his inability to have erections jeopardised the consummation of his marriage. His history also was that a bullock gored him (through the foreskin) and his penis disappeared, this is almost too extraordinary to be credible as a pure accident especially, as boys of his age wear a loin cloth, from one's knowledge of the East I quite believe the history, but I take the bullock to be a dissenting passive agent. On examination the penis again appeared perfectly normal, but on palpation the sheath was empty as far as the scrotal junction where a firm body was felt. Under chloroform the penis was easily seized and drawn through the sheath and fixed by strapping where it quickly became adherent in its old position. f have not been able to trace this case. months
[Nov.,
Several attempts including perineal incisions to find the urethra failed. A fortnight later an abscess formed opposite the iliac spine, and on opening it urine escaped, and on enlarging it down to the scrotal wound the penis was found buried in the abdominal fat and densely adherent except the glans. The patient objected to a free-ing operation
the sheath covered it like an apron. The sheath was then impermeable and undilatable by tents, but a plastic operation was performed with excellent results as regards the power of erection but with some shortening. The penile sheath was not then sufficient to form the entire covering of the replaced penis, scrotal tissue being also used. In 1895, Lieutenant-Colonel 6. Fischer, i.M.S., reported a case in the Lancet in full detail. A boy, aged 5 years, suffering from extravasation of urine due to a cart injury. Penis appeared normal at the time. Cock's operation performed with free incisions. Seen by Fischer six months later with a urinary fistula above and to the left of pubis, the penis appeared normal but shrivelled, and a catheter could only be passed a certain distance. The fistula was slit up and penis found firmly fixed at the base of the apparent penis. In this case the sheath was slit and sutured round the freed penis with excellent results. 7. In 1895, Reid reported in the Lancet a case of subluxation into the pubic region due to a horse rearing and falling on his rider. The case was seen within half hour of the accident. The empty sheath was at once diagnosed, and the organ reclaimed and refixed with a perfect result. Of these 7 cases 3 were due to cart-wheel injuries in the pubic region, one to machinery, two to bullock gores, and one to a horse falling on his rider. Only one case can strictly be called a direct dislocation by force applied to the penis in its sheath, the others appear to be indirect due to a vis a tergo applied to the perineum, scrotum or pubic skin lifting the sheath away from the penis, as in no case is the external surface of the sheath described as torn or bruised, even in case 4 very completely described in the original, the sheath is full of a bloody mass but not itself
injured. I
wish to lay stress on the appearempty sheath. In cases 4 and 7 only was a surgeon in immediate attendance and in neither was the condition diagnosed by sight, as Treves' description would lead us to expect " lookand, though painless erections occurred, was ing like blown out gold beater's skin." content with the penis in its new bed. The In case 4, the bloody mass was taken to be finding of the entire penis and not the ruptured the crushed glans and a catheter was inserted to urethra was a matter of the greatest surprise relieve tention from a ruptured urethra. to the surgeon. In case 7, it is not actually described but no 5. In 1898, Malinovski reported the case of one would attempt to pass a catheter knowingly a man whose trousers were caught between two into an empty sheath. ance
particularly of the
Nov., 1911.j
IDENTIFICATION OF SNAKES.
In case 5 only did the penile slieatli appear otherwise than normal, in this case the penis was protruding through the scrotum. In case G the penis appeared normal though
shrivilled. It
matter of great surprise in every case ; apparently to find on palpation or catheterism the penis to be absent except in case 4 where it was not even diagnosed until actually exposed by incision and case 5 where it was an obvious fact. The condition is unmistakeable, on palpation looking normal but feeling exactly like a rather thickened piece of the small bowel. As to treatment it is simple in recent cases, replacement either with or without incision secures a penis efficient in all its functions unless complicated by a ruptured urethra. In old cases a plastic operation may be necessary with an almost equally good result. was a
j
419
