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 http://www.archive.org/details/cloacalmorphologOOrick 
 
Cloacal Morphology in its Relation to Genito- 
 Urinary and Rectal Diseases. 
 
 (With 54 Plates and 93 Illustrations.) 
 
 BY 
 
 BENJAMIN MERRILL RICKETTS, 
 Ph.B., M.D., LL.D., F.A.C.S. 
 
 Member American Medical Association; (House Surgeon N. Y. Skin and Cancer 
 Hospital, 1S84-5); Ohio State Medical Society; Western Surgical and Gyneco- 
 logical Association; International Medical Congress, 1887; International As- 
 sociation Railway Surgeons; Mississippi Valley Medical Association; Cin- 
 cinnati Academy of Medicine; Honorary Member Medical Society State of 
 New York; Honorary Member St. Louis Medical Society; Fellow New 
 York State Medical Association; Member Societe Internationale de 
 Chirurgie; American Urological Association; American Proctological 
 Society; Cincinnati Society of Natural History; Pan-American 
 Congress; Honorary Professor of Surgery of the Tliorax and its 
 Viscera; Barnes and American Medical Colleges; National 
 University of Arts and Sciences, St. Louis, Missouri, and 
 Clinical Congress of Surgeons of North America; Author 
 of Volumes What to Do in Case of Accident; Surgery of 
 the Prostate, Pancreas, Diaphragm, Spleen, Thyroid 
 and Hydrocephalus, Surgery of the Ureter, Surgery 
 of the Heart and Lungs and Surgery of the 
 Thorax and Its Viscera; Founder and Director 
 of the B. Merrill Ricketts Experimental 
 Surgical Research Laboratory, Cincinnati, 
 Ohio, etc., etc., etc., etc., etc., etc., etc. 
 
 CINCINNATI 
 1916 
 

 Published by the Author 
 
 MCMXVI. 
 (1916.) 
 
 Copyright, 1916, 
 
 by 
 
 Benjamin Merrill Ricketts 
 

 This work is dedicatea to HOWARD 
 AYERS, B.S., Ph.D., L.L.D., Morpholo- 
 gist and Advocate of Scientific Research. 
 
Everything has a beginning, an existence, 
 and an ending, with changes of equal interest 
 and importance. It is therefore necessary to 
 become famihar with creation that existence 
 and dissolution may be better understood. 
 
 The thing created should be more perfect 
 than its creator, its existence superior and its 
 dissolution more natural, but there are errors 
 and variations evidenced upon every hand, 
 among them changes in the cloaca which are 
 herein considered. (B. M. R.) 
 
INTRODUCTION. 
 
 For fifteen years the anatomical relation of the perineum, coccyx, uro-genital and 
 rectal tracts has been attractive to me, especially symptomatology, which so much con- 
 cerns them and which is so much in doubt. But not until a more recent time, when the 
 importance of the pudic nerve and its many changes in distribution resulting from changes 
 in the cloaca to 4orm the perineum were suggested, was I convinced of the great similarity 
 of physiologic symptoms due to their anomalies, diseases and injuries, and now at the con- 
 clusion of this research, I find this thought crystallized into one more certain and enduring. 
 
 Especial attention has been given to the pudic nerve, lymphatics. Glomus coccygea, 
 coccyx, Cowper's and Bartholin glands, because they play a more important role in 
 symptomatology than has ever been ascribed to them. 
 
 With the exception of the Glomus and Coccyx, no form of treatment is considered 
 throughout this work. I have quoted freely from many authors, not only in histology, 
 but in the general text, because I felt my incompetency and because time would not 
 permit of a more general research. If therefore, I have been permitted to reflect only 
 a delicate ray of light upon this suggestion, the purpose of this work will have been 
 served. 
 
 I desire to thank Dr. D. D. DeNeen for his assistance in preparing the work on the 
 lymphatics, Miss Gladys Ayers and Hawley Zwick for photographic illustrations. Miss 
 Ayers for copy, my students Miss Nevada Hannah and Mr. R. A. White for assistance 
 in the preparation of the copy, Drs. Sappy, Cuneo, and Marcille, Deaver, Piersol, Kelley, 
 Schumacher, Jakobsson and others for permission to use illustrations and quote text. I 
 also want to express my deep appreciation to Mr. Howard Ayers for his contribution, 
 valuable suggestions and encouragement in this research, and to the A. R. Fleming Print- 
 mg Company for producmg the book m a form so pleasing. 
 
 Benjamin Merrill Ricketts, 
 
 February 14th, 1915. N. W. Corner Fourth and Broadway, 
 
 Cincinnati. 
 
 Page Five 
 
CONTENTS 
 
 Chapter I. 
 
 Chapter II. 
 
 Chapter III. 
 Chapter IV. 
 
 Chapter V. 
 
 Chapter VI. 
 
 Chapter VII. 
 
 Chapter VIII. 
 
 Chapter IX. 
 
 Chapter X. 
 
 Chapter XI. 
 
 Chapter XII. 
 
 Chapter XIII. 
 
 Chapter XIV. 
 
 Chapter XV. 
 
 Chapter XVI. 
 
 Chapter XVII. 
 
 Introduction. 
 
 A Summary of Development of the Rectum and Urogenital 
 Sinus from the Cloaca. Illustrated. 
 
 Perineum. — Anatomy, Anomalies Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Definitions. — Of Etiology, Symptoms and Diagnosis. 
 
 Blood Vessels. — Anatomy, Anomalies, Diseases, Injuries 
 and Symptoms. Illustrated. 
 
 Nerves. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Ly^mphatics. — Anatomy, Anomalies, Diseases, Injuries amd 
 Symptoms. Illustrated. 
 
 Glomus Cocc^gea. — Anatomy, Anomalies, Diseases, In- 
 juries and Symptoms. Illustrated. Bibliography. 
 
 Coccyx. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. Bibliography. 
 
 Urethra. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Bladder. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Ureters. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Kidneys. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Erectile Body. — Anatomy, Anomalies, Diseases, Injuries 
 and Symptoms. Illustrated. 
 
 Prostate Gland. — Anatomy, Anomalies, Diseases, Injuries 
 and Symptoms. Illustrated. 
 
 CoTvper's Glands. — Anatomy, Anomalies, Diseases, In- 
 juries and Symptoms. 
 
 Testicles. — Anatomy, Anomalies, Disecises, Injuries and 
 Symptoms. Illustrated. 
 
 Spermatic Ducts. — .Anatomy, Anomalies, Diseases, Injuries 
 and Symptoms. Illustrated. 
 
 Page Sevin 
 
Chapter XVIII. Scrotum. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Chapter XIX. Vagina. — Anatomy, Anomalies, Diseases, Injuries and 
 
 Symptoms. Illustrated. *^ 
 
 Chapter XX. Bartholin Glands. — Anatomy, Anomalies, Diseases, In- 
 
 juries and Symptoms. Illustrated. 
 
 Chapter XXI. Clitoris. — Anatomy, Anomalies, Diseases, Injuries and 
 
 Symptoms. Illustrated. 
 
 Chapter XXII. Uterus. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Chapter XXIII. Ovaries. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. Illustrated. 
 
 Chapter XXIV. Fallopian Tubes. — Anatomy, Anomalies, Diseases, Injuries 
 and Symptoms. Illustrated. 
 
 Chapter XXV. Rectum. — Anatomy, Anomalies, Diseases, Injuries and 
 Symptoms. 
 
 Page Bight 
 
CHAPTER 1. 
 
 A Summary of the Development of the Rectum and Urinogenital 
 Sinus from the Cloaca. 
 
 CLOACAL-COCCYGEAL HISTORY. 
 
 By 
 HOWARD AYERS. 
 
 N VERTEBRATE anatomy the term cloaca is applied to the 
 common chamber into which, in many forms, the intestine, the 
 ureters and the genital passages discharge. 
 
 Reptiles and birds all possess a cloaca generally well de- 
 veloped. Since both birds and mammals are descended from 
 the reptilian stock by divergent paths of development we would 
 expect to find traces of such an important organ as the cloaca 
 in the mammals also. 
 
 Living in Australia today, we find two primitive mammalian 
 forms, the duck-bill (Ornithorhynchus paradoxus) and the spiny 
 ant-eater (Echidna hystrix). Both of them are egg-laying mam- 
 mals — laying eggs like a reptile or bird and after hatching the 
 eggs in their abdominal pouches, nourishing the young with a 
 milk secretion from rudimentary or better — primitive milk glands. 
 They are clearly transitional forms between the reptihan stock 
 and the mammalian stock. These two forms are classed as Monotromes because 
 they have only one external opening for voiding the contents of intestine, ureters and 
 genital tubes. They are cloacal mammals and the cloaca is preserved in reptilian per- 
 fection. While none of the higher mammals normally possess a cloaca in the adult state, 
 all of them pass through a stage in embryonic growth in which the cloacal apparatus is 
 fully developed. However, before the permanent condition is reached the cloaca is 
 generally obliterated as a common chamber and it becomes separated into two tubes, one 
 for the reception of the intestine, the other for the ureters and the genital canals. 
 
 This separation always occurs, except when the developmental processes are in- 
 terrupted or inhibited. Such inhibitions do occur and that not infrequently. They may 
 occur at various stages in the growth of the parts — such individuals we call abnormal 
 — we can only mean that there has been an arrested or thwarted development of the 
 parts. For example, in the human female we occasionally find a double vagina — a 
 normal marsupial condition or again we may find the ancient and normal reptilian. 
 
 In the human male we not infrequently find a condition of the erectile organ which 
 we term hypospadia. Hypospadia is nothing more or less than the normal condition of 
 the erectile organ in the Monotromes. Various other conformations which we call 
 deformations when we find them in man are simply due to the persistence of normal con- 
 ditions of the parts as found in ancestors of the stock. 
 
 The persistence is due to some check in the evolutionary growth of the human 
 individual. 
 
 Let us now examine the embryology of the cloacal region in man. 
 
 Page Nine 
 
In the human embryo of fifteen days' growth, the cloaca is well formed. The 
 opening of the urinogenital sinus and the intestine are still confined to the common cham- 
 ber. The cloacal tubercle is prominent and lies in the center of the quadrangle formed 
 by the leg pads, the coccygeal tubercle, and the umbilical cord. Soon, however, changes 
 
 
 €t£ctac 
 
 ^Ureter 
 
 ■OVi'iu.d'- 
 
 Cloa£ctl \ 
 
 rtMettWl 
 
 Plate 1 . — Evolution of the Cloaca. 
 
 begin in the cloacal aperture into the definitive anus and the urino-genital sinus or pore. 
 Two folds of the lateral walls of the cloaca grow towards each other, until they meet 
 and coalesce, thus forming the perineum. The proctodaeum breaks through into the 
 lumen of the gut, and the cloaca, as such, is no more. These changes are completed 
 
 ' oviciujcT . 
 
 S. 
 
 Cloacal 
 
 Plate 2 — Evolution of the Cloaca. 
 Page Ten 
 
about the end of the fifth week. I here is, however, a short time during which the 
 human embryo possesses a true cloaca. 
 
 We have spoken only of the walls of the cloaca. Of course all other structures such 
 as blood-vessels, nerves, and muscles are involved in these transformations, so that in 
 the study of the cloacal region of the adult human we must bear in mind that all the 
 structures have an ancient pedigree. For example the old-time Musculus Sphincter Cloacae 
 is separated into M. sph. Ani. Ext. and M. sph. Urogenitalis. 
 
 The nervous pudendus breaks up into branches supplying the lower rectum and anus 
 and urethra and erectile organs, each branch receiving an appropriate name in the ter- 
 minology of human anatomy. 
 
 1 
 
 Tall. 
 
 Fig. 2. —Tailed Man. 
 
 Jk- ■ 
 
 |i\^>V*s'-^- 
 
 Fio. 3 Cloaca of Rabbit. Fig. 4. — Showng tail extended. {Johns Hopkins Bulletin.) 
 
 ( ]. M. Sph. Ani. Ext. 
 
 M. Sph. Cloaca ', "> a. M. bulbo cavernosas 
 
 j j (a) M. transversus perinei. 
 
 ^ 2. M. Sph. Urogenit. ' (b) M. urethralis. 
 
 b. M. ischio cavernosas. 
 
 In the rabbit for example, we have an intei mediate stage in the separation of the 
 cloacal muscle into its parts — for here the division is not complete and neither sphincter 
 forms a ring — but the two together an open-jointed figure eight. 
 
 Page Eleven 
 
The cloacal muscles are fastened more or less strongly to the coccygeal vertebrae 
 and thus these skeletal parts play an important part in the functionmg ot the cloacal 
 
 organs. 
 
 Coccpx.— In the mammals the tail vertebrae range m number from 49 (Mams 
 Macrura) to 3 to 5 as in the anthropoids and man. ^u, , 1 
 
 However, in embryonic stages (4 to 1 2 M. M.) man has as many as eight tail 
 segments with the notocord projecting beyond them, mdicatmg a still larger number 
 
 Fis. 3. — Ventral surface of tail. {Johns Hopkins Bulletin.) 
 
 Fig. 6. — Showing contracted tail. {Johns Hopkins Bullelin.) 
 
 in the ancestral stock from which the human species has descended. They form a true 
 
 external tail. _ , , . , ^ ,. 
 
 The coccyx is not a stable group of bones but is on the way to disappearance. 
 
 This is vividly shown by the reduction of the typical external tail of the human 
 embryo so that by the time adult Ufe is reached there is ordinarily no trace of the ex- 
 ternal tail and the internal tail is a mere rudiment attached to the tip of the sacrum. 
 
 Now and then the external tail is not reduced and we have a genuine tailed man. 
 
 Pasre Twelve 
 
From an examination of the coccygeal bones in the adult we might suppose that they 
 represented the bodies only of the caudal vertebrae but embryology shows us that is 
 not the case. 
 
 During development they possess membranous, and in the case of the first and 
 second coccygeal vertebrae, cartilaginous neural processes. 
 
 The articular and transverse processes are incomplete or entirely lacking. Although 
 separate centers are developed for the rib rudiments they do not mature as such. 
 
 Even the haemal processes appear in membranous form (3rd to 5th month) 
 
 Fig. 7. — Front- 
 al section of tail, 
 showng the ar- 
 rangement of the 
 muscle fibers (M). 
 a. Place from 
 %vhlch the cross- 
 section represent- 
 ed in Fig. 5 was 
 taken. X3. 
 
 Fig. 8. — Cross-section through 
 the middle of the tail (Fig. 4, 
 a). M, muscle; M', degenerat- 
 ing muscle; A, artery; A^, 
 nerve; L is placed on the left 
 and R on the right of the 
 appendage. X 9. 
 
 Fig. 9. — Caudal region of embryo of 
 14 mm. (No. 144 of Dr. Mall's collec- 
 tion), combined from several sagittal sec- 
 tions. An., anus; Ao., caudal aorta {A. 
 sacralis media); Ca. fil., caudal filament; 
 Ch., notochord; Med., medullary cord; 
 5. u§., sinus urogenitalis ; V. 32, third 
 coccygeal vertebra; 36, seventh coccygeal 
 vertebra; V. c. i., caudal portion of vena 
 cava inferior (F. sacralis media). X91. 
 
 to disappear — leaving no trace in the adult. From these bare facts we can recognize the 
 true vertebral nature of the coccygeal bones as vestigeal structures — the remains of com- 
 plete vertebrae in the ancestral stock of the human species. The facts set forth in this 
 brief sketch point unmistakably to the conclusion that the cloacal-coccygeal territory 
 has suffered extensive transformation in its descent to the human condition and to the 
 further conclusion that it is still undergoing change and reduction. The practitioner as 
 well as the surgeon, should have a thorough knowledge of the phylogenetic as well as 
 the ontogenetic history of the region in order to deal intelligently with the normal and 
 abnormal structure and functions of the parts. 
 
 Page Thirteen 
 
CHAPTER II. 
 
 PERINEUM. 
 ANATOMY. 
 
 "■-.BUcldt. 
 
 
 1* 
 
 \ci,n',,-. 
 
 IU«M. 
 
 J 
 
 D.j.itl .,CT cfcl.t;-.! 
 
 
 
 I,mi.<, lu.... I 
 
 Fig. 10. — Female pelvis and perineum — sagittal section Fig. II. — Male pelvis and perineum — sagittal section 
 
 (Deaver). (Deaver). 
 
 Anatomy of the Perineum. 
 
 Superficial and Deep Tissues of the Perineum. 
 
 Superficial. 
 
 Cutaneous. 
 
 Fat. 
 
 Fascia, superficial and deep. 
 
 Blood vessels. 
 
 Nerves. 
 Lymphatics. 
 
 Page Fourteen 
 
Deep. 
 
 1 . Sphincter ani externus. 
 
 2. Transversus perinei superficialis. 
 
 3. Bulbo cavernosus — or Erector penis and clitoris. 
 
 4. Ischia cavernosum. 
 
 5. Compressor Urethrae, beneath the triangular Hgaments. 
 
 Fig. 12. — Superficial fascia of male perineum (Deaver). 
 
 HE PERINEUM is of recent origin in the history of animal life 
 and found only in mammals, being absent in fish, reptiles and 
 birds and as has been stated, absent in a few mammals, for ex- 
 ample the rabbit. 
 
 The perineal body lies between the vagina and rectum 
 with the base pointing downward, one inch antero-posterior in 
 diameter and one one-half inches in height, but it may vary in 
 size in individuals of the same kind. In the male it is sup- 
 plied by the internal pudic and inferior hemorrhoidal vessels; 
 while in the female the blood supply is from the iliac artery. 
 It is inhibited by the pudic and small sciatic or pudendal nerves 
 and its lymphatics empty into the inguinal glands. 
 
 There is no part of the body possessing so great a variety 
 of organs and tissues as the perineum and its intimately asso- 
 ciated structures. 
 Tissues and organs entering into the structure of and most concerned in the forma- 
 
 Page Fifteen 
 
tion of the perineum, anj' one of which by reason of anomaly, disease or injury, may 
 cause subjective symptoms alone or combined, because of insult to one or more branches 
 of the pudic nerve, are classified as follow^s : 
 
 Perineum 
 
 Coccyx 
 
 Urinary 
 
 Genitalia 
 
 Rectum 
 
 Cutaneous 
 
 Fat 
 
 Fascia 
 
 Bone 
 
 Periostium 
 
 Glomus-Coccygea 
 
 Urethra 
 Bladder 
 Ureters 
 
 Male 
 Penis 
 Prostate 
 
 Sphincter ani 
 
 Rectum 
 
 Sigmoid 
 
 Muscles 
 
 
 Kidneys 
 
 Cowper's glands 
 
 
 Tendons 
 Ligaments 
 Bones 
 Blood vessels 
 
 
 
 Testicles 
 Spermatic ducts 
 Scrotum 
 
 
 Nerves 
 Lymphatics 
 
 
 
 Female 
 Vagina 
 
 Bartholini glands 
 Clitoris 
 Uterus 
 Ovaries 
 Tubes 
 
 
 Cutaneous structures reveal as objective the presence of induration, tenderness, color, 
 and subjective such as pain, location, temperature, loss of appetite, general depression and 
 reflected pain, distal to the perineum. 
 
 Fat is deposited within the integument and external to the superficial fascia and 
 more or less about the muscles. 
 
 The fascia in the perineum is both superficial and deep. 
 
 The superficial is a continuation of the superficial fascia of the abdominal wall, 
 thigh and buttocks and extends over the pelvis and scrotum. In the scrotum it is in- 
 termingled with involuntary muscular fibers and forms the dartos muscle which assists 
 in suspending the testicles and corrugating the skin of the scrotum. It also forms the 
 septum of the scrotum which separates the testicles. 
 
 The fascia over the posterior portion of the perineum fills up the ischio-rectal fossae 
 in the form of two pads of adipose tissue on either side of the rectum and anus, while 
 the fascia of the anterior part of the perineum resembles the same fascia in the groin. 
 The deeper layers are attached to the pudic arch posteriorly to the base of the triangular 
 ligament and in the middle line to the root of the penis (bulbus and corpus spongioseum) 
 and median line of the scrotum. The fascia is continued anteriorly over the spermatic 
 cords to the anterior abdominal wall, and its function is to prevent pus and extravasated 
 urine passing backwards into the ischio rectal fossa or laterally into the thigh. It is 
 directed forward into relation with the scrotum and penis and along the spermatic cord 
 to the anterior abdominal wall. The septum of the scrotum being incomplete, fluid ex- 
 travasated on one side according to Cunningham can pass across the middle line to the 
 opposite half of the perineum and scrotum. 
 
 The deep fascia of the perineum is only a delicate aponeuroses of the muscles. 
 
 The superficial perineal arter}) arises in the anterior part of the ischio rectal fossa, 
 pierces the base of the triangular ligament, and divides into long slender branches (scrotales 
 in the male, labiales posteriores in the female) which are continued forward in the 
 urethral triangle, beneath the superficial perineal fascia, to the scrotum. It anastomoses 
 with its fellow of the opposite side, with the transverse perineal and the external pudic 
 arteries, and supplies the muscles and subcutaneous structures of the urethral triangle. 
 
 The superficial transverse perineal muscle is not always present in the form of a 
 small delicate bundle of fibres arising from the ascending ramus of the ischium and the 
 fascia over it, and forms the base of the triangular ligament. It is directed inwards and 
 
 Page Sixteen 
 
forwards to be inserted into the central point of the perineum and conceals the base of the 
 triangular ligament. 
 
 The transverse perineal artery is a small branch which arises either from the internal 
 pudic or from its superficial perineal branch. It runs inward along the base of the 
 triangular ligament to the central point of the perineum, where it anastomoses with its 
 
 -Mijl 
 
 Fig. 13. — Superficial dissection of the perineum (Kelley), 
 
 f 
 
 \y 
 
 Fig. 14. — Deep dissection of the perineum (Kelley). 
 Page Seventeen 
 
fellow on the opposite side, with the superficial perineal branch and with the interior hemor- 
 rhoidal arteries. It supplies the sphincter vaginae, and the anterior fibers of the levator ani. 
 
 The nerve supply is from the perineal branches of the pudic nerve and its function 
 is to assist the deep transverse perineal in fixing the central tendon of the perineum during 
 the contraction of the bulbo cavernosi. 
 
 The transverse perinei profundi muscle arises from the ascending ramus of the 
 ischium just below the compressor urethra and is inserted into a median raphe, continues 
 with that of the compressor urethra in the form of two separate bundles of fibers one 
 below and the other behind the compressor urethra. Its function is to fix the central tendon 
 
 Fig. 15. — Triangular ligament and superficial perineal Fig. 16. — Ischio-rectal fossae and fascia of colles of male 
 
 interspace of female (Deaver). perineum (Deaver). 
 
 of the perineum during the contraction of the bulbo cavernosus. Some of its fibers unite 
 with those of the superficial transverse perineal muscle. 
 
 Its nerve supply is by a branch of the pudic which breaks up into many fine twigs, 
 branches of the fourth sacral nerve. 
 
 Deep muscles of the pelvic floor. 
 
 1. Levator ani. (See rectum.) 
 
 2. Obturator internus. 
 
 3. Pyriformis. 
 
 4. Coccygeus. (See coccyx.) 
 
 Obturator Internus arises by fleshy fibers on the pelvic aspect of the hip bone and 
 posteriorly opposite the small sciatic notch and, like the obturator externus, is fan-shaped. 
 
 Page Eighteen 
 
0«ncl * tf ^*<>\ 
 
 Supflifkial laysr af tr<angul»r 1.^ 
 
 Bulb o1 co'put tfJong.o^Ki 
 
 Fig. 17. — Superficial muscles, arteries and nerves of male Fig. 18. — Superficial layer of triangular ligament of male 
 
 perineum (Deaver) . perineum (Deaver) . 
 
 Fig. 19. — Muscles in floor of pelvis — superior view (Deaver). Fig. 20. — Triangular ligament and compressor urethras 
 
 muscle (Deaver). 
 
 Page Nineteen 
 
It is separated from the pelvic contents above by the peritoneum and below^ by the base 
 of the ischio-rectal fossa and is crossed by the internal pudic vessels and nerve in the 
 outer wall of the fossa in a special sheath of fascia. 
 
 Piriformis muscle arises within the pelvis between the first, second, third and*^fourth 
 sacral vertebrae, and from the adjacent part of the bone external to the anterior sacral 
 foramen. Passing out through the great sacro sciatic foramen it receives an origin from 
 the upper margin of the great sciatic notch of the ilium and from the pelvic surface of the 
 great sacro sciatic ligament, forming in the buttocks a round tendon which is inserted into 
 a facet on the upper border and inner aspect of the great trochanter of the femur partly 
 surrounding the insertion of the obturator internus. It lines the posterior wall of the pelvis 
 lying behind the rectum and is covered by a thin layer of the parietal pelvic fascia. It is 
 a muscle of abduction and flexion. 
 
 The first and second sacral nerves supply the pyriformis muscle which arises from 
 the sides of the sacrum between the first, second and fourth foramina, and which is in- 
 serted in the upper margin of the great trochanter. 
 
 ETIOLOGY. 
 
 Dis 
 
 r 
 
 Anomalies. 
 
 Benign. 
 
 Malignant. 
 
 ^ Injury. 
 
 ANOMALIES. 
 
 NOMALIES may be congenital or acquired, primary or second- 
 ary, single or multiple, absent in part or entirely, the result of 
 defective development, accident or design and involve any of 
 the adjacent tissues or cavities. 
 
 The causes of symptoms relating to the perineum, like 
 those in other regions, may be physical or functional and of 
 anomalous, pathologic or traumatic origin. It is therefore neces- 
 sary to review them briefly that their relations may be better un- 
 derstood, and because the object of this work is to associate 
 physiologic symptoms and their respective causes, such as pertain 
 to the perineal tissues and their intimate, associated organs, it 
 will be necessary to consider them separately. 
 
 Anatomical variations may be due to defective embryonic 
 development or defective development after birth, the result of 
 paralysis, disease, injury or surgical operation. 
 Variations from normal in the soft structures, may be of such a character as to 
 partially or completely destroy mechanical function, such as urination, defecation, impreg- 
 nation and delivery of the products of impregnation. 
 
 They may also destroy physiologic functions which result from defective blood, 
 nerve and lymphatic supply and bony structures, like the coccyx, sacrum and pelvis, may 
 possess such mechanical defects. 
 
 Any one or all of these will cause symptoms varying in character. 
 Pathologic changes result from acute or chronic diseases, due to infection or ac- 
 cidental or induced trauma. 
 
 Conditions of any character in any of the perineal structures or organs produce 
 
 symptoms which may or may not be significant with or without recognition of the lesion. 
 
 Physiologic changes may be due to anatomic, pathologic or traumatic conditions, 
 
 one or all combined, or they may be due to changes in the nervous system independently. 
 
 Defective blood, nerve and lymphatic supply not infrequently disturbs physiologic 
 
 function. Secretion and excretion may be increased or diminished in amount and then 
 
 Page Twenty 
 
materially changed and remain unrecognized. This function may be affected for a 
 few minutes or it may be hours, days, weeks or months or it may be permanent. 
 
 Traumatic changes are the result of repair following infections and accidental or 
 surgical injuries. 
 
 They occur quite frequently with more or less loss of tissue and function due to 
 cicatricial tissue. 
 
 This is especially exemplified with injury to the penis and testicles with their asso- 
 ciated ducts and the uterus with its appendages. 
 
 Surgical operations may change anatomical relations with or without interfering 
 with function. 
 
 Such trauma for the correction of anomalies, diseases or injuries is not without its 
 effects, and while it is often necessary, the degree of restoration to normal varies, occa- 
 sionally it fails, while in others it is only a partial success, but fortunately the great 
 majority are complete restorations or as near to normal as it is possible to obtain, but in 
 either event certain symptoms may result. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Papillomata may be congenital or acquired, primary or secondary, usually pedun- 
 culated, single or multiple, vary in size, shape and location, cease, continue to grow, dis- 
 appear spontaneously, upon the mucous or cutaneous surfaces and more frequently at or 
 near the muco-cutaneous border. 
 
 (See for all chapters, Papillomata and Adenomata: Historical Review (Ricketts), 
 Amer. Jour, of Dermatology, March and April, 1908. Also N. Y. Med. Jour., Vol. 
 LXXX, 1907.) 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape and in any portion or tissue of the perineum. 
 
 Tuberculosis may be primary or secondary, single or multiple, acute or chronic, in 
 any tissue or portion of the perineum, probably more frequent at the vaginal or anal border, 
 cease or continue to destruction, or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, vary in size in the superficial or deep perineum, more frequently primary, 
 in the form of a chancre. The primary form occurs more frequently in the female than 
 the male perineum, because of the additional amount of mucous membrane in the fe- 
 male, but it may occur in any of the perineal structures. 
 
 Osteomata may be congenital or acquired, primary or secondary, single or mul- 
 tiple, vary in size and location. 
 
 They seldom occur in the perineum except when they originate in the periosteum 
 or the attachments of tendons, and are usually single, round or irregular in shape. 
 
 Chondromala may be congenital or acquired, primary or secondary, single or mul- 
 tiple, vary in size and location, characterized by their development from cartilaginous 
 tissue, found in the attachments of tendons, about bony structures, and almost invariably 
 single. 
 
 Cysts may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, vary in size or location, and result from degeneration of any neoplasm or in- 
 jury. Those congenital may be dermoid or contain blood, pus, or serum, and the ac- 
 quired contain fluids of the same character, and echinoccocci. Any variety may rupture 
 externally, into the vagina, rectum, bladder, uterus, urethra, or peritoneal cavity. 
 
 Page Twenty-One 
 
Fistulae may be congenital or acquired, primary or secondary, acute or chronic, 
 single or multiple, vary in size, length and location, irregular in their course, traverse the 
 superficial or deep perineal structures, originate in them and open upon the cutaneous 
 structures after having connected the rectal, vaginal, uterine, peritoneal cavity, or urinary 
 tract, one or all, at the same time. One or more channels may connect vs'ith one tJpening 
 v^ithout either of these tracts being involved. 
 
 MALIGNANT. 
 
 Carcinomaia may be primary or secondary, single or multiple, usually primary and 
 single in any tissue or portion of the perineal body. 
 
 Sarcomata may be primary or secondary, single or multiple, usually primary and 
 single, in any portion or tissue of the perineum. 
 
 INJURIES. 
 
 Lacerations, incisions, punctures, contusions are the result of accident or design, 
 may be primary or secondary, single or multiple, complete or incomplete, with ragged or 
 sharply defined edges, complicate the rectum, vagina, uterus, urethra, bladder, prostate, 
 peritoneal cavity or any of their associated structures. 
 
 Foreign bodies may be made to enter the perineum by accident or design, from 
 without or through the rectum or vagina, remain indefinitely, by becoming encysted, or 
 escape through the cutaneous structures into the urethra, bladder, rectum, vagina, uterus 
 or peritoneal cavities. 
 
 SYMPTOMS. 
 
 S^mptomatically the perineum is perhaps first in interest in non-visceral anatomy, be- 
 cause of the numerous conditions within the urogenital and rectal tracts, three of the most 
 important channels within the realms of surgery. The intimate relations of these organs 
 during the cloacal period and their separation by the formation of the perineum, which 
 wrought so many anatomical changes, continues to be of interest worth while, especially 
 because the purport of certain nervous impulses is yet undetermined. 
 
 To symptomatology will credit probably be given for whatever great advance is made 
 within the next decade in the correction of beginning changes. 
 
 Three teachings of pathology within seventy-five years and as many of physiology, 
 would indicate their great uncertainty and difference between living and dead pathology 
 and that physio-symptomatology would seem most likely in importance. 
 
 Symptoms must be determined and classified before an advance can be taken, 
 whether they be due to anatomical, pathological, physiological, or traumatic conditions. 
 Anatomical are first and most important to know, before the cure of those pathologic _or 
 physiologic are attempted with any assurance of success. Those physiologic are de- 
 pendent upon anatomic, pathologic and traumatic conditions, one or all combined. 
 
 Page Twenty-Two 
 
CHAPTER III. 
 
 Etiology. Symptoms. Diagnosis. 
 
 GOULD'S DEFINITIONS. 
 
 TIOLOGY is the science of efficient causes." 
 
 "'Anomaly. Any deviation from the normal or typical 
 structure or occurrence. It may be congenital or acquired, ac- 
 cidental or induced." 
 
 ''Disease. A condition of the body marked by inharmo- 
 nious action of one or more of the various organs, owing to 
 abnormal conditions of structural change." 
 
 ''Injur]). Any damage or harm to the body or any of 
 its parts." 
 
 SYMPTOMS. 
 
 GOULD'S DEFINITIONS. 
 
 Semieology) is the science of signs ; in medicine of the 
 symptoms of disease. 
 
 Symptom. A coincident happening, change or phase vv^hich occurs synchronously 
 with a disease and serves to point out its nature and location. 
 
 Indirect Symptom. One only indirectly due to disease. 
 
 Negatively Pathognomonic. One which occurs in a certain disease and therefore 
 by its absence shows the absence of that disease. 
 
 Pathognomonic Symptom. Is one which exhibits itself only in a certain disease and 
 therefore undoubtedly proves itself. 
 
 Physical Symptoms. Are the physical signs of morbid conditions. 
 
 Static Symptom. Is one which indicates the condition in a single organ without 
 reference to the rest of the body. 
 
 Subjective Symptom. Is that observed only by the patient. 
 
 Objective Symptom. Is one observed by the physician. 
 
 The Sympathetic Symptom. One for which no adequate cause can be given, other 
 than so-called sympathy. 
 
 Symptoms. 
 
 Tenderness. 
 Tumefaction. 
 Color. 
 Trauma. 
 Rigidity. 
 
 Temperature variation. 
 Local Symptoms. 
 
 Tenderness is one of the first indications of pathology or irregularity, best de- 
 termined by the sense of touch, but does not always indicate the degree of affection. 
 
 1. 
 
 Local. 
 
 2. 
 
 General. 
 
 
 Local. 
 1 
 
 
 1 . 
 
 2. 
 
 
 3. 
 
 
 4. 
 
 
 5. 
 
 
 6. 
 
 Page Twenty-Three 
 
Tumefactions are not always perceptible to the eye, especially when the deep struc- 
 tures are involved, but when they are within the cutaneous structures they can usually be 
 observed. Palpation will reveal growth of ordinary size situated within the deeper struc- 
 tures and they may be recognized visually, this depending upon their size. ^ 
 
 Color. The cutaneous structures may ofttimes be discolored and its character may 
 aid materially in determining conditions. 
 
 Trauma of the perineal body is quite common and it may be inflicted from within 
 or without, or the two sources combined. It is only the more superficial wounds, the char- 
 acters of which may always be determined by visual inspection alone. 
 
 Rigidity may occur in any muscular tissue, especially that for sphincteric purposes, 
 such as is found about the rectum, vagina, urethra vesicle openings of the ureters, cervix 
 uteri and Fallopian tubes. In fact nearly all of the muscular fibers found in the perineal 
 tissues and their associated organs are of this character, for the purpose of relaxation and 
 contraction that matter may be received and expelled through them. 
 
 The function of contraction is probably more important in man, because of his 
 erect posture, especially at the conclusion of the act of urination and defecation, both of 
 which necessitate a more complete closure of the opening. 
 
 Temperature may be local and very several degrees below to the maximum above 
 normal. When the general temperature is high, the local temperature may be normal 
 or subnormal. This variation is more easily determined when the lesion is situated in the 
 hands and lower extremities, especially the feet. 
 
 General Physiologic Symptoms. 
 
 1. 
 
 Pain. 
 
 2. 
 
 Chill. 
 
 3. 
 
 Temperature, 
 
 4. 
 
 Lymphatic. 
 
 5. 
 
 Cardiac. 
 
 6. 
 
 Gastric. 
 
 7. 
 
 Perspiration. 
 
 8. 
 
 Respiration. 
 
 9. 
 
 Alimentary. 
 
 10. 
 
 Nervous. 
 
 11. 
 
 Cephalalgia, 
 
 12. 
 
 Delirium. 
 
 13. 
 
 Convulsions. 
 
 14. 
 
 Coma. 
 
 15. 
 
 Shock. 
 
 Pain and irregular growth probably rival in importance all other symptoms, the first 
 being subjective and the second objective, one described by the patient, the other ob- 
 served by the attendant. 
 
 Pain thus being of such importance must necessarily be attributed to involvement of 
 the nerves, where many branches of the pudic nerve are to be found. 
 
 The severity of pain does not always increase or diminish the pulse rate, even with 
 the most severe lesions, but when the rate is rapid and feeble, serious conditions may be 
 suspected. This may also be said of the pulse when it is slow, full and bounding in 
 character. 
 
 Pain of any degree may always be considered a symptom, though nervous tissue 
 be not pathologic. The causes of painful disturbances are indeed numerous, therefore 
 difficult to classify. Pain may be of local origin or reflected, for example when pain is 
 present in the distal end of the penis, due to the presence of a vesical calculus. 
 
 Chill usually occurs soon after infection but may be the result of shock and vary in 
 degree from mild to severe, and of but a few minutes' duration, though it may continue 
 for several hours without bacterial infection. 
 
 Temperature may vary from 95 to 106 degrees F., due to many causes, local or 
 general, continued or remittent, regular or irregular in course, and of short or long dura- 
 tion. It would seem at times to exist without infection when it rises suddenly to I 05 
 degrees or more, following the introduction of a urethral sound, for it will then disappear as 
 suddenly as it appeared. 
 
 It may be confined to certain localities, among them, the perineum and its imme- 
 diate, related organs and tissues or when general, affect the entire body. 
 
 Page Twenty-Four 
 
L'^mphatics. There may not be any evidence of lymphatic disturbances though 
 they probably exist, because it is difficult to understand how pathology of any character 
 can exist in the perineal region without affecting their normal status. 
 
 Cardiac disturbances are always manifested in the arterio-vascular system, and they 
 may vary from mild to severe, regular or irregular, slow or rapid, or the radial pulse may 
 be absent with the presence of severe shock. 
 
 Gastric. There may be severe or mild stomach disturbances such as nausea, acidity, 
 vomiting or eructation of gas. 
 
 Perspiration is due to varying degrees of heat produced from without or within the 
 body. When within, infection and cardiac stimulation are the exciting causes, while the 
 external cause is excessive heat or exercise. It may be due to nervous irritation of 
 any character. 
 
 Respiration is usually increased with the presence of infection, but it may be in- 
 creased or diminished without, as when nervous irritability or severe pain is present. 
 Increased respiratory movements are usually manifested when infection is severe and pro- 
 portionate with its degree. 
 
 Such disturbances are not manifested to any considerable degree, except when the 
 lesions or infection have become well advanced, then rapid, irregular, deep or shallow 
 breathing sometimes accompanied by sighing is in evidence. 
 
 These respiratory changes may occur as the result of neurosis independently or the 
 two factors combined. 
 
 Such disturbances are more frequent with aggravated conditions of the bladder, 
 ureters and kidneys and because of their relation and close proximity to the diaphragm 
 and other important structures and organs, especially the intimate association of the renal 
 sensory nerve fibers with those of the diaphragm. 
 
 Alimentary disturbances such as nausea and vomiting are not unusual and they may 
 be mild or severe, without indicating serious conditions, but they may when severe and 
 continuous, indicate the severity of their cause. 
 
 They may exist to a mild or severe degree without infection, or rise of temperature 
 and be purely of nervous origin. 
 
 The more severe types are usually confined to involvement of the bladder, ureters 
 and kidneys, though they may exist when the urethra alone is their origin. 
 
 Nervous disturbances are of many varieties and degrees, as the result of affections 
 within the perineum and its associated organs. They may be in the form of local or 
 general irritability with restlessness and their various associated phases. 
 
 Cephalalgia may exist with more or less severity and be localized or general, periodic 
 or constant, sharp or dull, in character, occur without infection, or the rise of temperature, 
 result from physiologic disturbances alone, or any other of the recognized causes. 
 
 Delirium not infrequently results from the more aggravated conditions herein de- 
 scribed, and its degree may not correspond with that of infection or involvement of the 
 perineal structures and organs. It may be mild or severe but usually is of short dura- 
 tion and usually accompanies a high degree of temperature due to infection. 
 
 Convulsions resulting from disease especially of the kidneys and uterus, or their ap- 
 pendages, are not uncommon, occasionally due to diseases of other parts of the uro- 
 genital or rectal tracts, or the perineal body, and without increased temperature in either 
 instance. They may be severe or mild, of short or long duration and of short or long 
 intervals. 
 
 Coma may follow immediately or soon after convulsions, or it may exist without or 
 the previous occurrence of convulsions, and vary from slight to profound in degree, with 
 distinct or muttering syllables, in the milder form, and of short or long duration. Like 
 convulsions it follows the more severe types of disease and during their last stages. 
 
 Shock may be mild or severe, of short or long duration, and usually due to some 
 form of trauma, though it may be the result of disease. The more severe forms are as- 
 sociated with loss of consciousness, but such is not the case with that milder in character. 
 
 Page Twenty-Five 
 
Because only physiologic symptoms are to be herein considered, it will be necessary 
 to deal only with functional disturbances, such as pertain to the following systems : 
 
 1 . Cardio-vascular. 4. Urinary. 
 
 2. Nervous. 5. Reproductive. 
 
 3. Lymphatic. 6. Rectal. 
 
 Conditions which cause symptoms, are mentioned in each chapter and each chapter 
 intended to describe symptoms and their relation to symptoms, caused by conditions men- 
 tioned in other chapters, that composite symptoms may when possible be definitely de- 
 termined. 
 
 The study of uro-genital and rectal diseases should not be divorced and because 
 of their very intimate relation, their consideration should represent but one specialty. 
 
 DIAGNOSIS. 
 
 GOULD'S DEFINITIONS. 
 
 "Diagnosis is the distinguishing, fixation or interpretation of a disease from its 
 symptoms." 
 
 "Differential diagnosis is the qualitative distinguishing between two diseases of similar 
 character by comparative symptoms." 
 
 "Direct diagnosis is the recognition of a disease from the existence of one or more 
 signs or symptoms, independently or in relation with other symptoms, or with age, sex, 
 physical or mental characteristics, residence or occupation or with the family history. 
 
 "Physical diagnosis is the application of physical methods to the study of disease." 
 
 "Exclusion diagnosis is the recognition of disease by excluding all other known con- 
 ditions." 
 
 Certain diagnoses may be made exclusive of subjective symptoms, by certain ob- 
 servations without the use of mechanical devices ; they may often be ascertained by 
 what is observed directly with or without such means, but there are many diagnoses that 
 cannot be made without the two methods combined and still others that can never be 
 made, with all known methods combined, including those objective, without mechanical 
 devices. (B. M. R.) 
 
 Mechanical devices for diagnosis have become so perfected that they are now in- 
 dispensable, for examination of regions unavailable to the eye or sense of touch. 
 
 Much therefore depends upon their proper use in making diagnoses certain. A 
 great many times symptoms alone will be of no avail, but now that symptoms have been 
 more properly classified and understood, they will serve a better purpose when me- 
 chanical devices are resorted to for diagnostic purposes. 
 
 One or more mechanical devices alone will frequently determine conditions, but their 
 employment in conjunction with subjective or objective symptoms will be more frequently 
 necessary. 
 
 Digital. The sense of touch and sight of the examiner are the first of the various 
 methods to be applied in determining conditions. The first to test sensibility, tension, size, 
 location and shape, which when aided by the second will be more definite. 
 
 Sounds may be employed in detecting the course and size of channels, their obstruc- 
 tion and contents, whether they be in soft or hard structures, or connected with normal or 
 abnormal cavities. 
 
 Sense of Sight. 
 
 Eye, alone. 4. X-Ray. 
 
 Mechanical. 5. Microscope. 
 
 1 . Specula. 6. Chemical. 
 
 2. Trocar. 7. Surgical exploration. 
 
 3. Thermometer. 
 
 Page Twenty-Six 
 
£];e alone may be all sufficient to determine certain conditions diagnostically. 
 
 Specula with or without reflected light are indispensable many times in canals and 
 cavities, because they bring to view that which could not otherwise be seen. 
 
 The trocar permits of fluid being removed from tissues and cavities for diagnostic 
 and curative purposes. 
 
 Thermometer. While temperature may be determined by the sense of touch and 
 general condition of the body, its degree variance in degree and location cannot be other- 
 wise determined. It is therefore a most important adjunct in diagonstic measures. 
 
 Radiography permits of shadow study in the discovery of the presence of anomalies, 
 disease, foreign bodies, concretions, and injuries, and has been the most resourceful of 
 the newer methods in vogue. 
 
 The Microscope for bacteriological findings should be employed with the earlier 
 examination and will often decide the diagnosis, without further difficulty, but its use to 
 determine the character of pathology usually comes after the completion of surgical work. 
 
 Chemical analysis constitutes the determination of the constituents of normal and 
 abnormal fluids and solids in the body, whether they be chemical, microscopical or bac- 
 teriological. 
 
 Surgical exploration should be made at the earliest possible period in the course of 
 conditions which necessitate a diagnosis, or it should be delayed until all other methods 
 have been resorted to and then completed if necessary, at the conclusion of the ex- 
 ploration. It will, as a rule, be more definite than all others, while in some, all methods 
 combined will be needed and a few will then remain undetermined. 
 
 Page Twenty-Seven 
 
CHAPTER IV. 
 
 BLOOD VESSELS. 
 
 ANATOMY. 
 
 N ATOMY OF ARTERIES. As the large and small arteries 
 are very similar, a description of the medium-sized will suffice. 
 An artery consists of three main coats: 1. The intima (or 
 inner layer) ; 2, the media or thick muscular layer; 3, the 
 adventitia or outer elastic coat containing the nervi vasorum, 
 vasa vasorum and the lymph channels of the vascular wall. 
 
 Anaiom]) of the l^eins. The walls of the veins are always 
 thinner than the corresponding arteries. They are very similar in 
 structure, containing the three coats somewhat less distinctly dif- 
 ferentiated. They are more flaccid and less contractile in con- 
 sequence of the smaller amount of elastic and muscular tissue 
 they contain. 
 
 The rich supply of blood to the perineum is important be- 
 cause of the presence of so great a variety of organs and tissues 
 and must therefore play an important role in symptomatology. 
 
 Fig. 21. — Internal iliac artery and its branches (Deaver). 
 
 Page Twenty-Eight 
 
ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 Anomalies. 
 p,.. f Benign. 
 
 Diseases | Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 vary in length, circumference, size of lumen, relation to other structures, or vessels en- 
 tirely absent. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Atheromata may be congenital or acquired, primary or secondary, single or multiple, 
 varying in location, number, extent, partial or complete. 
 
 Varicosities may be congenital or acquired, primary or secondary, single or multiple, 
 involve several vessels, remain stationary, continue to grow, or disappear spontaneously. 
 
 Aneurisms may be congenital or acquired, primary or secondary, single or multiple, 
 in any vessel or locality, vary in size, remain quiescent, continue to grow, or disappear 
 spontaneously. 
 
 Tuberculosis may be primary or secondary, single or multiple, acute or chronic, vary 
 in extent, location, remain quiescent, continue to develop or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, acute or chronic, in- 
 volve one or more vessels, disappear, or continue in its destruction. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape and location. 
 
 Occlusions may be congenital or acquired, primary or secondary, single or multiple, 
 partial or complete, vary in location and number of vessels. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, single or multiple, at any point, in any 
 vessel or tissue. 
 
 Sarcomata may be primary or secondary, single or multiple, at any point, in any 
 vessel or tissue. 
 
 INJURIES. 
 
 Incisions, ruptures, punctures, contusions are the result of accident or design, primary 
 or secondary, single or multiple, longitudinal or circumscribed, vary in extent and loca- 
 tion, through the perineal body, rectal or vaginal wall, urethral canal, bladder, or peri- 
 toneal cavity. 
 
 Veins. Trauma and infection, especially in the female, are prolific in their symp- 
 tom complex. Phlebitis of the broad Hgament veins, left iliac tributaries, is the most 
 common of complications. 
 
 The Pampiniform plexus phlebitis causes many obscure neuroses and possibly neu- 
 rasthenias, which develop repeated exacerbations with the slight uterine infections from 
 monthly changes. D^smenorrhoea is usually associated with slight infections but enough 
 
 Page Twenty-Nine 
 
to cause frequent phlebltic involvement that subsides usually after a free flow of blood 
 from the uterus. 
 
 Hemorrhoidal vessels are frequently infected, a condition that may be very serious, 
 especially when thrombotic. 
 
 Post-operative infections of the hemorrhoidal veins which are involved, intestinal ulcer- 
 ation causing mesenteric thrombo-phlebitis with gangrene of the intestines and appendicitis 
 infections, travel into portal veins causing a portal thrombo-phlebitis. 
 
 The uterine sinuses in aborting and parturient women with the associated clotting, 
 may be a prolific source of infection not only of the pelvic veins, but also of the general 
 peritoneal cavity, as is manifested by the frequency of Coli cystitis in parturient women. 
 Infected clots and decidual membrane in the puerperal state always cause some infection. 
 A perfect aseptic lochial discharge is rare because change of attendants is usually marked 
 by a temperature rise showing how very sensitive the parturient woman is to infection. This 
 is due entirely to careless handling and lack of asepsis. 
 
 SYMPTOMS. 
 
 Symptoms pertaining to blood vessels in the perineum, genito-urinary and rectal 
 tracts, are more or less characteristic, especially when the vessels have been opened by 
 disease or injury, in which instance their contents would escape into the various soft struc- 
 tures, thereby producing the same symptoms that are found with disease of the lymphatic 
 structures, except that pain, induration and tenderness would appear more suddenly, there- 
 fore more definitely determined. 
 
 Anomalies and disease of vessels offer greater difficulty in ascribing symptoms, and 
 like atheromatous degeneration which is usually due to senility, may occur in middle life 
 with all of the consequences, due to other causes. Arteriosclerosis may be local or gen- 
 eral, but when local, its efFects upon the genito-urinary and rectal tracts are manifested by 
 certain symptoms, such as loss of function, atrophy and sensation, each due to loss of blood 
 supply. The same condition may be the result of congenital vessel defect, but vessel 
 trunks or many of their branches must be deficient to cause such a condition, because of the 
 rich collateral blood supply within these structures. 
 
 Page Thirty 
 
CHAPTER V. 
 
 NERVES. 
 
 ANATOMY. 
 
 ^C5^ fS)/\ ^^ ANATOMY of the Nerve Trunk- The fibers composing 
 pj I J. J( H^ the peripheral nervous system are grouped into the larger and 
 
 N-^^ KaV^>, smaller nerve trunks, which extend to various parts of the body. 
 
 In the make-up of those that supply both muscles of sensory 
 surfaces (integument or mucous membranes) three sets of fibers 
 are included : 1 . The efferent axones of motor neurones, whose 
 cell bodies are situated in the spinal cord or brain; 2, the af- 
 ferent dentrites of sensory neurones withm the spinal and other 
 sensory gamglia; and 3, the efferent axones of neurones within 
 the sympathetic ganglia that accompany the spinal fibres to the 
 periphery and serve for the innervation of the involuntary mus- 
 cles of the blood vessels, and of the skin and glands. 
 
 These fibers are grouped mto bundles (funiculi). Each 
 funiculus is surrounded by a definite sheath of connective tis- 
 sue, the perineum, which is directly contmuous with the 
 delicate fibro-elastic tissue prolonged between the individual nerve fibers as the endo 
 neurium. (The perineurium may contain lymph spaces.) When, as is usually the case, 
 the nerve is composed of several funiculi; these are loosely bound together and the entire 
 
 Bim^l*. A^MrffMl .*B.'.A . 
 
 Fig. 22. — Diagram of the lumbar and sacral plexuses 
 (Deaver) . 
 
 Pag-e Thirty-One 
 
Fig. 23. — Diagram of sacral perineum (Deaver). 
 
 trunk so formed is invested by a general envelope, the epineurium, in which course the 
 blood-vessels and lymphatics. The envelopes of the nerve trunks are continued over its 
 branches even into its smallest subdivisions. The last representative being seen on the 
 individual fibre as the sheath of Henle. 
 
 The perineral and sympathetic nerves, the epithelium of the anus and the imme- 
 diately adjacent parts of the rectum and the epithelium of the vagina and urethra are 
 formed from the ectoderm, while the urinary and generative organs except the epithelium 
 of the urinary bladder and urethra are from the mesoderm. The whole of the vascular 
 and lymphatic systems and connective tissues are also from the mesoderm. 
 
 From the endoderm are to be found the rectum and epithelium of the urinary bladder. 
 
 The pudic nerve which supplies the perineum, the uro-genital and rectal tracts is both 
 motor and sensory, and derived from the second, third and fourth sacral nerves. It was 
 split mto many branches when the perineum was formed, which was the beginning of the 
 mammalian period. 
 
 One branch was for the purpose of supplying the uro-genital, the other the rectal 
 tract and while the nerve has been divided into two branches, their functions are iden- 
 tically the same and their impulses more or less the same, because the central nervous 
 system receives impulses from the two alike. Irritation of one, often produces irritation 
 of the other. Sometimes that of one dominates that of the other profoundly. This is 
 often demonstrated when irritation of the sphincter ani produces greater sexual excitement 
 than irritation of the sexual organs themselves, and vice versa. 
 
 The pudic nerve and its branches, sometimes vary slightly in their course, but it 
 usually passes forward in the outer wall of the ischio-rectal fossa, divides into the perineal 
 and dorsalis penis nerve and accompanies the pudic artery. Deaver states that nerve 
 terminals like blood vessels and lymphatics, are found in each muscle fibre, that each 
 tissue of the body may be brought under the control of the central nervous system, motor 
 and sensory fibers being alike influenced. 
 
 T op graphically the relation of the pudic nerve, its branches, lymphatic channels, 
 glands and blood vessels, have been materially changed to meet the requirements incident 
 to the passing from the cloacal to the mammalian type of the lower pelvis. Nerves travel 
 
 Page Thirty-Two 
 
under the endothelia, chiefly in bundles, sometimes in net work and all nerves, blood 
 vessels and lymphatics anastomose that they may be more perfect in function. 
 Among the many branches of the pudic nerve for consideration are the 
 
 1. 
 
 Sacro-coccygeal. 
 
 10. 
 
 Scrotal. 
 
 2. 
 
 Sacral (posterior division). 
 
 11. 
 
 Spermatic ducts. 
 
 3. 
 
 Coccygeal (posterior) . 
 
 12. 
 
 Uterine. 
 
 4. 
 
 Perineal. 
 
 13. 
 
 Vaginal. 
 
 5. 
 
 Penis-clitoris. 
 
 14. 
 
 Fallopian. 
 
 6. 
 
 Urethral. 
 
 15. 
 
 Ovarian, each of which is described 
 
 7. 
 
 Prostatic. 
 
 
 with the tissues which they inhibit, 
 
 8. 
 
 Rectal. 
 
 
 namely : 
 
 9. 
 
 Testicular. 
 
 
 
 1. 
 
 Integument. 
 
 7. 
 
 Glomus Coccygea. 
 
 2. 
 
 Fascia. 
 
 8. 
 
 Coccyx. 
 
 3. 
 
 Muscles. 
 
 9. 
 
 Cowper's glands. 
 
 4. 
 
 Organs. 
 
 10. 
 
 Bartholin glands. 
 
 5. 
 
 Blood vessels. 
 
 11. 
 
 Rectum. 
 
 6. 
 
 Lymphatics. 
 
 
 
 The multiplicity of nerve trunks and fibers supplying the perineal structures and 
 immediate associated organs and structures, must necessarily be the cause of a great 
 variety of symptoms. 
 
 Nerve centers and nerve fibers are distributed in the walls of all blood and lymph 
 vessels, especially in their deeper layers and are wound around them by the finer nerves. 
 The adventitia and muscularis contain two layers of these small fibers which penetrate the 
 intima. 
 
 Fig. 24. — The lumbar plexus (Deaver). 
 
 Ganglion cells are found in the superficial layers of the arteries of organs, but not 
 in their deeper layers. 
 
 Page Thirty-Three 
 
ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 p^. f Benign. 
 
 Diseases i a/t i- . 
 (^ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, length, course and location, or be entirely absent. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Neuromata may be congenital or acquired, primary or secondary, single or mul- 
 tiple, vary in size, shape, extent, location, remain quiescent, or continue to grow, but 
 probably never disappear spontaneously. 
 
 Sy^philis may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, vary in size, shape, location and degree, in one or more nerves or sheaths. 
 
 Tuberculosis may be primary or secondary, acute or chronic, single or multiple, vary 
 in location and degree, in any nerve or sheath. 
 
 Cysts may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, in the sheath or body of one or more nerves, contain blood, pus or serum 
 (usually serum), vary in size, location, rate of growth, remain stationary, continue to 
 grow, or disappear spontaneously, without loss of function when the sheath alone is 
 involved. 
 
 Fistulae may be congenital or acquired, single or multiple, primary or secondary, 
 remain open, close permanently, appear periodically, open upon the cutaneous struc- 
 tures, into the rectum, vagina, urethra, bladder, uterus or peritoneal cavity. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, single or multiple, in any nerve or sheath 
 (usually the sheath). 
 
 Sarcomata may be primary or secondary, single or multiple, in any nerve or sheath, 
 vary in size, location, rather of growth and usually in the sheath. 
 
 INJURIES. 
 
 Lacerations, incisions, punctures, may be the result of accident or design, primary or 
 secondary, single or multiple, vary in extent, location, irregular in form, partial or com- 
 plete, sharply defined, through the perineal body into the urethra, rectum, vagina, bladder 
 or peritoneal cavity. 
 
 Nerves are subject to injury cuid disease such as inflammation, acute and chronic, 
 simple and infectious, therefore must necessarily play one of the most important roles 
 in the category of symptoms such as are connected with the perineal body and its intimately 
 associated tissues and organs. The resistance of the nerves in this region to disease, would 
 seem greater because of the uro-genital and rectal tracts possessing a greater variety and 
 number of bacteria. 
 
 Page Thirty-Four 
 
This rule should obtain alike with blood vessels and lymphatics which are also the 
 distributors to muscle, fat, fascia, tendons, ligaments, periosteum, bone, cutaneous struc- 
 tures and organs. 
 
 Nerve sheaths probably have less resistance, but whether they can be inflamed to 
 any degree without more or less irritation to the nerves is uncertain. 
 
 Nerves like lymphatics and blood vessels undergo degenerative changes due to 
 senility, injury and disease. Then why should such changes not be earher in the perineal 
 region which is inhabited by so many infectious bacteria? 
 
 Is it not possible to have such changes appear locally and earlier in this region be- 
 cause of their presence? 
 
 If so, the manifestations would be atrophy, resulting in pain, discomfort, loss of 
 function or formation of concretions and new growth, such as are found to exist with 
 incontinence, calculi and prostatic hypertrophy. 
 
 SYMPTOMS. 
 
 Local. Tenderness is elicited by the sense of touch which may cause pain varying 
 in degree when a nerve is injured or pathologic. A nerve may be sensitive with or without 
 pressure at the point of lesion and though a nerve throughout its course may be sensitive 
 and painful when its distal libers are primarily involved, the pain and sensitiveness may be 
 limited to such an area or general nervous irritability may exist with severe pain, con- 
 stant or periodic in character throughout the pelvis and thighs, especially the genito-urinary 
 and rectal tracts. 
 
 Severe pain may be associated with, or followed by chill, headache, shock and per- 
 spiration. 
 
 Pag-e Thirty-Five 
 
CHAPTER VI. 
 
 LYMPHATICS. 
 ANATOMY. 
 
 N ATOMY of L^mph-Vesseh. The structure of the lymphatics is 
 very similar to that of the veins, the largest ones having the 
 three coats, mtima. media, and adventitia. The lymphatics aris- 
 ing from any network come together to form larger vessels, just as 
 do veins, but they are more uniform in caliber, while a lymph 
 vessel may be the same size as a vein at its origin, it will be much 
 smaller than the vein at its termination. 
 
 L))mphatics are numerous and generally distributed through- 
 out the perineal structures and organs, and their function probably 
 more important during the period of gestation. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 f Benign. 
 \ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, length, location and number of glands and channels or entirely absent. 
 
 D 
 
 iseases 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Lymphomala may be congenital or acquired, primary or secondary, single or mul- 
 tiple, in suF>erficial or deep structures, vary in size, shape, disappear, remain quiescent or 
 continue to enlarge. 
 
 Tuberculosis may be primary or secondary, acute or chronic, single or multiple, 
 vary in size, extent and location, remain quiescent, continue to grow, or disappear spon- 
 taneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, acute or chronic, 
 single or multiple, vary in size, extent and location, remain quiescent, continue to grow, 
 or disappear spontaneously. 
 
 C^sts may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, vary in size, shape and location, contain blood, pus or serum, rupture ex- 
 ternally, through the perineal tissues, internally into the rectum, vagina, urethra, bladder, 
 uterus, or peritoneal cavity. 
 
 Page Thirty-Six 
 
Fig. 25. — Lymphatics of the blad- 
 der in the new-born infant (Cuneo- 
 Marcille). 
 
 a. External iliac gland (external 
 chain). b. External iliac gland 
 (middle cham). c. External iliac 
 gland (internal chain), d. Deep in- 
 guinal glands. e. Left juxta-aortic 
 gland. /. Gland of the promontory. 
 §. Lateral vesical glands, h. Prae- 
 vesical glands. 
 
 Fig. 27. — Lymphatics of the pros- 
 tate (Cuneo and Marcille). 
 
 Fig. 26. — Iliopelvic glands (Cuneo- 
 and Marcille). 
 
 Fig. 28. — Scheme of the ileo-pelvic 
 glands (Cuneo and Marcille). 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, single or multiple, in any of the lym- 
 phatic structures within the perineal body. 
 
 Sarcomata may be primary or secondary, single or multiple (usually single) , in any 
 of the lymphatic structures of the perineal body. 
 
 INJURIES. 
 
 Incisions, Lacerations, Contusions, are acquired by accident or design, primary or 
 secondary, single or multiple, through the perineal body, rectum, or vagina, and vary in 
 degree. 
 
 Pag-e Thirty-Seven 
 
SYMPTOMS. 
 
 L})mphatic duds and channels supplying the perineum subject to anomalies, diseases 
 and injuries, offer symptoms which are manifested by enlargement, tenderness, redness, 
 pain, chill, temperature, nausea, headache and vomiting, and the presence of serum, Tblood 
 or pus, depending upon the degree of infection which may be acute or chronic, primary 
 or secondary. 
 
 Pain is not always localized because it may be reflected to adjacent healthy tissues 
 and may also be influenced by the degree of mfection. 
 
 Induration is a determining factor in the symptomatology of all structures even to 
 the slightest degree, but its importance increases with degree especially in lymphatic struc- 
 tures. 
 
 Rarely are the lymphatics of the inguinal or pelvic regions unpalpable. This en- 
 largement of the lymph nodes is associated with tenderness and pain which necessarily 
 causes nervous exhaustion and a symptom complex that space to describe would fill 
 volumes. Again referred pain or reflexes to the knee, heel and back are marked. The 
 necessary combined intoxication with a slight febrile rise has frequently associated head- 
 aches, general malaise, loss of appetite, and a general weakness, all of which causes in- 
 validism. Ulcers of the rectal wall may cause a marked lymphangitis and enlarged lymph 
 nodes. 
 
 Vascular influences upon the lymphatics are so slight in the begmning that they cannot 
 be recognized, but as the pulse rate increases and becomes uniformily rapid and feeble, 
 irregular or intermittent, from any cause, the lymph ducts and glands may justly be con- 
 sidered inactive. 
 
 // the temperature is high, lymphatic involvement is at once considered, though this 
 does not always obtain. 
 
 Tenderness is one of the first memifestations of glandular affections, and the degree 
 of pain increases with the amount of involvement until it becomes a distinct characteristic. 
 
 It may be local or general, acute or chronic, without local or general disturbances, 
 color, infection, or induration, but these are exceptions. Lymphatic glands being without 
 many sensory nerve fibers must necessarily be without much sensation, and for this 
 reason direct pressure upon the glands does not elicit much pain; it is the surrounding 
 structure, when involved, the nerve supply of which is greater, where pain is produced. 
 
 Normal glands are not sensitive to touch, but when infected, chill followed by 
 headache and febrile, disturbances may vary in degree and the temperature may be local 
 or general. Headache may, however, result from the slightest degree of infection, without 
 other symptoms even to the degree of severe cephalalgia, but this seldom occurs without 
 the more severe forms of infection. When they occur, nausea and vomiting and even shock 
 may be present and vary in degree. 
 
 Page Thirty-Eight 
 
CHAPTER VII. 
 
 GLOMUS COCCYGEA. 
 ANATOMY. 
 
 ISTORY. — A small reddish-yellow body situated about the tip 
 of the coccyx was first discovered by Luschka, 1 859, since which 
 time it has been known as Luschka's gland though it has long 
 since been discovered not to be a gland because it does not 
 possess glandular tissue. 
 
 Walker, 1904, suggested that this small body might be 
 a gland of internal secretion but it can not perform such a func- 
 tion if it does not possess glandular tissue. 
 
 Much has been written pertaining to the anatomy, func- 
 tion and pathology of this most interesting mass of cells without 
 revealing anything definite concerning its physiology. Until 
 such a discovery, continued interest will be manifested with this 
 in view. 
 
 It is a vascular plexus, a rete mirahele and not a gland. 
 The human coccygeal gland (so-called) or Glomus coccygea, 
 is a reduction product due to the decrease in size of the caudal region. In man it usually 
 is found as one ovoid body attached to the arteria sacrahs media, lying on or near the 
 ventral side of the distal end of the coccyx. Sometimes it is separated into several pieces 
 or distinct glomeruli. It is descended from the glomeruli caudales of the lower mammals. 
 In the adult human it is an arterio-venous plexus of varying complexity and size. 
 The plexus takes the form of a nodule inclosed in a fibrous sheath. The vessels com- 
 posing it may be divided into the afferent artery, the efferent vein and the connecting 
 anastomosing channels. Although sparsely innervated by the sympathetic it has no 
 special relation thereto. Besides the sheath and the vascular channels, the principal his- 
 tological element which forms a considerable part of its mass, are the endotheloid cells, 
 which are numerous and appear to be derived from the transformed muscle cells of the 
 arterial walls and which remain intim.ately associated with the walls of the vascular 
 channels. Other than these, there are no structural elements entering into the make-up 
 of this organ. 
 
 Non-striated muscle cells are distributed throughout the stroma. 
 It is not known what function the glomus serves in the human physiology. 
 Phylogeneticall]) the human Glomus coccygea is the descendant of the numerous 
 Glomeruli caudales of the lower mammals, which, due to the shortening of the tail, have 
 become condensed into the usually single and much larger Glomus coccygea of man. 
 
 The s})mpathetic nerve trunk accompanying the A. sacralis media is often enmeshed 
 in the substance of the glomus, but this is purely a mechanical relation as the innervation 
 of the tissues of the glomus is not in such cases increased. However, single and clusters 
 of "nerve end" bodies somewhat resembling Paccinian bodies, are found in juxtaposition 
 to the glomus. 
 
 The glomus occurs as one or man^ nodules lying near the anterior aspect of the 
 tip of the coccyx. If often appears pedunculate owing to the elongation of the artery 
 and vein connecting it with the median sacral vessels. 
 
 Page Thirty-Nine 
 
The glomus develops within a mass of embryonic cells, by the branching of the 
 median artery and vein, and first appears caudad of the actual tip of the last coccygeal 
 
 segmen^. ^^^ ^^^ ^^^ Glomeruli Caudales exist as a chain of knots extending fronvthe 8th 
 or the 9th caudal vertebra, caudad, to the tip of the tail increasmg m size backward, 
 the largest glomus occurring at the tip of the tail. The anatomical and histological struc- 
 ture is similar to that of man. • i -ru 
 
 In the Macacus monkey as many as ten glomeruli occur in one animal. 1 hey are 
 all closely attached to the A. sacralis (caudalis) media and increase in size from the 
 
 Fig. 29.— Tail of Macacus Monkey, showing a Glomus at each bony segment (Schumacher). 
 
 anterior caudal vertebrae caudad to the tip of the tail. They usually occur one in each 
 segment They constitute a series of segmental plexuses inserted between the artery and 
 the vein and afford a direct connection between the two without the mediation of capil- 
 laries. The largest of them is only a few millimeters in length. 
 Glomerulus cocc^geus. 
 
 Glomeruli caudales. . r i i i i . l 
 
 Among mammals the glomeruli occur in that section of the tail where the vertebrae 
 lose their ventral arches but still retain the haemal arches. 
 
 Page Forty 
 
Glomeruli have been found in Beginning at the 
 
 Macacus cynomolgus — common Macacus. 
 Macacus rhesus 
 
 Felis catus cat 8th caudal vertebra 
 
 Canis vulpes fox 
 
 Canis familiaris dog 8th to 9th caudal vertebra 
 
 Lutra vulgaris otter 1 2th caudal vertebra 
 
 Scuirus vulgaris squirrel 1 0th caudal vertebra 
 
 Lepus canniculus rabbit 
 
 Mus rattus rat, mouse 1 4th caudal vertebra 
 
 Sus scropa pig 
 
 Bos taurus ox 
 
 Equus caballus horse 
 
 Cynocephalus hamadryas Pavin. 
 
 DESCRIPTION OF FIGURES. 
 S. V. Schumacher-GIomus Coccygea and Glomeri Caudales. 
 
 1. Section of Gl. coccygeum of executed criminal. A., anastomosing vessels with epitheloid wall. 
 M., muscle bundle entering Glomus. S., con. tissue stroma. V., outgoing vein. X70. 
 
 2. Closed anast. vessel of Gl. c. of 3-year-old child. E., endothel EZ. epitheloid cells. S., 
 stroma. X 460. 
 
 3. Anast. vessels of Gl. c. executed g P. perimysium internum inclosing Epitheloid cells. E. S. 
 stroma. X 460. 
 
 4. Transition of artery with anast. vessel in Gl. c. new born babe. M., nonstriated muscles and 
 transition stages into epitheloid cells eZ. E., endothil X460. 
 
 5. Transition of anast. vessels into vein of Gl. c. 22-year-old man, shows that epitheloid cells 
 disappear as vein is approached X460. 
 
 6. Same as 5 from 5-year-old child X460. 
 
 7. Same as 5 and 6 from executed woman X460. 
 
 8. Three nerve end bodies lying near Gl. c. lumen foetus 34 cm. long. X460. 
 
 9. Same as 8 from new born. L., lammellated bodies. K., capsule. G., location of Gl. c. X 170. 
 
 10. Anlage of Gl. c. human emb. 52 cm. long. A., art. sacralis media showing thickening of 
 media. M., cells of media becoming epitheloid. V., vein. E., endothel. X460. 
 
 11. Section Gl. caudale Cynocephalus hamadryas. A. C. branch of art. cm. entering Gl. c. 
 
 12. Artery of Gl. c. of dog. Ac. wall of art caudalis media, showing muscular layers. X70. 
 
 13. Section of anastometic branch of vessel of Gl. c. of Cynocephalus hamadryas. E., endothel. 
 I h. inner longit. muscle. Z. M., circular muscle. A 1., outer long muscle. S., stroma. X460. 
 
 14. Section anastimolic vessel of dog. M., epitheloid muscle cells. E., endothel. S., stroma. X460. 
 
 15. Section anaslomol. vessel Gl. c. executed woman. E., endothel. E z. Epitheloid cells. S., 
 stroma. X460. 
 
 16. Two small Gl. c. 55-year-old woman, artery red, vein blue, anastomotic vessels violet. X57. 
 
 17. Vessels of tail of Macacus rhesus ventral vein. A c m., arteria caudalis media. V c m.. 
 Vena caudalis media. V c 1. Vena caudalis media. A v.. Anastomotic veins between V 
 media and V lateralis. G., Glomeruli caudales. 
 
 18. Vessels from distal section tail of Macacus rhesus. G., large Glomerulus. K., Small one. 
 1. J. H. Jakobsson. Glomus coccygea. X40. Sagittal section embryo 1.8 cm. long. 
 
 ar. arterio sacralis media. 
 
 bl. glomus. 
 
 bp. vascular papila. 
 
 c. central canal. 
 
 ccg. glomus coccygea. 
 ch. chorda dorsalis. 
 
 d. gut. 
 
 ep. epidermis. 
 
 ft. fllum terminale. 
 
 kaps. capsule of stroma. 
 
 m. non-striated muscle. 
 
 mv. medullary tube. 
 
 n. nerve. 
 
 par. cartilage parenchyma. 
 
 str. stroma. 
 
 su. caudal appendage. 
 
 sy. sympathetic anlage. • 
 
 tb. terminal vesicle of nerve tube. 
 
 Paae Forty-One 
 
-:y 
 
 
 
 <;»Q>'b 
 
 
 >. 
 
 
 /I 
 
 5^ 
 
 '.^■^.. 
 
 
 -r-^ ;-^r 
 
 
 Fig. 30. 
 
 Page Forty-Two 
 

 
 ,;-.-i>;^ 
 
 f3i«* 
 
 
 Fig. 31. 
 
 Fig. 32. 
 
 Page Forty-Three 
 
■1 \ .*' ' 
 
 
 Fig. 33. 
 
 Fig. 34. 
 
 
 Fig. 35. 
 
 Page Forty-Four 
 
2. X20. Sagittal section embryo 7.5 cm. long 
 
 3. Xl5. Sagittal section embryo 1.5 cm. long 
 
 4. X 15. Sagittal section embryo 6 cm. long. 
 
 5. X65. Transverse section embryo 8.1 cm. long. 
 
 6. X90. Section of Glomus coccygea. 
 
 7. X3(X). Sagittal section of Glomus and med. tube. 
 
 8. X300. Transverse section of Glomus. 
 
 9. X 55. Transverse section of Glomus of adult. 
 10. X350. Transverse section of Glomus of adult. 
 
 Page Forty-Five 
 
Fig. I. 
 
 Fig- 3 
 
 Fig. 36. 
 
 Page Forty-Six 
 
7*i?v 
 
 Fig. 4. 
 
 Fig. 5- 
 
 -56 
 
 Fig. 37. 
 
 Page Foi-ty-Seven 
 
Fig- 7- 
 
 
 
 ^vi^'<u 
 
 
 V 
 
 Fig. 8. 
 
 ^-^i/} 
 
 Fis. 38. 
 
 Page Forty-Eight 
 
Fig. 39. 
 
 Page Forty-Nine 
 
Anomalies may be in number when several distinct bodies exist in the same person, 
 when one is larger or smaller than usual, or when it is not situated immediately over and 
 in front of the tip of the coccyx. 
 
 It may be entirely absent but this, however, is only a conjecture based ilpon the 
 knowledge that other bodies are congenitally absent. 
 
 ETIOLOGY. 
 
 Etiology. — Investigation pertaining to the function, pathology and symptoms of the 
 Glomus is so very meagre, that it is difficult to draw emy very decided conclusions, but 
 with the existence of its irregularities an attempt will be made to give it greater consid- 
 eration in the role of symptomatology. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 Benign. 
 
 Diseases 
 
 Malignant. 
 Injuries. 
 
 DISEASES. 
 
 Benign, Malignant. 
 BENIGN. 
 
 Benign diseases may be of almost any variety and assume indefinite proportions. 
 Those most common are simple hypertrophy, lymphoma, adenoma, fibroma, tuberculosis, 
 syphilis, cysts and injury, either one of which except tuberculosis may be congenital or 
 acquired. 
 
 Simple h'^perlroph'^ due to some form of infection may be congenital or acquired, 
 primary or secondary, acute or chronic, vary in size and location, undergo cystic de- 
 generation or remain a solid growth. 
 
 Lymphomata may be congenital or acquired, primary or secondary, acute or chronic, 
 single or multiple, varying in size, shape and location. 
 
 Adenomata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Fibromata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Tuberculosis may be primary or secondary, acute or chronic, vary in extent, involve 
 other structures, subside, continue to destruction or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, acute or chronic, 
 remain quiescent, continue to grow, or disappear spontaneously. 
 
 Cysts quite frequently originate in the glomus and are of several varieties, such as 
 echinoccoccal, dermoid and hygroma, or they may contain blood, pus or serum, either 
 form of which may exist in the glomus primarily or secondarily from the articulating sur- 
 faces of the bony segments, or the soft structures overlying the coccyx. 
 
 Cystic degeneration may also occur in zmy neoplasms that may affect the glomus. 
 They may be congenital or acquired, acute or chronic, single or multiple, rupture into 
 and through the posterior soft structures, into the rectum, vagina, urethra, bladder, uterus 
 or peritoneal cavity. 
 
 Fistulae may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, open through the cutaneous structures into the rectum, its natural out- 
 let, urethra, bladder, vagina, uterus, perineum or peritoneal cavity. 
 
 Page Fifty 
 
MALIGNANT. 
 
 Carcmomata may be primary or secondary, more often primary, because the glomus 
 is so generally exposed when upon the tip of the coccyx, its normal position, where it 
 may become irritated by the contents of the rectum, or injury of any character. 
 
 Sarcomata may be primary or secondary (usually primary) and at once invade 
 any one or all of the surrounding soft or bony structures. 
 
 INJURIES. 
 
 Injuries to the glomus are contusions from within and without the rectum and many 
 times trans-vagino-rectal by the head of the child during delivery, especially when the 
 coccyx is ankylosed and pointing forward. This is probably the most frequent source 
 of injury, though it may be by design or other forms of trauma. 
 
 SYMPTOMS. 
 
 Being the origin of many varieties of pathology, and because it is so enriched with 
 nerve libers and highly sensitized tissues immediately overlying the coccyx, and because 
 of frequent pain and tenderness over the coccyx, the glomus must be considered symp- 
 tomatically. 
 
 It is a preeminent factor in causing symptoms associated with the perineum, coccyx, 
 uro-genital and rectal tracts, and it may be of far greater importance than the coccyx in 
 the production of pain or irritability, whether local or general, in character, and intensity 
 is increased with the character cuid rate of growth. 
 
 A diseased or injured glomus should always be suspected with the presence of rectal 
 pain, irritation, or tenesmus which should be the signal for a thorough examination of the 
 glomus. 
 
 SURGERY OF THE GLOMUS COCCYGEA. 
 
 With the evidence at hand there should be no reason for doubting the propriety of 
 placing the glomus in the surgical category, even when it is not perceptibly enlarged. 
 Especially would this statement be reasonable, if the glomus be for internal secretion. 
 Until a time when its function is discovered, but little attention will be given to it in any 
 way whatever, except so far as it may become involved with, or be the origin of growths 
 serious in their consequences. 
 
 History. — There is no specific history pertaining to the surgery of the glomus, 
 probably because it has not been dealt with in such a manner. There is, however, an 
 occasional report of a case, where neoplasms of various kinds originating in the glomus, 
 have been dealt with surgically, and then only when it had assumed a considerable size. 
 
 Indications for resorting to surgical measures when the glomus is slightly enlarged, 
 are probably infection or when it contains blood, pus or serum, or at the beginning of 
 enlargement due to any cause. Its destruction even when normal should be done when- 
 ever the coccyx or any of its associated tissues are removed, for any cause, especially 
 when done for the cure or relief of malignant neoplasms. 
 
 Extirpation of the glomus alone may be necessary when it becomes a source of 
 annoyance by hypertrophy, inflammation or degeneration from any cause. 
 
 Technique.— The removal of the glomus when of ordinary size is best accomplished 
 through a posterior incision three inches in length, in the median line directly over the 
 lower end of the coccyx. 
 
 Because of the various positions which it may occupy, number of bodies and their 
 minuteness, the removal of several segments of the coccyx and the tissues immediately 
 overlying them may be necessary to eliminate them. 
 
 Great care should be exercised to avoid injury such as partial or complete perfora- 
 tion of the wall of the rectum. 
 
 The method of anesthesia, dealing with the wound and the after-treatment is the 
 same as that pertaining to coccygectomy. 
 
 Page Fifty-One 
 
BIBLIOGRAPHY. 
 
 Luschka, H.: Der Hirnanhang und die Steissdriise des Menschen. Berlin, 1860. Also, Die Steiss- 
 druse, etc. Leipzig, 1860, and de ranat. et Physiol, etc., Paris, V, 269-271, 1868. 
 
 Arnold, J.: Ein Beitrag zur der sogenannten Steissdriise. Virch. Arch., Bd. 32, 1865; als*}- Cen- 
 talblat. f. d. med. IVissensch., Berlin, II, 881-883, 1864, and Arch. f. path, anat., etc., Berlin, XXXII, 
 293-331, I pi. 1865. 
 
 Senftleben., Deutsche klimk-< 174, 1865. 
 
 Krause, W. : Beitrag zur Neurologie der oberen Extremitat., Leipz. und Heidi., 1865; also Ztschr. 
 f. rat. med., 1866. 
 
 Krause, W. : Uber die Glomeruli caudales der Saugetiere. Virch. Arch., Bd. 39, 1867, Banks, Glas- 
 gow, M. J., 3, s, II, I, 1867. 
 
 Arnold, Arch. f. path, anat., etc., Berlin, XXXIX, 499-512, 2 pi. 1867. 
 
 Macallister, Brit. M. J., Lond., I, 125, 1868. 
 
 Sertoli, Arch.f. path, anat., etc., Berlin, XLII, 370-381, I, pi. 1868. 
 
 Sertoli, E.: Uber die Struktur der Steissdiise des Menschen. Virch. Arch., Bd. 42, 1868. 
 
 Macdonald, Glasgow M. J., 3, s, II, 171-73, 1867-68. 
 
 Macdonald: La glande coccygienne de I'homme. jour, el VAnat. el de la Physiol., V, 5, 1868. 
 
 Ecker: Glabella Coccygea. Arch. f. Anlhropol. Brschwg., XII, 129-155, 1879-80. 
 
 Waldeyer: Die Entwicklung der Carcione. Virch. Arch., Bd. 55, 1872. 
 
 Meyer, G. : Zur Anatomie der Steissdriise. Zeitschr. f. ral. med., Bd. 28, 1886. 
 
 Hoyer, H. : Uber unmittelbare Einmundung kleinsler Artenen in Gefassaste venosen Charakters. 
 Arch. f. mikr. Anal., Bd. 13, 1887. 
 
 Schaffer, J.: Zur Kenntnis der glatten Muskelsellen, insbesondere ihrer Verbindung. Zeitschr. 
 f. wissensch. Zool., Bd. 66, 1899. 
 
 Jackson: Upsal. Lalfaref, Forh. N. F ., Ill, 324, 1897-98, mikr. Anat. Bd. 
 
 Eberth: Von den Blutegefassen. Striclfcrs Ccwebelehre, I, 1871. 
 
 Von Ebner, V.: Uber klappenartige Vorrichlungenn in den .^rterien der Schwellkorper. Anat. 
 Anz. Erganzungsh. z., Bd., 18, 1900. 
 
 Jakobsson, H.: Beitrag zur Kenntnis der fcetalen Enl%sicklung der Steissdriise. Arch. /. mi'^r. Anal., 
 Bd. 53, 1899. 
 
 Grosser, O.: Zur Anatomie und Enlwicklungeschichte des Gefass-svstemes der Chiropteren. Anal. 
 Helle, H. 55, 1901. 
 
 Mayer, S. : Die Muscularisierung der capillaren Blutgefaisse. Anal. Anz., Bd. 21, 1902. 
 
 Mayer, S.: Uber arterio-venose Anastomosen an den Extremitatenenden beim Menschen and den 
 krallentragenden Saugetieren. Arch. f. mil^r. Anal., Bd. 60, 1912. 
 
 Vastarini-Cresi, G.: Communicazioni tra le arterie e le vene (anastomosi artere-venose) nei 
 mammiferi. Nola preliminare. Monit. zool. Ilal., V, 13, 1902. 
 
 Unger, E. und Baugach, Th.: Zur Kenntnis der fovea and fistula sarococcygea s. caudalis und der 
 Ent^vicklung des ligamentum caudale beim Menschen. Arch. f. mil^r. Anat., Bd. 61, 1903. 
 
 Unger, E. und Brugach: Le anastomosi arlere-venose nell 'uomo e nei mammiferi Studio anatomo- 
 istologico. Neapel. Sangiovanni, 1903. 
 
 Von Hleb-Kosznanska, Marie: Peritheliom der Luschkeschen Steissdriise in Kindesalter. Zieglers 
 Beilrag, Bd. 35, 1904. 
 
 Walker, Thomson: Uber die menschliche Steissdriise. Arch. f. mi^r. Anat., Bd. 64, 1904 
 
 Von Schumacher, S.: Uber die Nerven des Schwanzes der Saugetiere und des Menschen, mit 
 besonderer Beriicksichtigung des sympathischen Grenzstranges. Sitzungsber. d. }(. Al^ad. d. IViss, Wein, 
 math-nal. Kl. Bd. 114, Abt. Ill, 1905. 
 
 Stoerk, O.: Uber die Chromreaktion der Glandula coccygea und die Bezlehungen dieser Driise 
 zum Nervus sympathicus. Arch. f. mi\r. Anal., Bd. 69, 1906. 
 
 Index Catalogue Surg. Gen'!. Library, Vol. XVIII, p. 369-370. Tonsils (Pharyngeal). 
 
 Page Fifty-Two 
 
CHAPTER VIII. 
 
 THE COCCYX. 
 ANATOMY. 
 
 Fig. 40. 
 
 Pag-e Fifty-Three 
 
Glomus Coccygea. 
 
 Fig. 41. 
 
 THE many causes assigned lor diseases of the rectum and 
 prostate gland, there are perhaps none less frequently mentioned 
 than deformity and diseases of the coccyx. It has been demon- 
 strated in a number of cases of rectal, prostatic, bladder and 
 urethral conditions, of a more or less serious nature, that the 
 coccyx was directly or mdircctly responsible for their existence, 
 because of its close proximity to the rectal and genitourinary 
 channels. 
 
 1 he possibility of one alone being affected must always 
 be questioned. A review of their anatomical relations, especially 
 those of their nervous and lymphatic structures, is essentially to 
 prove the truthfulness of this assertion. While much has been 
 said about the coccyx being a causative factor in rectal symp- 
 toms, nothing has been said about it being the cause of those 
 diseases pertaining to the genito-urinary system, or those of 
 
 the genito-urinary being the cause of rectal symptoms. 
 
 (Evolution.) 
 
 Evolutionary changes of the pelvis and its contents from quadrupedal to bipedal have 
 not in many instances been altogether perfect, especially with the caudal extremity. 
 
 The coccyx in man is the caudal bony extremity composed normally of four tapering 
 segments extending do\\Tiward from the sacrum. Each joint is more or less movable 
 and the tip slightly curved forward, vanes somewhat in length and diameters, and covered 
 with dense periosteum. 
 
 Cocc^geus muscle is triangular in shape and supported externally by the sacro-sciatic 
 ligament, with which it blends. It arises from the spine of the ischium, immediately above 
 
 Page Fifty-Four 
 
Fig. 42. 
 
 the origin of the levator ani muscle, and inserted into the side of the coccjoc, the lateral 
 sacro-coccygeal ligament and the last two sacral vertebrae. 
 
 Nerve Supply is from fourth and fifth sacral and coccygeal nerves. 
 
 ligaments of th 
 
 le Pelvic Floor. 
 
 1. 
 2. 
 3. 
 
 Anterior communicating. 
 Ilio Lumbar. 
 Anterior sacro iliac. 
 
 4. 
 
 Greater sacro sciatic. 
 
 5. 
 6. 
 
 Lesser sacro sciatic. 
 
 Y Ligament of Bigelow^. 
 
 Anterior communicating ligament is a wide band of longitudinal fibers extending from 
 the front of the axis vertebra to the front of the upper segment of the sacrum and grad- 
 ually increases in width from above downward. 
 
 Ilio lumbar ligament is a thickened lacunia of the fasciae lumborum extending from 
 the tip of the transverse process of the last lumbar vertebra almost horizontally to the 
 inner lip of the ihac crest. 
 
 Greater sacro sciatic ligament is triangular in shape attached to the posterior inferia 
 spine of the ilium, besides being attached by the first segment of the coccyx is attached 
 to the third, fourth and fifth segments of the sacrum and inner side of the ischial tuber- 
 osity below the groove for the tendon of the obturator muscle. 
 
 Lesser sacro sciatic ligament lies in front under the great sacro sciatic ligament 
 triangular in shape, attached to the last two segments of the sacrum and the first segment 
 of the coccyx and ischial spine. It is intimately associated with the coccygeus muscle and 
 regarded as being derived from it by fibrous transformation of the muscle fasciculi. 
 
 Ilio Femoral or the Y ligament of Bigelow is a triangular set of fibers attached to the 
 lower part of the anterior inferior iliac spine and the rim of the acetabulum and its base 
 to the anterior intertrochanteric line of the femur. 
 
 Page Fifty-Five 
 
Nerves. The posterior primary division of the sacral nerves with the exception of that 
 of the fifth according to Piersol, emerges from the vertebral canal through the posterior 
 sacral foramina. 7 he first, second and third pass outward under cover of the multifides 
 spinae and divide into external and internal branches, while the external brcuicttes unite 
 over the upper part of the sacrum with a similar branch of the fifth lumbar and with the 
 fourth sacral nerve, form a series of loops called the posterior sacral plexus. 
 
 The posterior primary division of the coccygeal nerve does not divide into internal and 
 external branches, but unites with the fourth and fifth sacral to form the posterior sacral 
 coccygeal nerves, the fibers of which pierce the great sacro sciatic ligament and 
 are given off to be distributed to the integument in the coccygeal region, after 
 having passed along the margin of the coccyx. It is thus observed that these 
 nerves are involved with any traumatic or pathologic lesions of the coccyx and that any 
 such lesions should be eliminated before further attempt to differentiate any cause of pain 
 that might be suspected or associated with them. 
 
 BIBLIOGRAPHY. 
 
 ANATOMY OF COCCYX. 
 
 1 . Normal. 
 
 2. Abnormal. 
 
 Analom'^. 
 
 Trefurt, J. H. C. Ueber die Anchylose des Steissbeir.s; deren Einfluss auf die dadurch angezeigte 
 Kunslhiilfe. Gottingen, 1836. 
 
 Summers. Projecting Coccyx. Am. J. Sc. Phila., ns. xix, 400, 1850. 
 
 Perrin, E. Die la glande coccygienne et des tumeurs dent elle peut etre le siege. Strasbourg, 1860. 
 
 Krause, W. Ztschr. f. rat. Med., Leipzig und Heidelberg, 3, R. 293-299, 1861. 
 
 Meyer, G. Zlschr. f. rai. Med., Leipzig und Heidelberg, 3, R, xxviii, 135-144, 1 pi. 1866. 
 
 Banks, W. M. Clasgon> M. j ., 3, s, ii, 1-16, 1 pi., 1867. 
 
 Sertoli, E. Ceniralb. f. d. med. IVissensch., Berlin, v. 449, 1867. 
 
 Brezzi, D. Cicr. di. med. mil. Firenze, xv, 3-9, 1867. 
 
 Monod. Une piece anatomique provenent d'un enfant ne avec une queue. Bull. Soc. d'anthrop., 
 Paris, 2, s, IV, 407-411, 1869. 
 
 Philipeaux, J. M. Experieces sur la glande de croupion faite sur le canard. Comp,. rend. Soc. 
 biol, Paris, 5, s, iv, 49-52. 1874. 
 
 Sayre. Congenital Malformation of Coccyx, Operation. Med. Rec, New York, ix, 242, 1874. 
 
 Vinogradof, K. Malformation in the Region of the Coccyx. /. J/pa normal i patrol, gistologii, 
 S. Petersburg, x, 506-524, 1876. 
 
 Ecker, A. Ueber gewisse Ueberbleibsel embryonaler Formen in der Steissbeingegend beim un- 
 geborenen, neugeborenen und erwachsenen Menschen. Arch. f. Anihrop., Braunschweig, xi, 281-284, 
 1878-9. 
 
 Bastian. Ueber geschwantzte Menschen im indischen Archipel. Verhandl. d. Berl. Cesellsch. 
 f. Anthrop.. BerUn. 412, 1879. 
 
 Bartels, M. Arch. f. Anthrop., Braunschweig, xiii, 1-41, 1 pi. 1880-81. 
 
 MacDonald, A. Backward Projection of Coccyx with Anchylosis of Sacro-Coccygeal Joint. 
 Edinh. M. ]., xxxi, 318-320, 1885-86. 
 
 Gruber, W. Ein seltener Curvator Coccygis Accessorius bei gewissen Menschen Homolog deni 
 constanten Depressor Candae Longus bei gewissen Saugethieren vorher nicht gesehen. Arch. f. path. 
 Anal, Berlin, cix. 1-4, 1887. 
 
 Jacobi, F. H. Arch. f. Anal. u. EntiDcklngsgesch., Leipzig, 353-364, 1888. 
 
 Fry, H. D. The Function of the Coccyx in the Mechanism of Labor. Am. J. Ohst., New York, 
 xxi, 1257-1265, 1888. 
 
 Farr, F. W. Case of Rigid Coccyx. Guy's Hosp. Gaz., London, ns, iii, 173, 1889. 
 
 Torngren, A. Ett fall af kongenitalt coccyxkystom. Klns^a lal( salls}( handl., Helsingsfors, xxxii, 
 388-394, 1 pi., 1890. 
 
 Fere, C. Une anomalie du coccyx chez un epileptique. A^. inconog. de la Salpetriere, Paris, v. 
 89-91, 1 phot. 1892. 
 
 Biancha. Sulla interoretazione morfologica della prima vertebra coccigea nell'uomo. R. Accad. 
 D. fisioerit. in Siena, Proc-verb, 9, 1895. 
 
 Hlrschberg, R. Un cas se mal perforant coccygien. Rev. neurol, Paris xii, 792, 1904. 
 Lindquist, S. Some Remarks on Obstetrical Coccyx Ankylosis. 
 
 Page Pifty-Six 
 
Fig. 43. — Posterior view of coccyx of Chimpanzee 
 (Pat Roony the First, Cincinnati Zoo). 
 
 Nord. Tidsskr. f. Terpi, Kobenh., vii, 103, 129, 1908-9. 
 
 Sappy. On the Lymphatic System. A Volume Frequently Referred to and Freely Quoted. 
 
 Hyrtl. Sitzungsbericht der Wiener Accad. Moth, watern. Kl. Bd. liii. 
 
 Rosenberg. Morphol. Jahrbuch, Bd. L. 
 
 Page Fifty-Seven 
 
Fig. 44. — Lateral View of the Coccyx of Chimpanzee (Pat 
 Roony the First, Cincinnati Zoo). 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 r Anomalies. 
 Diseases < Benign. 
 
 [^ Malignant. 
 
 I Fractures. 
 
 Injuries - Ankylosis. 
 
 f Luxations. 
 
 Page Fifty-Eight 
 
ANOMALIES. 
 
 Anterior v.ev 
 
 Antfirio Postener Curve 
 LiUra^l view 
 
 Personal Cases of 
 Abnormalities. 
 (Ayers Arrist.) 
 
 Anterior viev 
 
 tjlrcmi Antciior Lutve 
 
 llm Sei^mciiUd. Coccyx. 
 
 A-ntcrior viev 
 
 An Attcmpl. J>1 Seimcntalio 
 
 Fig. 45. 
 
 Anomalies of the coccyx being of such a diversity, especially in shape, must play a 
 certain role in general symptomology. Any variation from normal to total absence must 
 be determined before considering the subject in a general way. This may be done by 
 palpation with the finger except in a few instances where segments are wanting, then it is 
 difficult to define the hmitations of the lower portion of the sacrum. The sacrococcygeal 
 line may never be determined with the existence of such a condition. 
 
 Congenital def 
 
 ects of the coccyx 
 
 1. 
 
 Length. 
 
 2. 
 
 Diameter. 
 
 
 Shape. 
 
 4. 
 
 Flexibility. 
 
 D. 
 
 Ankylosis. 
 
 6. 
 
 Absence. 
 
 Paee Fifty-Nine 
 
Length may vary from long to short. When long it may be due to increased length 
 of the segments or sacrum, or both. Sometimes though infrequent, the segments may be 
 increased to six or more in number. 
 
 Excessive length more frequently causes inconveniences than excessive shorteess, which 
 is due to the segments being diminished in length or number. 
 
 Diameters of the segments of the coccyx vary considerably from large to small. 
 Any one or all may be excessive in the lateral or anterior-posterior measurements. 
 
 Shape may be regular or irregular, smooth or rough, sharp or blunt on the edges, 
 or at the point. 
 
 Flexibility varies in degree and direction. It may be unilateral, bilateral, anterior, 
 posterior or movable in all directions, and occasionally displaced downward by traction, 
 a type referred to as floating coccyx. 
 
 Ankylosis may be partial or complete, straight, angular or curved laterally, anterior 
 or posteriorly. 
 
 Absence. Several instances have been cited where the coccyx was congenitally 
 Wcuiting in part or its entirety, thus indicating that it is on the road to disappearance and 
 that it is not an anatomic or physiologic necessity. 
 
 Anomalies. 
 
 Post. Ne-w York M. /.. xxx, 517, 1879. 
 Imlach. Brh. Gpnec. /., London, i, 319, 1885. 
 Whitehead. Lancet, London, ii, I 12, 1886. 
 Odell. Lancet, London, 1088, 1887. 
 Evans. Phila. Med. Times, xviii, 35, 1887-88. 
 Dunn. Cu^'s Hosp. Rep., London, xxx, 191, 1889. 
 Darrach. Boston M. & S. J., xxviii, 36, 1893. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 Neoplasms niop be congenital or acquired, of many kinds and varieties, primary or 
 secondary, vary in size, shape, number cind location, develop in any direction, involve by 
 extension any of the soft or bony structures of the lower pelvis and perineum. 
 
 History. 
 
 Zeddler, 1 834, reported a case of steatoma of the coccyx, the first of its kind 
 to be recorded. 
 
 Heschel, 1 860, reported simple hypertrophy, and Clemantais, 1 883, one of simple 
 growth with fistulae. Erass, 1883, a congenital tumor, Jewett, 1884, an angioma. 
 Barber, 1910, a tumor in the coccygeal region of an infant six months old, and Bod, 1910, 
 a ccLse of hernia of the spinal cord in the coccygeal region operated upon by Zenenk's 
 method. 
 
 BENIGN. 
 
 Benign diseases of the coccyx may be congenital or acquired, primary or secondary, 
 acute or chronic, remain small or assume a considerable size, of many varieties, and asso- 
 ciated with angioma of the spinal cord and various other types of new growth to com- 
 plicate their differentiation. 
 
 Coccygitis may be the result of injury or disease of the coccyx, tissues overlying 
 or indirectly associated with the coccyx. 
 
 Chondromata may be congenital or acquired, primary or secondary, single, vary in 
 size, shape, location, usually in the lower segments, slow or rapid in growth, remain 
 quiescent, increase in size or disappear spontaneously, though this seldom occurs. 
 
 Osteomata may be congenital or acquired, primary or secondary, single or multiple, 
 originate in any one or more of the segments or their periosteum and vary in size. The 
 
 Page Sixty 
 
secondary growths extend from the sacrum and the primary growth of the coccyx may 
 in turn become secondary in the sacrum. 
 
 Degeneration of one or all segments of the coccyx may be in the form of caries or 
 necrosis due to tuberculosis (Caubet) syphilis, osteomolitis (Monnier) or injury. Kuss, 
 1909, reports a case of retro-anal fistula due to tuberculosis of the segments of the coccyx. 
 Such degeneration may be secondary to disease of the sacrum or the soft tissues im- 
 mediately surrounding the coccyx. 
 
 Tubercular degeneration may be acute or chronic, mvolve one or more segments, 
 primary or secondary rupture into the rectal cavity, externally through the cutaneous struc- 
 tures, or extend into the sacrum and rupture in any direction. 
 
 Syphilitic degeneration may be congenital or acquired, primary or secondary, acute 
 or chronic, occasionally destroy the coccyx without manifestations elsewhere, or the over- 
 lying soft structures posteriorly, laterally or anteriorly into the rectal cavity. 
 
 Osteomyelitic degeneration rarely occurs in the coccyx, but when it does occur, it 
 is subject to the same rules concerning the destruction of its overlying soft structures. 
 It, too, may be primary or secondary to the sacrum, which it usually involves when primary. 
 
 Etiology. 
 
 Cummenus, A. H. Misc. Acad. net. curios, 1672, Lips, el Francof, iii, 1672, 209. 
 
 Faye, F. C. Norsk- Mag. f. Laegevidensk, Christiana, ii, 591-593, 1848. 
 
 Boyer, L. Rev. med. chir., Paris, xi, 246, 1852. 
 
 Cleaveland, C. H. New Jersey M. Reporter, Burlington, vi, 171-1853. 
 
 Hersher, D. W. Boston M. & S. /., liv, 516, 1856. 
 
 Roeser. Luxalio ossis coccygis. Memorabillien, Beilbr. 1856, i, No. 18, 1, also (Abstr.) Noliz. 
 f. prakl. Aerzte, etc., Berlin, 1858, n, F. i, 415, also Trans. Brit. & For. M. Chir. R., London, xx, 
 544, 1857. 
 
 Uhde, C. W. F. Fraclura. Deutsche Klinik, Berlin, ix, 108, 1857. 
 
 Bonnefont. Luxation. Union Med., Paris, 2, s, i. 136-138, 1859. 
 
 Mouret. Rec. de. mem. de. med. mil., 3, s, i, 350-376, 1859. 
 
 Faye, F. C. Norsk J^og. f. Laegevidensk, Christiana, xv, 137-146, 1861. 
 
 Barrt de la Faille, J. Nederl. Tijdschr. v. Heel-en Verlosk, Utrecht, xxi, 537-541, 1861-2. 
 
 Sky, Lancet, London, ii, 326, 1861. 
 
 Belts. Memorabil., Heiibronn, x, 58, 1865. 
 
 Warren, J. M. Injuries. In his Surg. Obs., Boston, 593-597, 1867. 
 
 Macdonald, W. Glasgow M. /., 3, s, li, 171-173, 1867-8. 
 
 Denuce, P. Des fistules ossifluentes de la region anale. De la resection du coccyx et des ses 
 indications, Paris, 1874. 
 
 Bellamy, W. J. H. Nort. Car. M. /., Wilmington, 1, 151, 1878. 
 
 Blockwood. Proc. Phila. Med. Soc, ii, 56, 1880. 
 
 Couraud, J. Contribution a I'etude des depressions fistules congenitales cutanees et kystes dermoids 
 de la region sacrococcygienne, Paris, 1883. 
 
 JoUv, W. J. Med. Rec, New York, xxxii, 762, 1887. 
 
 Baiiey, W. W. J. Med. Soc, A.kansas, Little Rock, iv, 108, 1893-4. 
 
 Jackson, Pausdale. Lancet, London, i, 209, 1896. 
 
 Le Ray. Echo Med., Toulouse, 2, s, x, 61, 1896. 
 
 Dieulafe and Giles. Toulouse Med., 2, s, v, 248-250, 1903. 
 
 Necrosis. 
 
 Shidsgaard Hosp. Tid. Kjobenh., vi, 121, 1863. 
 
 Braune, W. Monaischr. f. Cehurtsk. u. Frauenkr., Berlin, xxiv, 1-10, 1 pi, 1864. 
 
 Dunn, L. A. Guys Hosp. Rep., London, 3, s, xxxi, 191-196, 1889. 
 
 Darrah, R. E. A. Boston M. & S. /., cxxviii, 36-38, 1893. 
 
 Raymond, F. N. Iconog. de la Salpetriere, Paris, viii, 65-106, 1 pi., 1895. 
 
 Monmer, L. Rev. d'orthrop.. Pans, xxx, 201-396, 1904, xxxi, 643, 1905. 
 
 Villemin, P. Tubercul. inf., Paris, ix, 97-100, 1906. 
 
 Marro, G. Arch, di pschiat. Torino, xxviii, 445-454, 1 pi., 1907. 
 
 Kuss, G. Bull, el mem. soc. anal., Paris, Ixxxiv, 645, 1909. 
 
 Cysts may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple. When primary they originate from the articulating surfaces of the long 
 segments, while those secondary may originate from the sacrum or the soft structures sur- 
 rounding the coccyx. They may be tubercular, syphihtic, dermoid or hydatid, and con- 
 tain serum, blood, pus, echinococci, or epithelial structures such as hair, teeth and some- 
 Page Sixty-One 
 
times bone known as teratoma or dermoid. Either of these forms may be congenital and 
 all with the exception of the dermoid variety may be acquired. 
 
 Cysts may result from degeneration of osteomata or other benign or malignant neo- 
 plasms. Indeed, these are quite frequently their origin. 
 
 They may rupture externally, into the vagina, uterus, urethra, bladder, peritoneal 
 or rectal cavity, usually into the rectum, remain open indefinitely to close spontaneously, 
 or continue to form a permanent fistulous tract. 
 
 History. 
 
 Fistulae have been reported by Macdonald, 1867, Denuce, 1874, Couraud, 1883, 
 and Jolly, 1887, the last named having seen a case in which the coccyx passed per anum, 
 after having been subjected to fracture. Gehrung, I 888, reported a case of dislocation of 
 the coccyx and Bailey, 1 893, one of fracture in \vhich an incorrect diagnosis was made. 
 Le Roy, 1 896, one of coccygeal fistula, and GiUes, 1 903, of retro-expulsion of the coccyx. 
 
 Sinuses in the overlying soft structures almost invariably result from any injury 
 or disease of the coccyx. 
 
 Fistulae may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, connect any part of the uro-genital, peritoneal or rectal tracts or coccyx, 
 their strutcures, or the structures of the perineum. 
 
 The fluids passing through these fistulous tracts may be fecal, urinary, seminal, 
 peritoneal, blood, pus or serum, from the uterine cavity, any bony tissue about or near 
 the pelvis, or from a lesion within the soft structures of the perineum independently. 
 
 MALIGNANT. 
 Sarcomata. Carcinomata. 
 
 Malignant Neoplasms of the coccyx aie numerous in variety and probably grow as 
 rapidly as when other tissues or organs are similarly affected. 
 
 History. 
 
 Heretaux, 1882, reported a case of sarcoma of the coccyx and Raingeard, 1884, 
 observed a case of sarcoma originating at the sacro-coccygeal junction with complete 
 degeneration of the coccyx. 
 
 Many such cases have been observed before and since the time of these reports. 
 
 Sarcomata may occur in many varieties, develop slowly or rapidly and become of 
 considerable sizes. They may be primary or secondary, involve the sacrum or secondary 
 to the sacrum, originate in the segments, their synovial linings, periostial or other soft 
 tissue coverings and in the form of teratomata. 
 
 Carcmomata are probably of rare occurrence in the coccyx but as its overlying soft 
 structures are frequently its origin it is necessary to consider it especially in secondary 
 involvement. 1 hey may be primary or secondary, vary in size, shap)e and location. 
 
 Neoplasms. 
 
 Zedler. Cen. San. Ber. v. Schlesien, fur das Jahr. 1832, Breslau. 334, 1834. 
 Lepellepetries. Lancet, London, 4-11, 158, 1883. 
 Stanley. Med.-Chir. Trans., London, xxiv, 1841. 
 Chibb. Med. Times, London, xvi, 274, 1874. 
 Johnson. Lancet, London, ii, 35, 1847. 
 
 Herschl, I. Oesterr. Ztschr. f. prakl. Heilk.. Wien, vi, 221-224, 1860. 
 
 Baune. Das Doppelbild und Geschw. d. Krenzbein Geg., Leipzig, 1862, Ang. Steissbeingeschen. 
 Monatschrift filr Ceburishilfe und Frauen}(ran}(heiten, xxiv, 1864. 
 Ellis. Boston M. & S. J., ixxii, 417, 1865. 
 
 Buck. Coccyx Cysts. l\. Y. Med. Record, 96, 1866. 
 
 Holmes. Brit. M. J., London, 315, 1867. 
 
 Mason. Trans. Path. Sac, London, xxv, 194, 1874-5. 
 
 Cabot. Sacral Teratom. Boston M. & S. J., xcviii, 112, 1878. 
 
 De Rothschild. Bull. Soc. d'obst., Paris, ii, 112, 1878. 
 
 Shattuck. Trans. Path. Soc, London, xxiv, 197, 1880-1. 
 
 McDowell. Med. Press & CiVc, London, xxxiii, 271, 1882. 
 
 Hertaux, /. de Vouesl. Nantes, xvi, 377, 1882. 
 
 Paae Sixtv-Two 
 
Chenantais. /. de med. de I'ouesl, N antes, xvii, 457, 1883. 
 
 Eross, G. Orvosi helil, Budapest, xxxix, 973-979, 1883. 
 
 Jewetf, F. A. N. A^en; York M. /., xxxix. 612, 1884. 
 
 Raingaard. /. de Med. de I'ouesl, Nantes, xviii, 281-284, 1884. 
 
 Favel & Jackson, Lancet, London, i, 843, 1885. 
 
 Leriche. Cong, franc, de. chir., proc-verb., 1886, Paris ii, 519-525, 1887. 
 
 Owen. Trans. Path. Soc, London, xxxi, 425-7, 1887-8. 
 
 McCarthy. Lancet, London, i, 920, 1888. 
 
 Bowlby. Coccygeal Tumors. Brit. M. J., London, i, 663, 1890. 
 
 Vincent, E. Mem. el compl. rend. soc. d. sc. med. de Lyon, (18S9) xxix, pt. 2, 180-182, 1890. 
 
 Borst. Die angie Geschwulst der sacr. Region. Centralb. f. Allg. path. u. path., Jena, ix, 449, 1896. 
 
 Jahr. d. Basn. Herzegovina, landespil in Sarjeno, 1894-96, 787-90, Wien, 1898. 
 
 Alezais-Peyron. Compl. rend. Soc. de. Biol, Paris Ixvi, 1121, 1909. 
 
 Barbarin, P. Paris Chirurg., ii, 229-231, 1910. 
 
 Brod, I. S. Khirurgia. Mosff., xxviii, 31-33, 1910. 
 
 INJURIES. 
 Fractures. 
 
 Injuries of this character in the male are usually caused by direct force applied from 
 below or behind, while in the female, the pressure from the foetal head during delivery is 
 an added cause. 
 
 History. 
 
 Fractures of the coccyx have been of many varieties and due to many causes. 
 Cummenus, 1672, reported on its luxations, Faye, 1848, fracture, Boyer, 1852, fracture 
 with reduction, and Cleaveland, 1853. on fracture due to difficult labor. Herschey, 
 1856, observed a case of simple exfoliation of the coccyx, Mouret, 1859, an incomplete 
 luxation, Faye, 1861, one of fracture resulting in ankylosis, and Bellamy, 1878, one of 
 gunshot wound of the coccyx and perforation of the rectum. 
 
 Fractures of the coccyx are due to injury or disease, and are classed as acquired 
 causes. They too will produce sjanptoms which are associated with the uro-genital and 
 rectal tracts 
 
 tractures. 
 
 
 a. 
 
 Simple. 
 
 b. 
 
 Compound. 
 
 c. 
 
 Comminuted. 
 
 d. 
 
 Compound comminuted. ' 
 
 Simple fractures may occur in one or more segments, transverse, oblique, lateral or 
 perpendicular, or they may be associated with fractures of the sacrum. 
 
 Simple fractures of the coccyx may be associated with a simple fracture of the sacrum, 
 such a case having been observed in a woman 38 years of age as the result of a fall, 
 the force of which was directed perpendicularly through the sacrum from below. This 
 is the only case found recorded. The fracture apparently was transverse through the 
 sacrum, while that of the coccyx was transverse through the articulating surfaces of the 
 third and fourth segments. The pain resulting from the fracture was excruciating and 
 only relieved by excision of the coccyx by local anesthesia. The pain and tenderness, 
 however, continued for several months thereafter in the region of the sacral fracture. 
 
 Compound fractures may occur in one or more segments, even to being associated 
 with that of the sacrum, and the laceration of soft tissue, extend laterally, posteriorly through 
 the cutaneous structures, or anteriorly through the wall of the rectum. 
 
 Comminuted Fractures may involve one or more segments alone or be associated with 
 that of the sacrum. 
 
 Compound Comminuted Fractures may occur in one or more segments alone, or 
 with that of the sacrum and involve the soft structures laterally, posteriorly, or anteriorly 
 through the wall of the rectum. 
 
 Either of the foregoing fractures may result in infection, and abscess which may 
 
 Pag-e Sixty-Three 
 
rupture into the bladder, uterine or peritoneal cavity, the vagina or rectum, which is the 
 most common course. 
 
 Ank})losis may be of any degree from slight movement to complete mobility, and 
 in many positions from straight to curve, or angular, laterally, emteriorly or posteriorly. 
 
 Flexibility is more frequent in the female and ankylosis in the male. The latter 
 probably being due to hardship and a smaller pelvis. Ankylosis is also produced by 
 prolonged sitting posture. 
 
 Luxations may occur in one or all joints, even to complete separation from the 
 coccyx, anteriorly, posteriorly or laterally, and such conditions are very much inclined to 
 cause considerable irritation and pain. Their degree being influenced by occupation. 
 
 SYMPTOMS. 
 
 {Coccyalgia. 
 Coccygalgia. 
 Coccygodynia. 
 
 The coccyx having not escaped the influences wrought by the anatomical changes 
 in the perineum, should be considered an important factor in the causation of symp- 
 toms and surgical conditions, which are many times extremely complex in character and 
 their relation to the rectal and uro-genital systems. 
 
 Sensory impulses pass upward, motor impulses downward, indicating that the coccyx 
 plays the role of a disturber more than that of the disturbed. It is an offender, not 
 defender, therefore must be the cause of complex symptoms especially because of its 
 relations, attachments and exposed position. 
 
 The congenital or acquired absence of the coccyx does not interfere in the least 
 with the function of muscular fibers which are attached to it normally. 
 
 The periosteum enveloping the coccyx may be primarily or secondarily affected by 
 disease or injury or their consequences and for this reason must be considered independently 
 in the causation of symptoms, though it may not have received proper recognition. 
 
 History. 
 
 Pain neuralgic in character, in the coccyx, has been recognized for many years 
 but little was written about it until after Nott, 1 844, of New Orleans, delivered an 
 address upon the subject. Since then much has been said about the coccyx being a causa- 
 tive factor. 
 
 Scanzoni, 1861, Jenks, 1873, Worms, 1876, and Rockwell, 1877, each reported 
 a case of pain due to injury. Hale, 1 888, also had one due to disease of the segments. 
 
 Goodall, 1883, Sutton, 1888, Montgomery, 1895, Fletcher, 1897, and Courtois- 
 Suffit, 1 904, and 1910, reported coccygodynia of traumatic origin. 
 
 Many others have contributed most excellently to the sum total of our knowledge 
 of this subject. 
 
 Pain and tenderness are probably the most common symptoms and they may be 
 due to many causes direct or indirect, primary or secondary, such as injury or disease 
 of the coccyx or nerves associated with it. It may be mild or severe, acute or chronic, 
 constant or periodic, and appear at any age, in either sex, but more frequent in the female 
 before fifty years of age. It is rare in the very young and old, and any degree of pain 
 may exist with or without infection of any character or degree and when a deformed 
 coccyx pulls on muscular fibers that are out of their normal position. 
 
 The coccyx when diseased or deformed quite frequently produces irritation of the 
 rectal and urinary system in part or in general, and frequent urination and defecation as- 
 sociated with or without pain or tenesmus and general nervousness are quite commonly 
 associated with its abnormal conditions. Tenderness is usually pre-ent with all and any 
 irritation resulting from such a condition may result in infection and abscess with all of 
 their sequellae at any point within the genito-urinary or rectal tracts. 
 
 Page Sixty-Pour 
 
Rcclal or uro-gcnital pathology of any kind or degree may produce coccyalgia vary- 
 ing in severity and resuil in general or sexual neurasthenia, especially when severe in either 
 the acute or chronic form. 
 
 COCCYALGIA. 
 
 Bibliography. 
 
 Coccyalgia. 
 
 Nott. Aem Oilcans M. /.. i, 1844. 
 
 von Scanzoni, F. W. Ueber coccygodyn. IVurzburg mcd. Zbcbr., 820, 1861. 
 
 von Scanzoni. Ueber coccydynie, Wiirzburg, 1861. 
 
 Gosselin. Coccyodynie. Caz. J. hop., Paris, xxxiv, 489, 1861. 
 
 Faye, F. C. Coccyodynie Resulting from Fracture. Norsf;. Mag. f. Laegc\>idensk< Christiana, xv, 
 
 137-146. 1861. 
 
 von Frangui. Ueber Coccygodynie. McmoTabilien, Heidelberg, viii, 109, 1862. 
 
 von Scanzoni. Memorabilien, Heilbronn, vii, 40, 1862. 
 
 von Franque, A. Memorjbilien, Heilbionn, vii, 105-107, 1863. 
 
 Am. I. ObsL, New York. 243, 1869. 
 
 Coccyigodinia. Barth. Malta., i-iii, 213-219, 1871-5. 
 
 Jenks. E. W. Tr. M. Soc, Michigan, Lansing, vi, 118-128, 1873. 
 
 O'Reilly. J. Am. PracL, Louisville, ix. 327-334, 1874. 
 
 Worms, J. Did. Encyclop. d. sc. med., Paris, xviii, 174-179, 1876. 
 
 Jenks, E. W. Med. Rec, New York, xvii. 417-421, 1880. 
 
 Goodell, W. Clin. News, Philadelphia, i, 219, 1880. 
 
 .Aschenborn, O. Arch. f. k^in. Chir., Berlin, xxv, 174, 1880. 
 
 Laub, H. Cynael. eg. obsl. Medd., Kjobenhagen, 3, R. iii, 29-37, 1881. 
 
 Woodward, A. T. Med. & Surg. Reporter, Philadelphia, xlv, 398. 1881. 
 
 Goodell. W. Phila. M. Times, xiv. 756-758, 1883-4. 
 
 Madelung, O. Cenlralh. f. Chir., Leipzig, xii. 761-764, 1885. 
 
 Ferouson. A. H. Canad. Pracl. Toronto, xi, 233-235, 1886. 
 
 Morion, A. E. Med. Reg., Philadelphia, iv, 126, 1888. 
 
 Hale, E. M. Homeop. ]. Obsl., New York, x, 9-26, 1888. 
 
 Grafe, M. Ein Beitrag zur Astiologie and Therapie der Coccygodynie. Ztschr. f. Ceburlsh. u. 
 Cynak; Stuttgart, xv. 344-353. 1888. 
 
 Sutton, R. S. A new and reliable remedy for coccygodynia and puntis am. Med. & Surg. 
 Reporter, Philadelphia, Ixiii. 563. 1888. 
 
 Kuezora. W. Ueber Coccygodynie und ihre Behandlungsweise. Wiirzburg, 1888. 
 
 Peyer. A. Centralb. f. Klin, med., Leipzie, ix, 657-662. 1888. 
 
 Cooper. H. P. Atlanta M. & S. J., ns, vii. 1-10, 1890-91. 
 
 Carriere. La sacro-coccygod. Echo. med. du nord. Lille, ii, 315, 1892. 
 
 Cooper and Edv/ards. Diseases of the Rectum and Anus. 315, 1892. 
 
 Phocas. G. Arch. prov. de chir., Paris, i. 407-412, 1892. 
 
 Kasack. M. R. Ueber Coccygodynie. Berlin. 1892. 
 
 Harris. A. H. North. Car. M. J., Wilmington, xxxi. 261-263, 1893. 
 
 Barwell, R. Med. Week., Paris, ii. 149. 1894. 
 
 Tilmann. Charite-Ann., Berlin, xix. 361. 1894. 
 
 Montgomery, E. E. Charlotte N. C. M. J., vii, 711, 1895. 
 
 Elliott. C. S. Med. Arena, Kansas City. iv. 257-262. 1895. 
 
 Brenner. W. Med. Rec, New York. 1, 154. 1896. 
 
 Rohleder. W. Ueber Coccygodynie. Berlin. 1896. 
 
 Schaffer, O. (Pseudococcygodynie). Centralb. f. C\^nakol., Leipzig, xxi, 1249-1254. 1897. 
 
 Fletcher. W. B. Indiana M. /.. Indianapolis, xvi, 301-304, 1897-98. 
 
 Borst. Die angeb. Geschwulst. d. sacr. Region, Centralb. f. ailg. path. ii. path. anat.. Jena, ix, 449 
 501, 1899. 
 
 Van Lennep, W. B. Hahneman Inst., Philadelphia, x. 136, 1902-3. 
 
 Courtois-Suftt. Ann. d'hvg., Paris, 4. s, ii, 66-69, 1904. 
 
 Ferrari, G. Policlin. Roma., xii, sez, prat. 1190-1193, 1905. 
 
 Sutton. J. B. Clin. /.. London, xxxiii. 97-100. 1908-9. 
 
 Courtois-Suffit & Bourgeous, F. Caz. d. hop., Paris, Ixxxiii. 1945-1949. 1910. 
 
 SURGERY OF THE COCCYX. 
 
 {Coccygectomy. 
 Coccygogectomy. 
 Tenotomy. 
 The propriety of removing a part or all of the coccyx for anomalies, diseases and 
 injuries can not be disputed, nor can any question arise for doing so when pain or tender- 
 ness exists without these conditions. 
 
 Pag-e Sixty-Five 
 
Historv. 
 
 Coccygeciomy has been done for deformity, disease and injury without danger or 
 inconvenience. Nott, 1 832, was first to report the removal of the coccyx. Thomas, 
 1835, removed it for parasitic infection, and Nott again, 1844, and Simpsofr, J. Y., 
 1861 , were among the first to call attention to pain, disease and deformities of the coccyx. 
 
 Todd, 1874, cured neuralgia of the coccyx and pelvic viscera by coccygectomy. 
 Blackwood, 1879, wrote on the necessity of accurate diagnosis of fractures at the sacro- 
 coccygeal junction, drawn inward and the lemoval of the coccyx, and Stcuiford, 1879, 
 and Burt, 1881, cases of pain cured by removing the coccyx. 
 
 Garretson, 1 881 , applied the surgical engine for the purpose of removing the coccyx. 
 Guillet, 1882, reported a case of dermoid cyst removed from the ano-coccygeal region 
 and Cottrell, 1 883, reported having performed Garretson's operation (surgical engine) 
 for the removal of the coccyx without disturbance of the perineum. Imlach, 1885, 
 removed the coccyx for caries, and Welch, 1886, for neuralgia, Evans, 1887, cured 
 mental symptoms by removing a necrosed coccyx. 
 
 Bowlby, 1 889, reported three cases of coccygeal cysts, and Davis, 1 892, one of 
 extirpation of the coccyx in which was located a congenital cyst. 
 
 Kasley, 1 893, records a case of irreducible luxation of the coccyx which was cured 
 by extirpation, and Coe, 1 895, one of dermoid cyst of the coccyx. 
 
 Adler, 1895, cured by excision of the coccyx constant pain resulting from an un- 
 united fracture, while Brewer, 1 896, states that the knife for coccygodynia is a failure, 
 Liell, 1897, excised the coccyx in four cases of fracture and necrosis. Hirst, 1897, one 
 for ununited fracture and Lange, 1897, one for dermoid cyst, de Vesian, 1907, injected 
 alcohol (60 per cent.) about the coccyx for rebellious pain. 
 
 Courlois-Suffit & Bourgeois, 1910, interpretated the medico-legal question of sur- 
 gical intervention in pain due to injuries to the coccyx, thus showing that there are many 
 medico-legal phases concerning this bony appendage. 
 
 Berber in 1910 ablated successfully a hernia of the spinal cord in the region of 
 the coccyx in an infant as was also done by Brad during the same year. 
 
 Until within the last ten years coccygectomy was done more frequently for neuralgia 
 than for all other causes combined, but this operation grows rapidly in favor for fractures, 
 ankyloses and flailed conditions, especially when they excite great general irritability 
 without pain, neuralgic in character. 
 
 Technique. 
 
 Coccygectomy — Complete — Incomplete. 
 
 Complete. Removal of all the coccyx may be easily accomplished, with local or pul- 
 monary anesthesia, preferably local, through a median incision extending from the first 
 to the fifth segment, after separating the soft parts from the coccyx with a periosteome and 
 dividing the bone with sharp forceps. The hemorrhage is usually insignificant, but drainage 
 should always be instituted, because of the great possibility of infection of tissues so in- 
 timately related to the anus and vulva. 
 
 The same methods should be followed with partial excision of the coccyx, care 
 always being observed in both instances not to injuie the rectal wall. Sutures when 
 possible, should be avoided because of the distress caused by their presence. They should 
 when necessary be inserted close to the edges of the incised skin, but many such incisions 
 will close by the infold of the cut edges without suture. 
 
 Gant, 1902, Diseases of the Rectum and Anus, second edition, pp. 168-1 72, tab- 
 ulates 37 cases operated for injuries and tumors. 
 
 Personal Coccygectomies (Acquired) . 
 3 Sarcoma, one 5|/2 lbs., one 7 oz., and one 2|^-^ lbs. 
 2 Necrosis ; one syphilis, one tuberculosis. 
 
 1 Fractures ; four males, six females. 
 
 1 1 Neuralgia; six females, five males. 
 6 Ankylosis; four males and two females. Two right angle (males), one right 
 angle (female). 
 
 Pag-e Sixty-Six 
 
Cocc\)gectom^ (Congenital). 
 
 1 long, sharp and flexible, (male). 
 
 2 long, sharp and flexible, (female), also 9 of recent date. 
 Total, 44. 
 
 TENOTOMY. 
 
 Tenotomy, suggested by J. Y. Simpson, 1861, is done by dividing subcutaneously 
 the soft structures along the lateral borders of the coccyx. This method has received 
 high commendation by quite a number of operators but the results observed after three 
 such operations upon as many subjects, by as many operators, are not commendable. 
 
 Technique for tenotomy may best be accomplished by a posterior lateral incision ex- 
 tending through the cutaneous and other soft tissues overlying the coccyx, the incision 
 being upon one or both sides, as necessity may require. With the left index finger within 
 the rectum and upon the coccyx for a guide, the danger of incising the wall of the rectum 
 may be avoided, as the tendons are divided at their attachments along the lateral bony 
 borders. The point of a narrow bladed knife may be made to pass from the tip of the 
 coccyx upward, or from its sacral border downward, there being no special advantage 
 with either course, but the incision should extend about one and one half inches downward 
 from the tip of the coccyx. 
 
 There may be difficulty in palpating the entire rectal surface of the coccyx, but 
 this IS only when it is very short or when the subject is extremely fleshy, or of great height. 
 This difficulty is more frequently encountered in the male subject, because these con- 
 ditions may be overcome by an examination of the female coccyx, with the finger in the 
 vagina. 
 
 The after care of such posterior incisions is the same as for coccygectomy already de- 
 scribed. 
 
 Trans rectal tenotomy is a method not to be recommended because the incisions are 
 made through the rectal wall along the lateral borders of the coccyx, wath a knife upnan 
 a long handle inserted through a speculum, thus being more difficult and dangerous because 
 of the possibility of infection and hemorrhage, sufficient causes for condemnation. 
 
 Novocain or cocain injected subcutaneously will suffice for anesthetic purposes, the 
 pulmonary method being seldom indicated for either excision of the coccyx or incision of its 
 tendon. 
 
 BIBLIOGRAPHY. 
 
 (Surgical.) 
 
 Excision : 
 
 Thomas. Prov. San. Ber. d. Med. Coll. v. Pommern, i&34, Stettin. 79-81, 1835. 
 
 Nott, J. C. Nerv Orleans M. /., i, 58, 1834-1844. 
 
 Simpson, J. Y. Med. Times & Caz., London, i, 317, 1861. 
 
 Kidd, G. H. Med. Press & Circ, Dublin, 1867, 111, 596-598, also Dublin Q. /. M. Sc, xliv, 
 477-481, 1867. 
 
 Bourillion. Neciose du coccyx paralysie generale procedee d'un affection de la moelle symptoms 
 de paralysis agitans autopsie. Rec. d. trav. Soc. med. d'obs., Paris, 1866-70, 2, s, li, 455-464. .Also 
 in Caz. d. hop., Paris, xliii, 198, 202. 1870. 
 
 Amann, Aertzll. Int. hi., Munchen, xvii, 394, 1870. 
 
 Adams, Z. B. Rec. Bost. Soc. M. Improve., 1866-74, vi, 140; also Boston M. & S. /.. v, 458, 1870. 
 
 Plum. Hasp. Tid., Kjobenhagen, xiii, 33-35, 1870. 
 
 Simpson. J. Y. In his Works (Dis. of Women) Edinburgh, iii, 202-224, 1871. 
 
 Betz, F. Memorabilien, Heilbronn, xvi, 40, 1871. 
 
 Seelismuller, .\. Coccygodynie seit zwolf Jahren bestehend, geheilt durch den faradischen Strom. 
 In his Neuropathol. Beobacht., Halle, 25-27, 1873. 
 
 Todd, S. S. Med. Herald, Leavenworth, 1874-5, viii, 99; also Kansas Ciip M. J., iv, 138. 1874. 
 
 Svenson, I. Upsala Lakaref, Fori}., xi, 337-339, 1875-6. 
 
 Irish. J. C. Boslon M. & S. J., xcii. 613, 1875. 
 
 Mursick. G. A. Am. J. M. Sc, Philadelphia, clxi, 122-124, 1876. 
 
 Broca. Sur un cas de traumatisme frave du coccyx ayant necessite la resection. Tribune med 
 Paris, xii, 112-114, 1879. 
 
 Pag:e Sixty-Seven 
 
Blackwood, W. R. D. Ptoc. Phila. Co. M. Soc, Philadelphia, 1880, ii, 56, also PhUa. M. Times, 
 X, 295, 1879-80. 
 
 Stanford, F. A. A'en> York M. J., xxx, 400, 1879. 
 
 Burt, W. J. Mississippi Valley M. Month., Memphis, 1, 1-4, 1881. 
 
 Garretson. Phila. M. Times, xii, 303, 1881-2. ^ 
 
 Guillet. /. de Med. de I'Ouest, Nantes, xvi, 240, 1882. 
 
 Binzer. Gl;nae^. og obsL Medd. Kjobenhagen, iv, 1, 2, Hft. 52-61, 1882. 
 
 Browne, B. B. Maryland M. J., Baltimore, ix, 284, 1882. 
 
 Marr, L. Hosp. Tid., Kjobenhagen, 2, R, ix, 284, 1882. 
 
 Ward. yVen> Yor^M. /., xxxvi, 70, 1882. 
 
 Werner, Marie. B. Med. & Surg. Reporter, Philadelphia, xlviii, 287, 1883. 
 
 Cottrell, 3. P. Independ. PracL, New York, iv, 8-10, 1883. 
 
 Dawson, B. F. Am. ]. Obst., New York, xvi, II 89, 1883. 
 
 Harrison, G. T. New York M. J., xxxvii, 268, 1883. 
 
 Macdonald, A. Tr. Edinb. Ohsl. Soc, x, 183, 1884-5. 
 
 Goodell, W. Med. & Surg. Reporter, Philadelphia, 1, 588, 1884. 
 
 Browne, B. B. Maryland M. J., Baltimore, xiii, 26, 1885. 
 
 Tilaux. Practicien, Paris, viii, 293-295, 1885. 
 
 Imlach. Brit. Gpnec. /., London, i, 319, 1885. 
 
 Welch, C. T. Tr. M. Soc., New Jersey, Newark, 288. 1886. 
 
 Whitehead, W. Lancet, London, i, 112, 1886. 
 
 Odell, W. Lancet, London, i, 1088, 1887. 
 
 Evans, Z. H. Phila. M. Times, xviii, 351, 1887-8. 
 
 von Swiecicki. Wien. med. Presse, xxLx, 1136, 1888. 
 
 Bowlby, A. A. Tr. Path. Soc, London, xli, 284-289, 1889-90. 
 
 Post, A. Boston M. & S. /., cxxiii, 300, 1890. 
 
 Sutton, B. Med. Presse & Circ, London, ns, liv., 607, 1892. 
 
 Lucy. Lancet, London, ii, 1046, 1892. 
 
 Davis, E. P. Am. Gijnec. & Pediat., Philadelphia, vi, 542, 1892-3. 
 
 Pine, Aleinda A. Northwest Lancet, St. Paul, xii, 180-182, 1892. 
 
 Early. T. B. Med. Ball., Philadelphia, xv, 138, 1893. 
 
 Coe, H. W. Pacific M. Rec, Portland, Ore., i, 78 1893. 
 
 Adler, L. H.^ Jr. Med. News, Philadelphia, Ixvii, 348, 1895. 
 
 Jackson, J. N. Langsdale's Lancet, Kansas City, i, 299, 1896. 
 
 Bremer, L. Med. Rec, New York, 1, 154, 1896. 
 
 Liell, E. N. Med. News, New York, Ixx, 382, 1897. 
 
 Hirst, B. G. Am. J. Obst., New York, xxxv, 794, 1897. 
 
 Lange, K. Eira, Stockholm, xxi, 352, 1897. 
 
 De Vesian. Rev. Prat, de g\^nec. d'obst. el de pediat., Paris. Ixxxii, 206-263, 1907. 
 
 Irwin, J. R. Charlotte (N. C.) M. J., Iviii, 170, 1908. 
 
 Pons. Kyste dermoide de la region coccygienne. Marseille med., xlvl, 167-169, 1909. 
 
 Cortois-Suffit & Bourgois, F. Soc. de med. leg. de France Bull., Paris, xhi, 239-255, 1910. 
 
 MISCELLANEOUS BIBLIOGRAPHY. (Coccyx.) 
 
 Miscellaneous Bibliography. 
 
 Krimer, W. Bruch des Steissbein's, Ursache langjahrner Nervenleiden. Med. ConVers. Bl., Hud- 
 burgh, 1, 93-96, 1830. 
 
 Godfrey, A. Am. J. M. Sc, Philadelphia, ns, xhi, 576, 1860. 
 
 Broers, H. J. Bijeen Jong meisie. Nederl. Tifdschr., v, Heelen Verlosk, Utrecht, xiii, 595-601, 
 
 1862-3. 
 
 Horschelmann. St. Petersb. med. Ztschr., iii, 117-120, 1862. 
 
 Betz, F. Ueber den wahrend der Geburt entstehenden Steissbeinbruch. Memorabilien, Heilbronn, 
 X, 58-62, 1865. 
 
 Arnold, J. Zur Steissdriisenfrage. Arch. f. path, anal., Berlin, xxxiii, 454-456, 1865. 
 
 Arnold, J. Ein weiterer Beitrag zu der Steissdriisenfrage. Arch. f. anal., Berlin, xxxv, 
 220-223, 1866. 
 
 Fox, W. R. Chicago M. Exam., xl, 76, 1870. 
 
 Gilette. Courrier med.. Pans, xxiv, 235, 1874. 
 
 Lanz, E. Ueber die Beweglichkeit des Steissbeines und ihre Beziehung zu der Geburt. Bern, 1878. 
 
 Greve. Ein Fall von Schwanzbildung beim Menschen. Arc. f. path, anal., Berlin, Ixxii, 129, 1878. 
 
 Ornstein. Schwanzbildung beim Menschen. Verhandl. d. Berl. Cesellsch. f. AnthropoL, Berlin. 
 
 303-305, 1 pi, 1879. 
 
 Post. Disease of coccyx. A^eD; York M. J., xxx, 517, 1897. 
 
 Bartels, M. Eine schwanzahnliche Neubildung beim Menschen. Arch. f. path, anal., Berlin Ixxxiii 
 
 189-192, 1 pi., 1881. 
 
 Virchow, R. Schwanzbildung beim Menschen. Arch. f. path, anal., Berlin, Ltxxiii, 560, I pi., 1881. 
 Schmidt, M. Zwei Falle von Geschwiilsten in der Gegend des Schwanzbeines. Arb. a. d chir 
 Univ. Poliklin., zu Leipzig, 2 Hfte., 15-22, 1892. 
 
 Blum, F. Die Schwanzmuskulatur des Menschen (Freiburg i. B.) Wiesbaden, 1894. 
 
 Page Sixty-Eight 
 
CHAPTER IX. 
 
 URETHRA. 
 
 ANATOMY. 
 
 ITH THE exception in length of the urethra, the urinary apparatus 
 in the male and female are similar, especially alike from the 
 lower portion of the bladder to and including the kidneys. 
 
 The urethra m the male is of two portions, approximately 
 less than 2-3 cm. long from the bladder to the opening of the 
 ducts of reproduction, the membranous portion 1 cm. and the 
 distal or spongy portion terminating with the external meatus, I 4 
 cm. long and is lined with a mucous membrane throughout. 
 
 It contains much fibrous tissue with the muscular coat of 
 circular and longitudinal fibers, intermingled with many lymphatic 
 glajids. Stripped muscle fibers are present in the outer aspect of 
 the muscular coat of the urethra, forming a complete ring or 
 sphincter in the upper part, while the lower fibers form the uro- 
 genital sphincter. 
 
 An imperforate urethra, when complete in the unborn, is 
 said by Deaver to always cause death before delivery, but two personal experiences do 
 not bear out this statement. 
 
 Urethral blood supply is from the spermatic or ovarian internal iliac, visceral 
 vessels, inferior renal arteries, inferior vesical and middle hemorrhoidal arteries. 
 
 Urethral nen>es are from the pudlc which carry sensory fibers to the mucous 
 membrane and motor fibers to the striped muscle, and from the hypogastic and renal 
 plexus of the sympathetic by way of the prostatic, cavernosus plexuses and pelvic 
 sympathetic plexuses. 
 
 The compressor urethra is also dominated by branches of the pudlc nerve. Its 
 function is to constrict the membranous urethra in the male and flatten the walls of 
 the vagina in the female. 
 
 The lymphatics of urethra in the male (Sappy) arise from a network attached 
 to the mucous membrane from the utricle to the meatus urinarlus. Posteriorly, the 
 network formed by these vessels and by the anastomosis which unites them, is con- 
 tinued on the vesiculae semlnales and the vasa deferentla. 
 
 In front it is continuous with the tortuous branchlets on the surface of the gland. 
 This network has an exceptional arrangement; the larger and smaller branches which 
 form It, follow the direction of the urethral walls by many transverse and oblique 
 anastomoses; they unite very frequently and are grouped in parallel and unequal bundles, 
 separated by longitudinal ridges. From this network emanate several collecting trunks 
 which may be divided into four groups. 
 
 The onl\) collecting trunks which Sappy mentions, are those which come from the 
 mucous membrane covering the glands. They transverse the Inferior wall of the 
 urethra at the level of the fraenum, unite with the lymphatic trunks coming from the 
 glans, <Jid terminate in the same manner as those vessels. 
 
 The collecting trunks which come from the remainder of the penile portion vary 
 in number. They emerge on the Inferior surface of the penis, turn round the lateral 
 surfaces of the corpus cavernosa and unite ^\'ith trunks coming from the glandular 
 
 Page Sixty-Nine 
 
portion. The majority run to and terminate in the same way as the latter, but some 
 take an entirely different course, for instance, one of these vessels passes over the 
 symphysis, runs between the two recti muscles, then turns directly to the left and 
 terminates in the internal retro-crural gland. More rarely it may be found to terminate 
 in the middle gland of the internal chain of the external ihac glands. Kuttner was 
 the first to note the presence of the vessel, but he was wrong in believing that it came 
 from the mucous membrane of the glans. A second collector passes underneath the 
 symphysis and unites with the vessels coming from the bulbar and membranous portions 
 of the urethra. 
 
 The lymphai'ics of the bulbar and membranous portions end in three systems of 
 collecting trunks. 
 
 One of the vessels makes its appearance on the upper surface of the bulb in the 
 angle formed by the divergence of the two corpora cavernosa. It embraces either the 
 tiansverse artery of the bulb, or the artery to the corpus cavernosum, it then becomes 
 a branch of the trunk of the internal pudic artery and terminates in the gland attached 
 to the intra-pelvic portion of the trunk of this artery. 
 
 A second vessel runs toward the posterior surface of the symphysis and then behind 
 the pubes to terminate in the internal retro-crural gland. 
 
 A third trunk ascends on the anterior surface of the bladder, and unites with the 
 trunks coming from the inferior segment of this surface, and terminates with the latter 
 in the middle gland of the internal chain of the external iliac glands. 
 
 The lymphatics of the prostatic portion pass into the collecting trunks which emerge 
 from the glandular parenchyma. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Diseases. I ?5"^.g"- 
 
 (^ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies of the urethra may be congenital or acquired, primary or secondary, 
 vary in length, diameter, regularity, location of external opening, relation to other 
 structures, entire absence, number of channels, the distal opening may be into the 
 rectal, vaginal, uterine or peritoneal cavity, one or all in the same individual, or there 
 may not be any opening, as shown by an imperforate urethra, when the urethra is 
 otherwise normal. Hypospadias and epispadicis are not uncommon forms of embryonic 
 ducts, and about 40 per cent, of those so afflicted are also defective mentally. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Benign diseases include those not cancerous in character, though they may be 
 otherwise malignant. 
 
 Urethritis may be primary or secondary, acute or chronic, local or general, mild 
 or severe. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, in any tissue or portion of the urethra. 
 
 Page Seventy 
 
Papillomala in the urethra may be congenital or acquired, primary or secondary, 
 single or multiple, vary in size, location, disappear spontaneously, develop sufficiently 
 to cause obstruction, exist indefinitely and necessitate removal, after which they may 
 again appear. Usually pedunculated. 
 
 Polypi may be congenital or acquired, primary or secondary, vary in size, shape, 
 number, location, usually pedunculated, and sometimes disappear spontaneously. 
 
 Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, location, disappear spontaneously, or develop sufficiently to cause ob- 
 struction, usually have a broad base, exist indefinitely and necessitate removal, after 
 which they may again appear upon the mucous membrane. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, location, disappear spontaneously, or develop sufficiently to cause 
 obstruction, usually appear in the wall of the urethra, and develop in the surrounding 
 tissues, external to the wall. 
 
 Tuberculosis may be primary or secondary, single or multiple, acute or chronic, 
 in the mucosa or muscularis, and usually in the membranous or prostatic urethra; but 
 rare in occurrence. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, in the mucous or muscular fibers of the urethra, usually in the mem- 
 branous, prostatic or anterior portion. 
 
 Concretions and Foreign Bodies may enter from without or within, the most 
 common source being from the bladder where they have formed or have escaped from 
 the kidneys or ureters, though they may be formed in the urethra alone, especially in 
 the prostatic portion, single or multiple and vary in size, shape and consistency. 
 
 Strictures may be congenital or acquired, primary or secondary, single or multiple, 
 partial or complete, in any portion of the urethra, and result from injury or disease. 
 Occasionally they will open spontaneously, but such a resolution is indeed rare. 
 
 Cysts may be congenital or acquired, single or multiple, primary or secondary, 
 usually in any portion of the wall of the urethra, contain blood, pus, serum or urine, 
 and rupture externally through the soft structures, into the rectum, vagina, uterus, bladder 
 and occasionally into the peritoneal cavity. 
 
 Fistulae may be congenital or acquired, single or multiple, primary or secondary, 
 acute or chronic, open externally upon the cutaneous structures, into the rectum, vagina, 
 uterus, bladder, seminal ducts, or peritoneal cavity, one or all, at the same time, in 
 one individual. 
 
 MALIGNANT. 
 
 Carcinomata are the most frequent forms of cancer, and they may be primary or 
 secondary, usually primary, occur anywhere upon the mucosa, or muscularis, especially 
 in the membranous or prostatic portion, the most frequent origin being in the mucosa. 
 
 Sarcomata, of rare occurrence, may be primary or secondary, usually primary zmd 
 single, and occur more frequently in the muscularis, in any portion of the urethra, usually 
 in the posterior. 
 
 INJURIES. 
 
 Lacerations, Incisions, Punctures may be single or multiple, complete or incomplete, 
 from without or within any portion of the urethra, the result of accident or design. 
 They may complicate the rectum, vagina, bladder, uterus, peritoneal cavity, perineal 
 body, seminal ducts, testicles or scrotum. 
 
 SYMPTOMS. 
 
 Urinary (Male and Female). 
 
 Reflex disturbances in the urinary tract vary slightly in the sexes because of 
 anatomical arrangement, but the variation is so slight that it is almost impossible to 
 
 Page Seventy-One 
 
define them physiologically. It will therefore be necessary to consider each of the 
 four divisions of the tract singly and collectively for a more perfect understanding of 
 their correlated symptoms. 
 
 Pain, induration and tenderness are first and most prominent in any of the anomalies 
 or diseases ascribed to the urethra but localized or general pain is not always an in- 
 dication that its cause is in any of the urethral tissues. The intimate relation of these 
 structures with those of the erectile body so rich in nerve fibers, both sensory and 
 motor, and blood and lymphatic vessels give to it a very high degree of sensibility. 
 
 Pathology of any character, especially the obstructive form, including foreign 
 bodies and concretions in the urethra and the bladder, ureters and kidneys, may cause 
 impulses to be transmitted downward to the distal end of the erectile body in both sexes 
 because the seime group of nerves are carriers of impulses to and from the kidneys, ureters, 
 bladder and prostate. 
 
 It would therefore seem unreasonable for such a complex relation of sensory and 
 sympathetic nerve fibers to carry impulses at all times, independently. The motor fibers 
 of the pudic nerve which dominate the compressor urethra in the male, the function of 
 which is to constrict the membranous urethra in the male and flatten the walls of the 
 vagina in the female, are exemphfications of their duality. 
 
 Urinary disturbances of the urethra must necessarily exist when the upper tracts 
 are primarily involved because the urethra is the channel through which the urine with 
 its constituents must escape. These disturbances may exist independently and there- 
 fore possess the same indications, but the disturbances which the bladder, ureter and 
 kidneys produce, are more severe and serious. The urethra being the most available 
 portion of the urinary tract for examination, does not necessitate so great a classification 
 of symptoms for diagnosis except so far as its physiological effects upon other tissues 
 and organs are concerned. 
 
 Vascular changes are proportionate with the rate of pulse, though there may not 
 be any perceptible difFerence in the earlier periods. 
 
 Arterio-vascular disturbances in the urethra are quite common and varied, as they 
 are in the general urinary system. Their progress and severity are determined by the 
 rate and quality of the pulse especially when the bladder, ureters, or I^idne^s are in- 
 volved by infection of various kinds with or without increase of temperature. The pulse 
 may intermit or be otherwise irregular, such being especially observed in senility. 
 
 Urethral changes are less likely to cause such disturbances though they may do 
 so when far advanced, especially in severe urethritis due to gonococci. 
 
 Page Seventy-Two 
 
CHAPTER X. 
 
 BLADDER, 
 
 ANATOMY. 
 
 i«^ ^^ ^^ J^ HE BLADDER has been constant from the beginning with all 
 ^1*^ £ I W forms of animal life, that it may receive urine indirectly by means 
 
 Clvvl K^>^^ of folds of mucous membrane when the ureters do not enter di- 
 
 rectly into it, or directly when they enter the bladder. It is 
 largest at its base and varies in size and shape, very distensible, 
 located in the extreme lower pelvis and richly endowed with 
 blood, lymphatic vessels, glands and nerve fibers. 
 
 It varies in thickness because of being distended and is 
 composed of mucosa within, a serosa without, and muscular 
 fibers between the two layers. 
 
 Its blood, lymphatic and nerve supplies are alike in the 
 male and female. 
 
 The blood suppl); is from the superior middle and inferior 
 
 vesicle, obturator and internal pudic arteries and branches of the 
 
 uterine and vaginal arteries in the female. 
 
 The venous plexus about the organ is larger at its base and communicates with the 
 
 prostatic plexus from the vesico-prostatic plexus which empties into the internal iliac vein. 
 
 Its fundus or base, spermatic ducts, and recto-vesical pouch are directed toward the 
 
 rectum, and in the female, is attached to the anterior vaginal wall. 
 
 The arteries are chiefly the inferior and superior vesical from the anterior division 
 of the internal iliac, reinforced by branches from the middle hemorrhoidal and twigs 
 from the internal pudic and obturators. 
 
 Nerves include sympathetic and spina] fibers; the sympathetic follow the arteries 
 and join the vesical branches from the sacral plexus which is derived from the 3rd and 
 4th and possibly the 2nd sacral spinal nerves. 
 
 The larger nerves divide in the outer fibrous coat of the bladder, into small fibers 
 that are connected with ganglia especially near the ureters. 
 
 The bladder in general is but a trifle sensitive, but it is very sensitive about the 
 entrance of the ureters into the bladder at which point nerve fibers predominate. 
 
 Fibers from the pelvic plexuses of the sympathetic and third and fourth sacral nerves 
 supply the urinary bladder, while fibers from the sympathetic plexuses supply the ureters 
 and fibers from the hypogastric plexuses of the sympathetic with central fibers mingled 
 with Pacinian corpuscles, inhibit the prostate gland. 
 
 Tlie lymphatics of the bladder. The only network of origin which exists in the 
 bladder is an intramuscular one. The emergent vessels of this network end in a second 
 network placed on the outer surface of the vesical muscle, under the peritoneum of the 
 umbilico-praevesical fascia. The course and termination of the collectors of this net- 
 work vary according to their situation on the anterior or posterior surface of the bladder. 
 Anterior surface. The collecting trunks coming from the anterior surface form 
 two groups. The trunks coming from the inferior segment of this surface run almost 
 transversely outward, and pass into a gland placed on the lateral surface of the pelvic 
 cavity, between the external iliac vein and the obturator nerve, a few millimeters behind 
 the cervical ring. The trunks which come from the superior part of the anterior surface 
 are remarkable for their sinuosities. They run upwards and outwards, cross the hypo- 
 
 Page Seventy-Three 
 
gastric artery, passing either above, or not frequently below it, and eventually terminate 
 in the middle gland of the middle chain of the external iliac group. In the course of 
 these lymphatic trunks are placed small glands, which are only visible after injection, 
 they belong to the group of interrupting glomular nodules. Some of these glaftds are 
 placed in front of the bladder (pre-vesical glands) , they maj' become hypertrophied in cer- 
 tain pathological conditions (Bazy) and may form the starting point of certain prae-vesical 
 phlegmons. Others are placed at the spot where the lymphatic vessels cross the hypo- 
 gastric artery, (latero-vesical glands. Waldeyer, Gerota). 
 
 Posterior surface. The trunks which come from the posterior surface, also form 
 several groups. 
 
 The trunks which come from the superior portion of this surface run outwards 
 describing several curves. They cross the hypogastric artery, where they traverse some 
 small lateral-vesical glands, and terminate in the external iliac gland in which the superior 
 lymphatics of the anterior surface also end. 
 
 Other trunks pass backwards following the course of hypogastric artery, and end 
 in a gland which is situated like the preceding, on the external iliac vein, but more 
 posteriorly to it, immediately in front of the bifurcation of the common iliac artery. 
 
 Other trunks which come from the middle segment of the posterior surface, end 
 in the hypogastric glands. 
 
 Others finally arising from near the neck of the bladder run directly backwards, 
 and crossing the lateral surface of the rectum, ascend onto the anterior surface of the 
 sacrum and terminate in the glands situated in the angle of bifurcation of the abdominal 
 aorta, in front of the promontory. 
 
 The vesical lymphatics end in the glands of the bifurcation of the aorta. We may 
 add that the prae-vesical network is continuous with the network which surrounds the 
 prostate, the vesiculae seminales, the vasa deferentia, and the terminal parts of the ureters. 
 
 Etiology. 
 
 Anomalies, Diseases and Injuries. 
 Anomalies. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, inverted, ex- 
 ceedingly large or small, entirely absent, open upon the abdominal wall, (exstrophy), 
 abnormally placed in the pelvis, partially or completely septinated, or contain two 
 or more cavities, when the urachus is present. 
 
 Ectopy is evidenced by the bladder protruding through a cleft in the abdominal 
 wall. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Cystitis may be primary or secondary, acute or chronic, local or general, mild 
 or severe. 
 
 Atrophy may be congenital or acquired, primary or secondary, local or general. 
 Usually in all of the structures. 
 
 Pag-e Seventy-Four 
 
H^perlroplt^ may be congenital or acquired, local or general in any one or all 
 of the structures, usually all, primary or secondary. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, 
 vary in depth, due to trauma or infection, acute or chronic, in any tissue or portion 
 of the bladder wall, cease or continue in size or disappear spontaneously. 
 
 Fissures at the neck may be congenital or acquired, usually acquired, acute or 
 chronic, single or multiple, primary or secondary, usually in the mucosa, sometimes 
 the muscularis. 
 
 Papillomata are probably the most frequent forms of new growth in the bladder. They 
 may be congenital or acquired, single or multiple, upon any portion of its inner surface, 
 develop to considerable size, remain quiescent or disappear spontaneously, though such 
 a resolution seldom occurs. 
 
 Ader\orr\ala frequently found in the bladder, may be congenital or acquired, single 
 or multiple, (usually multiple), upon any portion, small or large, cease to develop but 
 seldom disappear spontaneously. 
 
 Polypi may be congenital or acquired, single or multiple, large or small, pedun- 
 culated, vary in shape and location. 
 
 Fibromata may be congenital or acquired, single or multiple, usually single, in any 
 portion of the muscularis, where they originate, remain small, become large, cease to 
 grow, or disappear spontaneously. 
 
 Myomaia may be congenital or acquired, primary or secondary, vary in size, 
 shape, number and location. 
 
 Angiomala may be congenital or acquired, primary or secondary, acute or chronic, 
 vary in size, number and location and disappear spontaneously. 
 
 Liponiata may be congenital or acquired, primary or secondary, vary in size, 
 shape, location and number. 
 
 Chondromala may be congenital or acquired, primary or secondary, vary in size, 
 shape, location and number. 
 
 Tuberculosis may be primary or secondary, single or multiple, acute or chronic, 
 involve any part or all of the bladder, or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 in any portion or all of the bladder. 
 
 Parasites may be congenital or acquired, primary or secondary, without or within, 
 become encysted, or remain in the bladder cavity, the most common being cysticircus. 
 Any form may be temporary or become permanent. 
 
 Concretions may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, location, encysted in any portion of the wall of the bladder, especially 
 in its lower extremity, originate in the kidney or ureter, and pass into the bladder. 
 
 Foreign Bodies may be introduced by accident or design, be single or multiple, enter 
 from ^vithout or within, through the urethra, surrounding soft structures, ureters, uterus 
 or peritoneal cavity and escape from the bladder into any one or more of these cavities or 
 tissues. 
 
 Cysts may be congenital or acquired, single or multiple, large or small, in any portion 
 of the bladder wall, contain pus, blood, serum, urme or parasites, such as ecchinococci, 
 or other forms, rupture into the rectum, vagina, uterus, peritoneal cavity, bladder, urethra, 
 or soft structures externally. 
 
 Fislulae may be congenital or acquired, single or multiple, primary or secondary, 
 acute or chronic, vary in size and length, through any portion of the bladder wall, 
 open externally through the soft structures into the rectum, vagina, uterus, peritoneal 
 cavity, urethra or seminal vesicles. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, usually primary and single, in 2uiy 
 portion of the bladder wall and of slow or rapid growth. 
 
 Page Seventy-Five 
 
Sarcomata may be primary or secondary, usually primary and single, upon any portion 
 of the bladder wall and slow in their development. 
 
 INJURIES. 
 
 Herniae of the bladder, usually in the groin, may be congenital or acquired, into 
 the rectum, vagina, through the inguinal canal or abdominal wall, of rare occurrence, 
 but sufficiently frequent to require consideration. The inguinal variety is almost always 
 unilateral, the perineal usually due to pregnancy, the urethral is the inversion of the 
 bladder, occurs only in the female, the crural form exceedingly rare. 
 
 Ruptures may be by accident or design, primary or secondary, complete or incom- 
 plete, single or multiple, due to force applied from without or within, in any portion 
 of the bladder wall, extend into the peritoneal, uterine, rectal or vaginal cavities, 
 complicate ureters. Fallopian tubes, bloodvessels, nerves, lymphatics, intestines, cutaneous 
 structures or abdominal wall. 
 
 Incisions may be by accident or design, single or multiple, penetrating or non- 
 penetrating, from without or within, to the same degree as rupture. 
 
 Punctures may be by accident or design, single or multiple, penetrating or non- 
 penetrating, without or within, through any of the overlying structures, involve any of 
 the associated organs, through the rectum, vagina, urethra, or peritoneal cavity. 
 
 SYMPTOMS. 
 
 Symptoms pertaining to the urinar^) bladder are quite varied and uncertain, especially 
 because of the great variety of conditions found within its structures, and the adjacent 
 soft tissues, and because of their inhibition being from the same source, and similar 
 in both sexes. Any one of the conditions herein ascribed, involving the bladder, may 
 cause subjective symptoms identical in character. 
 
 It is inhibited by both motor and sensory fibers from the pelvic plexus of the 
 sympathetic, and third and fourth sacral nerves, and therefore must be a source of great 
 general disturbance within the uro-genital and rectal tracts, especially as their fibers 
 coalesce with the motor and sensory fibers of other nerves. The bloodvessels and 
 lymphatics alike coalesce with their associates, adding greatly to this general disturbance. 
 
 Local manifestations in the bladder such as tenderness and pain may or may 
 not vary with the degree of involvement as may those that are general, which are indicated 
 by increased sensibility, pain, chill, headache, shock, with added nausea and vomiting. 
 
 The effect of neuroses of any character upon the urinary system and its associated 
 structures or organs, is shown by the frequent desire to void urine. Incontinence or reten- 
 tion may also occur as may tenesmus or the sensation of burning be induced by nervous 
 irritability. 
 
 Page Seventy-Six 
 
CHAPTER XI. 
 
 URETER. 
 ANATOMY. 
 
 >^ ^-^ ^^ jr> HE URETER is composed of mucous, muscular and fibrous coats 
 ^ I^ Sf w rather thick and white. 
 
 C/^/^ >^\^^ ^/ic mucous membrane has many layers of epithelial cells, 
 
 and the muscular coat is composed of unstriated muscle fibers in 
 bundles which are separated by connective tissue and arranged 
 longitudmally and cnxularly. 
 
 The fibrous coal varies in thickness at different levels, the 
 lower part blending with the connective tissue which lies among 
 the muscle fibers forming the sheath of the ureter. 
 
 In the female about three inches can be palpated through 
 the vagina. 
 
 The ureters extend from the bladder backwards, outward 
 and upward to the base of the broad ligaments and toward the 
 lateral walls of the true pelvis. 
 
 The ureters are behind the peritoneum covering the psoas 
 muscle and in front of the common iliac arteries, and in the true pelvis in front of the in- 
 ternal iliac arteries, entering the bladder about one inch apart. 
 
 Blood supp/l; is from the renal and spermatic arteries in its abdominal portion 
 and the superior vesical and the middle hemorrhoidal vessels in its pelvic portion. 
 Nerve supply is through the renal, the spermatic and hypogastric plexuses. 
 Lymphatics of the Ureter. Our knowledge of the lymphatics is still imperfect. 
 Sappy was able to inject them only in the horse, and met with them only in the muscular 
 coat. In the course of his injections of the vesical lymphatics several times he has 
 seen the subserous network of the bladder extend itself a few millimeters round the 
 ureter. The lymphatics of the ureter end in multiple collecting trunks which pass to 
 the neighboring glands. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 ,g f Benign. 
 1^ Malignant. 
 Injuries. 
 
 Di 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 vary in length, size, origin, entrance into the bladder, course and relation to other 
 structures, one or both absent, the right enter the bladder upon the left, the left upon the 
 right side, or anywhere upon the surface. 
 
 Page Seventy-Seven 
 
DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Urethritis may be primary or secondary, acute or chronic, and involve any part 
 or all of the mucosa. 
 
 Tuberculosis may be acute or chronic, primary or secondary, in any portion, in 
 the mucosa or any of the fibers w^ithin the wall. Primary tuberculosis, however, is 
 much less frequent than the secondary form, which is usually from the kidney or bladder, 
 especially the kidney. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, in any portion of the ureter, but more frequently near the extremities, 
 in which instance it is usually secondary. 
 
 Papillomata may be congenital or acquired, usually acquired, primary or secondary, 
 single or multiple, in emy portion, but most frequently at the extremities, destroy the 
 lumen, cause the formation of concretions, strictures or general destruction. 
 
 Adenomata may be congenital or acquired, single or multiple, not pedunculated, 
 in any portion, but most frequently at the extremities, destroy the lumen, cause concretions, 
 strictures or general destruction. 
 
 Fibromata may be congenital or acquired, single or multiple, large or small, 
 originate in the muscular tissue of the ureter, destroy the lumen, and cease to grow 
 at any stage of development. 
 
 Prolapsus may be congenital or acquired, acute or chronic, into the bladder, vagina, 
 through the inguinal or femoral ring. 
 
 Concretions may form within or enter through the kidney and foreign bodies 
 through the peritoneal cavity, or from without through the overlying structures, single 
 or multiple, primary or secondary, remain or pass into the kidney, bladder, peritoneal, 
 rectal, vaginal, uterine cavity, or exterior through the overlying soft structures. 
 
 C})sts may be congenital or acquired, single or multiple, primary or secondary, 
 parasitic or non-parasitic, within the lumen, muscular coat of the ureter, rupture into 
 the ureter, kidney, bladder, vaginal, uterine, rectal, peritoneal or intestinal cavities, through 
 the cutaneous structures. Fallopian tubes or blood vessels. 
 
 Strictures may be congenital or acquired, single or multiple, primary or secondary, 
 partial or complete, vary in size, shape, and in any portion. 
 
 Fistulae may be congenital or acquired, single or multiple, primary or secondary, 
 acute or chronic, in any portion of the ureter, open into the rectum, vagina, uterus. 
 Fallopian tubes, peritoneal or alimentary cavities, or through the overlying soft cutaneous 
 tissues. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, single or multiple, in any portion or 
 structure. 
 
 Sarcomata may be primary or secondary, single or multiple, in any portion, especially 
 the muscularis, slow or rapid in growth, depending upon their character and origin, 
 the result of accidental or induced injury, the presence of concretions, foreign bodies, 
 or the introduction of sounds, and of myxomatous, rhabdomyomatous, or other varieties. 
 
 Page Seventy-Eight 
 
INJURIES. 
 
 Ruptures of the ureter may be primary or secondary, single or multiple, partial 
 or complete, longitudinal or circular, lateral, posterior or anterior, into the peritoneal, 
 uterine, rectal or vaginal cavities, bladder, surrounding soft structures, or kidney. 
 
 Punctures may be induced from within, primary or secondary, through the kidney 
 or bladder, result from foreign bodies, concretions or introduction of sounds, through 
 the peritoneal, uterine, rectal, or vaginal cavities, or overlying soft structures, and in 
 any portion of the ureteral vv^all. 
 
 Incisions may be accidental or induced, primary or secondary, longitudinal, or 
 circular, in any portion of the ureteral wall, kidney, bladder, through the rectal, vaginal, 
 uterine, or peritoneal cavities, or through the overlying soft structures when induced 
 for extra-peritoneal ureterotomy. 
 
 SYMPTOMS. 
 
 Symptoms pertaining to ureteral conditions herein described too frequently fail in 
 diagnosis, especially the symptoms of pain and tenderness, two of the prominent and 
 constant mdications, because the sensitive nerve fibers which supply the ureter are 
 intimately associated with those of the kidney and bladder and their adjacent structures, 
 thus permitting similar impulses due to nregular conditions within them to be transmitted 
 through their nerve fibers. This difficulty obtains with the existence of occlusion which 
 greatly aggravates all others and becomes the most prominent factor. 
 
 Pain and tenderness in the ureter predominate in local manifestations but un- 
 fortunately they are not diagnostic, especially in the female, but when they persist with 
 general disturbances such as chill, headache, shock, perspiration, nausea and vomiting, 
 sufficient evidence is deduced to suspect ureteral conditions. There is probably no part 
 of the genito-urinary tract so difficult to determine symptomatically. 
 
 Tenderness may indicate many conditions or none at all because its degree 
 varies with the closeness of the ureteral lesion to the bladder which increases intensity. 
 Bladder symptoms of every kind, especially those due to irritation, frequent urination 
 and tenesmus are very confounding. The lower male ureter may sometimes be palpated 
 through the rectum, but the point of lesion is not then made certain. 
 
 Page .Sevoiit\-Nim 
 
CHAPTER XII. 
 
 KIDNEYS. 
 
 (Male and Female.) 
 
 ANATOMY. 
 
 Fig. 46. 
 
 IDNEYS exceed in weight that of the other urinary tissues com- 
 bined, bmt their consideration will be but slightly more than passing 
 because their blood, nerve and lymphatic systems are independent 
 of the other portion of the urinary apparatus and far distant from 
 the pelvic tissues. 
 
 It might be said that there is no physiologic relation of the 
 kidneys to the other portion of the urinary tract, except that of 
 a mechanical character, because of their independent relation. 
 
 Blood Vessels. There should be one renal artery for each 
 kidney, but there may be two or even more and the right is greater 
 in length. 
 
 Vessels supplying the kidney do not anastomose with each 
 other as each end artery provides for a particular area of renal 
 substance (Piersol). 
 
 The nerves of the kidney are derived from the renal plexus 
 
 Page Eighty 
 
formed by contributions from the solar and aortic j^lexuses and the least splanchnic 
 nerve. 
 
 The plexus accompanies the renal artery which it surrounds. Within the latter is 
 formed a well-marked perivascular network from which a number of twigs are given off 
 to supply the walls of the pelvis and ureter, while the majority accompany the vessels into 
 the kidney. 
 
 Because of the almost total absence of sensory nerve fibers in the kidney tissue, very 
 little if any pain, can be produced within from any cause except obstruction. 
 
 I he lymphatics of the l(idney)s arise from two networks, one superficial and the other 
 deep. 
 
 The superficial network, which was observed by Mascagni, has not been seen by 
 Ludwig and Kolliker. The new classical researches of Leichmann and Stahr, however, 
 leave no doubt as to its existence; but it is extremely difficult to infect. Immediately under- 
 neath the capsule, it is remarkable for the tenuity of its meshes. 
 
 This network tw^o systems of collecting trunks arise which, following Sappy, 
 we may divide into convergent and divergent. The convergent empty themselves into the 
 collecting trunks of the deep network either by immediately sinking into the depth of the 
 kidney, or by running under the capsule only to join the deep collecting trunks near the 
 hilum, the divergent trunks perforate the fibrous capsule, and pass into the network which 
 vv^e shall describe further on when dealing with the fatty capsule of the kidney. The ar- 
 rangement of the deep network eventually gives origin to large collecting trunks, varying 
 in number from four to seven, which leave the kidney at the hilum. These trunks course 
 around the artery and the renal vein. They are usually satellites of the vein, some running 
 on into anterior, and some on its posterior surface. The mode of termination of the renal 
 lymphatics varies on the two sides. On the right, we may divide the vessels into anterior 
 and posterior. The anterior trunks run in front of the renal vein, and pass downwards 
 and inwards and terminate in the pre-venous mass of right juxta-aortic glands. They 
 usually terminate in the group of the above mentioned glands, which is situated on the 
 anterior surface of the vena cava, immediately below the opening of the renal veins into 
 the inferior cava, but one of them may often be seen to end in a gland belonging to the 
 same group, placed much lower down, close to the bifurcation of the aorta. It is equally 
 common to see one of these trunks end in a gland of the pre-aortic group. The posterior 
 trunks are shorter than the preceding, and are placed behind the vein and renal arteries. 
 They terminate in two or three large glands situated behind the inferior vena cava, in front 
 of the right pillar of the diaphragm. These glands belong to the retro-venous group of 
 the right juxta-aortic glands. Their different vessels pass through the right pillar of the 
 diaphragm traversing it through the same orifice as the great splanchnic nerve, and ter- 
 minate in the thoracic duct. On the left, the collecting trunks, which leave the kidneys 
 at the hilum terminate in four or five glands which belong to the juxta-aortic group of the 
 corresponding aorta. The highest of these glands are situated in front of the left pillar of 
 the diaphragm, through which their efferent vessels pass on their way to join the thoracic 
 duct. To sum up, the lymphatics of the kidneys end principally in the juxta-aortic glands 
 of the corresponding side and accessorily in the pre-aortic glands. In any case it is, if 
 not absolutely incorrect, at least insufficient, to state that the lymphatics of the kidneys 
 terminate in the glands placed at the level of the hilum of these organs. At the level 
 of the hilum, however, we may meet with some small glandular nodules, but by reason of 
 their contiguity and their small size, they should be regarded as belonging to that variety 
 of gland which we have described above as the interrupting glandular nodule (Schalt- 
 driisen) and which it is important to distinguish from the regional glands which are much 
 more constant in their presence and situation (Stahr). One of these nodules is, however, 
 distinguished by its relative frequency and by its fairly constant situation beneath the right 
 renal vein, in the angle which this vessel forms with the inferior vena cava. 
 
 The fatt^ capsule of the l(idne^ possesses a rich lymphatic network which has been 
 recently described by Stahr. The efferents of this network end in the same glands as the 
 collective from the kidney itself. The network of the fatty capsules communicates, as 
 
 Page Eighty-One 
 
we have seen, with the lymphatics of the kidney, and it is not rare to find during the 
 progress of epithehal cancers of this organ, lines of new growth in the fatty capsule. 
 
 Lymphatics of the Suprarenal Capsule. — The lymphatics of the suprarenal capsules, 
 whose mode of origin will be studied together with the structures of these organs, end in 
 four or five collecting trunks, which emerge at the same point as the large centre^^ vein, 
 and terminate in the juxta-aortic glands of the corresponding side. In several subjects, 
 these collecting trunks have been seen to perforate the pillars of the diaphragm and end 
 in the glands placed between the posterior surface of these pillars and the vertebral column. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Diseases | Bf^/.^"- 
 
 (^ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, vary in shape, size, position, number 
 and relation to other structures. One or both may be absent, which last event would 
 preclude the possibility of life existing after birth for any great length of time, but the 
 absence of one does not prevent the continuance of life. One or both kidneys may be ex- 
 cessively lobulated, large or small, and functionate normally in amount and frequency. 
 
 One or more ureters originate in the same kidney and the proverbial horseshoe kidney, 
 probably exists as one kidney. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Nephritis may be congenital or acquired, primary or secondary, unilateral or bilateral, 
 acute or chronic, local or general, mild or severe. 
 
 Tuberculosis may be primary or secondary, acute or chronic, single or multiple, more 
 frequently primary, infected simultaneously, at different times, or one alone affected, ap- 
 pear in any portion, disappear spontaneously, or continue to its destruction. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, in 
 any portion of one or both simultaneously. 
 
 Papillomata may be congenital or acquired, primary or secondary, involve any por- 
 tion or all of one or both, usually both. 
 
 Adenomata may be congenital or acquired, primary or secondary, unilateral or 
 bilateral, single or multiple, vary in size, shape, number and location. 
 
 Lipomata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Rhahdomyomata may be congenital or acquired, primary or secondary, vary in size, 
 shape and location. 
 
 Concretions may be congenital or acquired, primary or secondary, single or multiple, 
 remain in the pelvis, escape into the cortex, and vary in size (from sand-like grains, to 
 several ounces) , shape and number. 
 
 Fistulce may be congenital or acquired, single or multiple, primary or secondary, acute 
 or chronic, originate in the pelvis, or cortex, appear in the peritoneal cavity, upon the 
 
 Pag-e Eighty-Two 
 
cutaneous surface, through the overlying soft structures, pleural cavity, stomach, intestinal 
 tract, rectum, vagma, bladder or Fallopian tubes. 
 
 Floating l(idne^ may be congenital or acquired, primary or secondary, unilateral or 
 bilateral, vary in degree; it is usually the right kidney and is more frequent in the female. 
 
 Cysts may be congenital or acquired, primary or secondary, single or multiple, vary 
 in size, shape, in any portion, the pelvis alone, contain blood, pus, serum, occeisionally 
 ecchinoccocci, or dermoid material, rupture into the ureter, peritoneal, alimentary or pleural 
 cavities. Fallopian tube, uterus, bladder, rectum, vagina or overlying soft structures. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, usually primary, and single, and extend 
 into the ureter before involving the surrounding structures. 
 
 Sarcomata may be primary or secondary, usually primary, seldom multiple, and 
 extend into the adjacent soft structures. 
 
 INJURIES. 
 
 Rupture may be accidental or induced, single or multiple, primary or secondary, from 
 causes without or within, longitudinal or circular, each varying in extent, partial or com- 
 plete, into the pleural or peritoneal cavity or overlying soft structures. 
 
 Lacerations may be accidental or induced, primary or secondary, single or multiple, 
 complete or incomplete, from without or within, in any direction, involve the peritoneal, 
 pleural, or alimentary cavity or organs. 
 
 Punctures may be accidental or induced, primary or secondary, single or multiple, 
 in any part of the organ, from without or within, through the peritoneal cavity or the 
 overlying soft structures, the result of instrumentation, through the ureter or pelvis of the 
 organ. 
 
 Incisions may be accidental or induced, single or multiple, primary or secondary, 
 penetrating or non-penetrating, from without or within, in any portion of the organ, longi- 
 tudinal or circular and involve the surrounding tissues. 
 
 SYMPTOMS. 
 
 Symptoms of f(idney irregularities are highly intensified because of its size, function 
 and intimate association with organs of equal importance, namely the liver, pancreas, 
 stomach, duodenum, biliary tract, and diaphragm, each of which is supplied with numer- 
 ous sensitive nerve fibers, many of which are from the same origin, but few of which have 
 even slight association with the perineal group. 
 
 It is thus observed that nephritic symptoms are almost independent of those found 
 in the uro-genital tract which is so thoroughly dominated by the sympathetic and sacral 
 plexuses. For this reason nephritic symptomatology cannot be placed in parallel lines 
 with that of the pelvic organs and perineum. But as all kidney secretions, both normal 
 and abnormal, naturally drain through the ureters into the bladder to make their exit 
 through the urethra, primary symptoms are produced within these organs and tissues which 
 cause symptoms of all combined. 
 
 The general influence of renal pathology is usually severe, and local manifestations, 
 such as pain, and tenderness, are fair indications of beginning renal disease, but when 
 these exceptions are increased in severity, and associated with chill, headache, shock, per- 
 spiration, nausea, and vomiting, their intensity is lost. 
 
 rage Eishty-Three 
 
CHAPTER XIII. 
 
 ERECTILE BODY. 
 
 (Penis Clitoris.) 
 ANATOMY. 
 
 Fig. 47. — Male urethra cleft dorsally (Deaver). 
 
 "^OV Q/^ HE ISCHIO-CAVERNOSUM, also named erector penis, and 
 w ji\ if Cy erector clitoris, represents the lateral portion of the sphincter 
 
 S^/^ RxV-y^ cloacae. The two muscles occupy the lateral parts of the super- 
 
 ficial perineal interspace, each arising from the base of the tu- 
 berosity of the ischium enclosing the base of the crus penis- 
 clitoris as in a sheath and passing forward to be inserted into the 
 corpus cavernosum. The muscle in the female differs from that 
 in the male only in size. 
 
 Its function is to compress the corpus cavernosum and thus 
 assist in producing or maintaining erection of the penis or clitoris. 
 The artery of the corpus cavernosum (profunda penis in 
 the male, profunda clitoris in the female) is usually the larger 
 of the two terminal branches. Immediately after its origin it 
 enters the crus penis and runs forward in che corpus cavernosum 
 which it supplies. 
 Bulbo Cavernosum differs in its relations in the two sexes, being in the male the ac- 
 
 Page Eig'hty-Four 
 
celerator urinae, the two muscles of the opposite sides being united in a median fibrous 
 raphe which extends forward from the central tendon of the perineum over the bulbo and 
 corpus spongiosum. Arising from this raphe the fibers are directed laterally and forward 
 over the bulb and corpus spongiosum to become inserted into the under surface of the 
 inferior layer of the uro-genital trigone and into the fibrous sheath of the corpus caver- 
 nosum, some of the more anterior fibers being continued dorsally to be inserted mto the 
 fascia covering the dorsum of the penis and forming what has been termed the muscle of 
 Hauston, or compressor venae dorsalis penis, and sphincter vaginae in the female. 
 
 The arler}) to the bulb, a branch of which is usually of relative large size, is given 
 off between the layers of the triangular ligament. It runs transversely inwards along the 
 posterior border of the compressor urethra, and then turning forwards a short distance from 
 the outer side of the urethra, pierces the anterior layer of the triangular ligament amd enters 
 the substance of the bulb. It passes onwards in the corpus spongiosum to the glans where 
 it anastomoses with its fellow and with the dorsal arteries of the penis. It supplies the 
 compressor urethra muscle, Cowper's gland, the corpus spongiosum, and the penile part of 
 the urethra. In the female this artery supplies the bulb of the vestibule. 
 
 The dorsal artery of the penis passes forward between the layers of the suspensory 
 ligament, and runs along the dorsal nerve immediately to its outer side, whilst it is sepa- 
 rated from its fellow of the opposite side by the median deep dorsal vein. It supplies 
 the superficial tissues on the dorsal aspect of the penis, sends branches to the corpus 
 cavernosum, and its terminal branches enter the glans penis, where they anastomose with 
 the arteries to the bulb. It also anastomoses with the external pudic branches of the femoral. 
 
 The nerve supply of the bulbo cavernosus is from the perineal branches of the pudic 
 nerve and its purpose to compress the bulb and corpus spongiosum and to assist in ex- 
 pelling the fluid contained in the urethra. The muscular fibers which pass to the dorsum 
 of the penis or clitoris may aid slightly in their erection either directly or by compressing 
 the dorsal vein. 
 
 The integument of the root of the penis is supplied by the ilio-inguinal and inferior 
 pudendal nerves and the body and prepuce by the branches of the dorsal nerves. Branches 
 of the pudic supply the bulbus urethra and mucous membrane of the urethra and each corpus 
 cavernosus by a deep branch from the dorsal nerve. 
 
 Perineal branches of the pudic, ilio inguinal, and sympathetic nerves from the hypo- 
 gastric plexus control the erection of the penis and clitoris. 
 
 Lymphatics of the Clans Penis. — The collecting trunks of the glands arise from a 
 fine network which partly drains the network of the prepuce and the balanitic portion of 
 the urethra. These collecting trunks are two or three in number. The exact point of 
 origin is at the frenum, since a series of finer collecting trunks drain and converge at this 
 point. Two or three trunks which drain the mucous membrane of the urethra also empty 
 into the main collecting trunks. The course of the main collecting trunks is around the 
 corona of the glands and from two to four collecting trunks and anastomose with those 
 of the opposite side, which run parallel with the dorsal vein of the penis, and terminate in 
 the pre-symphysical at the penile root. 
 
 The cutaneous lymphatics of the penis are divided into two sets the lymphatics of 
 the sheath, and the lymphatics of the prepuce. 
 
 Lymphatics of the sheath have four or five collecting trunks. They differ in length. 
 Those most anterior are longer. These collecting trunks take their origin from the dense 
 lymphatic network of the prepuce. The collecting trunks pass around the lateral surface 
 of the penis to the dorsal surface; after which they pass to the penile root, where they 
 make a sharp turn outwards to the inguinal glands. 
 
 Lymphatics of the prepuce originate from the fine network in the plicature of the 
 skin of the preputial fold. They are also continuous from the lymphatics of the glands in 
 the balanitic portion. The collecting trunks vary in number from, one to two, to a mul- 
 tiplicity of collecting tmnks. 
 
 Their course is along the dorsum of the penis, near the superficial dorsal vein. When 
 more than one trunk exists they give off anastomosing branches along their course, at the 
 
 Page Eishty-Five 
 
penile root. If only one trunk is present it may divide into two trunks, which are equal in 
 size or it may continue without division to its limitation which is an inguinal gland. When 
 several trunks exist they form two at the penile root. They usually terminate in the supero- 
 internal group. Yet, however, they may also terminate in other glandular groups of this 
 region. The collecting trunks are located just beneath the integument. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 Male Erectile BodV- 
 
 Anomalies. 
 
 D"l Benign. 
 iseases ^ ^;, ,•* 
 
 J Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies of the erectile bodies may be congenital or acquired, primary or secondary, 
 vary in position and relation to other tissues, the blood, nerve, and lymph supply more or 
 less than normal and any one or more of its structures, wanting in part or their entirety. 
 
 Shape may be regular or irregular, smooth or nodulated, curve upward, down- 
 ward, to either side, taper excessively from the proximal or distal end. 
 
 Blind Pouches may be congenital or acquired, single or multiple, vary in size, shape 
 and location and contain mucus or serum. 
 
 Shape may be excessively long or short, diameter vary greatly from end to end, single 
 or multiple, position to the right or left of the median line, high or low, concealed in part 
 or its entirety, within the scrotum, perineum, groin or upper thigh. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, due to trauma or infection in any tissue or portion of the erectile body, 
 continue, cease to grow or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, acute or chronic, primary or seconda^y^ in 
 the form of chancre, chancroid, gumma, single or multiple, vary in size, shape and location. 
 
 Tuberculosis may be acute or chronic, primary or secondary, single or multiple, vary 
 in size, shape or location in any tissue. 
 
 Fibromata may be congenital or acquired, single or multiple, primary or secondary, 
 in any portion of the gland, originate in any tissue and extend into the adjacent structures. 
 
 Lipomata may be congenital or acquired, single or multiple, primary or secondary, 
 round, oblong, smooth or lobulated in any of the fatty structures, vary in size, remain 
 dormant, increase or diminish in size or disappear spontaneously. 
 
 Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in shape, location, usually without pedicle, and in any tissue. 
 
 Concretions may be congenital or acquired, primary or secondary, single or multiple, 
 soft or hard, usually between the gleind and prepuce, vary in size, shape, and number in 
 
 the body. 
 
 Bon^ deposits may be congenital or acquired, primary or secondary, single or mul- 
 tiple, hard or soft, vary in shape, size and location, involve a part or all of the organ, the 
 walrus, raccoon, many monkeys, dog and many members of the negro race being examples. 
 
 Page Eighty-Six 
 
Horn^ g;olP//is may be congenital or acquired, primary or secondary, single or mul- 
 tiple, vary in size, shape and location, continue or cease to grow, or disappear spontaneously. 
 
 Lymphangitis may be congenital or acquired, primary or secondary, acute or chronic, 
 mild or severe. 
 
 Lupus may be primary or secondary, vary in shape, size and position. 
 
 Gangrene may be mild or severe, in any portion, with partial or complete loss of the 
 organ, always acute. 
 
 Elephantiasis may be congenital or acquired, primary or secondary, acute or chronic, 
 from slight to enormous in size, usually general. 
 
 Cysts may be congenital or acquired, single or multiple, primary or secondary, con- 
 lain blood, pus, mucus or serum, originate in any of the structures, especially externally, 
 rupture into the rectum, urethra, bladder, perineum, scrotum, vagina, uterus or peritoneal 
 cavity. 
 
 Fistulae may be congenital or acquired, single or multiple, primary or secondary, 
 extend from the urethral canal through the cutaneous structures, connect with the rectum, 
 vagina, bladder, peritoneal or uterine cavities or through the perineal body, several chan- 
 nels existing at the same time. 
 
 Phimosis may be congenital or acquired, primary or secondary, acute or chronic, 
 partial or complete, with or without adhesions. 
 
 Paraphimosis may be congenital or acquired, primary or secondary, acute or chronic. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, usually primary, and single, in any 
 tissue, especially the prepuce corona or distal end of the gland. 
 
 Sarcomata may be primary or secondary, in any tissue amid portion of the glauid. 
 
 INJURIES. 
 
 Ruptures, lacerations, punctures, incisions and contusions may be the result of acci- 
 dent or design, penetrating or non-pentrating, primary or secondary, smooth or irregular, 
 longitudinal or circular, in any portion of the body. 
 
 Fractures may be congenital or acquired, usually acquired, single or multiple, by 
 accident or design, complete or incomplete, in any portion of the body. 
 
 Dislocations may be congenital or acquired, forward, backward or to either side. 
 
 SYMPTOMS. 
 
 Symptoms pertaining to the erectile body in the male and female are very similar 
 physiologically, tenderness, pain and general nervous disturbances being most prominent. 
 
 Pain of any degree may be acute or chronic, primary or secondary, and sometimes 
 due to conditions far distant to the erectile body. Adhesions and furuncles about the 
 clitoris are not uncommon causes, but any disease or irritation may cause erection of this 
 body, or it may be purely psychical, \vith or without frequent desire to urinate and the 
 amount of urine increased. 
 
 Cardio-vascular disturbances resulting from abnormal conditions of the male repro- 
 ductive organs are more or less in evidence, especially with infections and advanced pros- 
 tatic conditions. Those affecting the erectile body, testes, spermatic ducts and scrotum 
 being not so highly manifested. 
 
 Vascular symptoms of the male erectile body are induced by severe and prolonged 
 pain, the pulse-rate varying from slow to rapid as the result of these causes but the rate 
 and quality may change from time to time without any perceptible irregularity in the organ. 
 
 Urinary disturbances are always present with any pathology or trauma that may 
 exist in the erectile body of the male. The amount of urine may be greatly increased' or 
 diminished and contain blood, pus, concretions or necrotic tissue and cause severe burning 
 or tenesmus, or it may escape through one or more of the many forms of artificial openings. 
 
 Page Eighty-Seven 
 
CHAPTER XIV. 
 
 PROSTATE GLAND. 
 ANATOMY. 
 
 open into the prostatic 
 
 Fig. 48. 
 
 HE PROSTATE GLAND normally is composed of two lateral 
 and a m.iddle lobe, the three combined being about the size and 
 shape of a large horse chestnut, in the adult, and weighs about 
 '/2 ounce. The middle lobe which is about the size of a pea is 
 frequently absent while the lateral lobes vary in shape and size, 
 one of which may be also absent. The three lobes are enclosed 
 m a thin, firm, fibrous, capsule and the urethra and seminal ducts 
 pass through the gland but often vary in their course. The two 
 small yellow bodies about the size of a pea which lie beneath the 
 anterior part of the membranous urethra close behind the bulb 
 and are enclosed in the transverse fibers of the compressor urethra 
 muscle, were discovered by Cowper for whom they are named. 
 The prostate gland is composed of many fcllicles and muscular 
 fibers in such a number as to form fifteen to twenty channels 
 designated as secretary ducts lined with columnar epithelian and 
 urethra. 
 
 Page Eig-hty-Bight 
 
The prostatic muscle is supported upon the anterior wall of the bladder by fibers of 
 the levator ani, which are also called levators of the prostate on the sides. 
 
 Leuckhart states that in women there exists a true rudimentary prostate, consisting 
 principally of mucous follicles and situated between the beginning of the urethra and the 
 reflection of the vagina. Flodgson also states that Virchow admitted the existence of this 
 body, found at the neck of the bladder, especially in old women. 
 
 Most observers have held that the glandular portion of the prostate originates from 
 the urethra and the stroma of the organ develops from a thickening of the genital chord, 
 but Griffiths and Richardson who have made a detailed study of this gland say that no 
 part is developed from the genital chord. 
 
 The blood suppl]; is from the middle hemorrhoidal, inferior vesical and internal pudic 
 artery while a large venous plexus surrounds it. Into this plexus veins of the penis open 
 and communicate with the vesical plexus and drain into the iliac veins. These veins which 
 become larger with advanced age, besides draining the dorsal veins, also drain those of the 
 
 Fig. 49. — Bladder, prostate, seminal vesicles, vasa deferentia (Deaver). 
 
 bladder, seminal vesicles and the rectum, and are continued as the prostatic vesical plexus, 
 tributary to internal iliac veins. 
 
 Nerve supply is from the hypogastric plexus in the form of sympathetic fibers asso- 
 ciated with small ganglia along their course. Pacinian corpuscles are said to be con- 
 nected with the sensory fibers (Piersol). 
 
 Lymphatics of the prostate arise by fine capillaries arranged in the form of a net- 
 work around each glandular acinus. From these periacinous networks, run larger ves- 
 sels which pass towards the periphery of the gland, and form at its surface a second 
 network, the peri-prostatic network, from which the collectors start. The latter which 
 are symmetrically arranged on each side of the gland, may run in four different directions. 
 
 A primary trunk starts from the posterior surface of the prostate, and runs on to 
 the bladder in the triangle between the vasa deferentia. It ascends as far as the middle 
 part of the postero-superior surface of the bladder, where it curves sharply outward, across 
 
 Page Eighty-Nine 
 
the hypogastric artery, and terminates in the middle gland of the middle chain of the 
 external iliac group. In its retro-vesical course, this trunk describes numerous curves; it 
 may pass through some small interrupting glandular nodules (Schaltdriisen) close to the 
 spot where it crosses the hypogastric artery. This ascending channel frequently consists 
 of two trunks which then terminate in the middle and superior glands of the middle chain. 
 
 A second collector arising like the preceding from the posterior surface of the pros- 
 tate, accompanies the prostatic artery. Like the latter, it runs upwards, outwards and 
 backwards, and terminates in one of the middle glands of the hypogastric group. In 
 the neighborhood of the prostatic origin of this trunk, two or three small glandular nodules 
 are almost constantly found. 
 
 Ttpo or three other collecting trunks also start from the posterior surface of the 
 gland, and run at first downwards, and then backwards. They enter the sacro-recto- 
 genital aponeurosis, cross the lateral surface of the rectum, and then ascend on the an- 
 terior surface of the sacrum. They do not all terminate in the same manner. The 
 shorter and more external end in the lateral sacral glands, which as we have already seen, 
 are usually situated internal to the second sacral foramen, the longer and more internal 
 pass as far as the promontory to terminate in the glands situated there. 
 
 Finally, from the anterior surface of the prostate may be seen a descending trunk 
 which runs towards the pelvic floor, where it unites with the vessels coming from the 
 membranous portion of the urethra. In company with the latter, it embraces the artery 
 of the corpus spongiosum, and then runs with the internal pudic ; it finally terminates in a 
 gland of the hypogastric group, situated on the intrapelvic portion of the trunk of the 
 internal pudic artery. The descending prostatic channel, which was observed in the dog 
 by Walker, has also been found in man by Marcille (three times in fifteen subjects). 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 P^. / Benign. 
 
 Uiseases. S iv/r r . 
 ^ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, single or multiple, primary or secondary, 
 vary in shape, number, position, size and relation to other tissues, or none at all but doubt 
 exists about the total absence of prostatic tissue. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Adenomata may be congenital or acquired, single or multiple, primary or secondary, 
 usually primary, in any portion of one or more glands, vary in size, shape, location, cease 
 to grow, continue to increase in size, disappear spontaneously, undergo cystic or malig- 
 nant chcinges. 
 
 Papillomata may be congenital or acquired, single or multiple, primary or secondary, 
 usually primary, in any portion of one or more glands, vary in size, shape, location, cease 
 
 Pag-e Ninety 
 
to grow, continue to increase in size or disappear spontaneously, and are usually pedun- 
 culated when upon the surface. 
 
 Tuberculosis may be primary or secondary, acute or chronic, vary in size, shape and 
 location in any tissue. 
 
 SypInUs may be congenital or acquired, primary or secondary, acute or chronic, vary 
 in size, shape, location, in any tissue in the form of gumma. 
 
 Cysts may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, contain blood, pus, mucus, serum, seminal fluid, dermoid material, eccliinococci, 
 rupture into the bladder, urethra, rectum, perineum, peritoneal cavity, or through the over- 
 lying soft structures anywhere upon the surface about the pelvis or upper thigh. 
 
 Concretions may be congenital or acquired, primary or secondary, single or multiple, 
 large or small, soft or hard, escape from the bladder into the prostate, rupture to pass into 
 the rectum, urethra, perineum or peritoneal cavity. 
 
 Foreign bodies may enter the gland through the bladder, rectal wall, urethra, peri- 
 neum, skin, the overlying soft structures become encysted or pass into the rectum, urethra, 
 bladder, perineum, peritoneal cavity or overlying soft structures. 
 
 Fisiulae may be congenital or acquired, single or multiple, acute or chronic, open 
 into the bladder, rectum, perineum, urethra, peritoneal cavity or soft structures and skin, 
 vary in size, shape, and number. 
 
 MALIGNANT. 
 
 Carcinomaia may be primary or secondary, usually primary, single, or multiple in 
 one or all of the three lobes and involves by extension one or all of the surrounding tissues. 
 
 Sarcomata may be primary or secondary, single or multiplle, almost invariably 
 single, usually originate in the body of the gland, and extends into the surrounding structures. 
 
 INJURIES. 
 
 Ruptures, punctures, incisions, may be primary or secondary, in the gland through 
 the urethra, bladder, rectum, perineum or peritoneal cavity, by accident or design, and 
 involve a part or all of the adjacent soft structures. 
 
 SYMPTOMS. 
 
 S]^mpioms, prostatic in character, are pronounced when extreme irregularities are 
 present especially when the flow of urine is obstructed. 
 
 They are often difficult to define because the gland is concealed within a capsule and 
 because of the relation of the capsule to other important structures richly supplied ^vith nerve 
 fibers, blood vessels and lymphatics. The earlier symptoms are especially difficult to de- 
 fine but those advanced are more definite. 
 
 Pain becomes more severe with advanced conditions but pain in the prostate may 
 be reflected from sources far distant from the gland. 
 
 The pain may be dull and heavy, of a bearing down character, at times resembling 
 the sensation of burning with more or less urethral and rectal tenesmus. There is always 
 local tenderness and when far advanced it may be general throughout the pelvis asso- 
 ciated with general irritability, emaciation and exhaustion. Pain may be suprapubic, in 
 the lumbar region, at times of urination or defecation, retention, tenderness, frequent urina- 
 tion, all of which resemble those pertaining to stone in the bladder. 
 
 All of these symptoms may indicate conditions other than prostatic. 
 
 Page Ninety-One 
 
CHAPTER XV. 
 
 COWPER'S GLANDS. 
 
 it/Ov^T^i - 
 
 Fig. 50. (Ayers.) 
 
 OWPER'S GLANDS are situated between the two layers of the 
 triangular ligament, anteriorly to the prostate gland. Normally 
 there are two in number, but there may be only one. Discovered 
 1696. 
 
 They are ovoid in shape just beneath the membraneous por- 
 tion of the urethra, close to the mid-line on each side. They 
 are the size of an ordinary pea, irregular and somewhat knobbed 
 in shape. They are of a pinkish hue, firm imbedded in the 
 fibers of the compressor urethra muscle. The ducts are 1 .5 mm. 
 in diameter, 3.4 mm. in length. They open by small slit-like 
 orifices on the lower wall of the bulbus urethra near the mid line. 
 The ducts sometimes open into the urethra by a common orifice. 
 They are homologous with the Bartholin glands in. the female 
 and are accessory organs. 
 
 TliQ blood supply are twigs from the arteries of the bulk, 
 and the veins are tributary to those returning the blood from the bulbus spongiosum, which 
 empty into the internal pudic. 
 
 The lymphatic are afferents to the internal iliac lymph nodes. 
 
 Besides anomalies (which is probably of little importance), the various forms of 
 disease and growths may be found involving these glands. If so, they must play a 
 
 Page Ninety-Two 
 
prominent role in symptomatology, especially mflammation due to gonorrhea, the most 
 common form of disease. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Diseases | P,^"'^"- 
 
 l^ Malirnant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location or entirely absent. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Inflammation (Cowperitis) may be primary or secondary, acute or chronic, unilateral 
 or bilateral, usually the result of gonorrheal infection, more frequent than suspected, and 
 of more importance as an etiologic factor than accredited. 
 
 Adenomata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Papillomata may be congenital or acquired, primary or secondary, vary in size, 
 shape, number and location. 
 
 Tuberculosis may be primary or secondary, acute or chronic, local or general, cease 
 to grow or disappear spontaneously. 
 
 Syphilis may be congenital or acquired, primary or secondary, acute or chronic, 
 become arrested, continue to destruction or disappear spontaneously. 
 
 Cysts may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, vary in size, shape and rupture mto the urethra (its natural course), rectum, 
 bladder, perineum or peritoneal cavity. 
 
 Fisiulae may be primary or secondary, usually acquired, single or multiple, vary in 
 size, shape and location, open into the urethra, bladder, prostate, rectum, perineum or 
 peritoneal cavity. 
 
 MALIGNANT. 
 
 Carcinoma may be primary or secondary, single or multiple, vary in size, shape and 
 location. 
 
 Sarcomata may be primary or secondary, usually primary and single, vary in size, 
 shape and location. 
 
 INJURIES. 
 
 Lacerations and contusions may be by accident or design, primary or secondary, single 
 or multiple, through the urethra, or rectum and usually caused by the introduction of sounds. 
 
 SYMPTOMS. 
 
 S})mptoms of conditions within Cowper's gland have not been given due considera- 
 tion because of their size and inaccessibility. Their exposure to infections is equally as 
 great if not greater than the spermatic ducts beyond them, but their concealment in the 
 deeper structures prevents any definite conclusions whatever bemg devolved from symptoms 
 which they produce. They are no doubt similar to those resulting from genito-urinary and 
 rectal conditions in general, but especially of the prostate and posterior urethra. 
 
 It is therefore impossible to ascribe to Cowper's glands at this time, any definite 
 symptomatology. 
 
 Pase Ninety-Three 
 
CHAPTER XVI. 
 
 TESTICLES. 
 ANATOMY. 
 
 held together by delic 
 
 Fig. 51. (Deaver.) 
 
 HE TESTES are two glandular organs which secrete the semen. 
 They are slightly compressed ellipsoidal bodies, suspended in 
 the scrotum by the spermatic cord, the left lower than the right. 
 They each measure about 4j/2 cm. in length, 2 J/2 cm. in width 
 and 2 cm. in thickness. 
 
 In early foetal life they are in the abdomen, post-peritoneal. 
 Before birth they descend into the scrotum through the inguinal 
 canal, carrying along the various layers, nerves, blood vessels, etc. 
 
 The framework proper consists of a stout capsule, the tunica 
 albugima, which gives form to the organ and protects the sub- 
 jacent glandular tissue. 
 
 From the greatly thickened posterior portion of the tunica 
 
 albuginea, numerous septa arise which pass forward and divide 
 
 the organ into separate compartments (or lobules) each of which 
 
 contains from one to three greatly convoluted seminiferous tubules 
 
 ate vascular, intertubular connective tissue. 
 
 Pas-e Ninety- Four 
 
Blood supply is from the spermalic artery which is a branch of the aorta. It is a 
 long slender vessel entering upon the posterior border of the testis, where it imnnediately 
 breaks up into many branches which enter the diastinum testis to become distributed along 
 the septa and on the deep surface of the tunica albuginea. 
 
 The veins issuing from the posterior border of the testis, form a dense plexus called 
 the plexus pampiniformis, which finally pours its blood through the spermatic vein, on the 
 right side, into the vena cava, on the left side the spermatic vein joins the left renal vein. 
 (Cunningham.) 
 
 Nerve supply for the testis accompanying spermatic artery and is derived through 
 the aortic and renal plexuses from the tenth thoracic segment of the spinal cord. The 
 afferent fibers from the epididymis appear to reach the spinal cord through the posterior 
 roots of the eleventh and twelfth thoracic and first lumbar nerves. The arteries and nerves 
 of the testis communicate with those on the lower part of the vas deferens, namely, with 
 the artery of the vas and with twigs from the hypogastric plexus. 
 
 Gerald Maichant laid great stress upon the sinuosities of these collecting trunks. They 
 are caused by the penis alternating between the erect and flaccid state. 
 
 Lymphatics of the testicles anastomose with those of the epididymis, and those of 
 the visceral layer of the tunica vaginalis. They pass along the spermatic cord, in intimate 
 relation with its blood vessels. The former are more superficial than the latter. In the 
 lumbar region the lymphatics leave the spermatic cord and vessels, and as they do so 
 they make a regular curve or an acute angle. On the right side they terminate in the 
 juxta-aortic glands. One or two afferent trunks are received by the lowest gland, which is 
 located just above the bifurcation of the inferior vena cava. One or two of these lymphatics 
 also terminate in one-third of the cases, in the pre-aortic glands. 
 
 On the left side these lymphatics terminate in three or four of the juxta-aortic glands. 
 The latter are arranged in rows below the renal vessels. Sometimes, however, some of 
 these lymphatics also terminate in the pre-aortic glands. 
 
 The terminals of the left testicle are on a higher level than those on the right, except 
 in one-third of the cases, when they are on the same level. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Diseases ^ P,^";^"- 
 
 ( Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, single or multiple, primary or secondary, 
 vary in size, location, shape and structure, partially or completely concealed within the 
 abdominal wall, between the outer inguinal ring and scrotum, or one or both entirely wanting. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Orchitis may be congenital or acquired, primary or secondary, acute or chronic, 
 local or general, unilateral or bilateral. 
 
 Tuberculosis may be primary or secondary, single or multiple, acute or chronic, in 
 one or both simultaneously, in any of their tissues, especially in the earlier statues, in the 
 
 Payo Xinet\-Fi\-( 
 
primary form, confined to the gland or glands, or extend into their surrounding soft 
 structures. 
 
 Sy^philis may be congenital or acquired, primary or secondary, single or multiple, in- 
 volve one or both glands, continue in its destruction, remain stationary, disappear spon- 
 taneously or involve the overlying soft structures. ^^ 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, and involve either one or both glands, in any tissue. 
 
 Lipomaia may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, location and extend into the surrounding structures. 
 
 Retraction may be congenital or acquired, primary or secondary, partial or com- 
 plete, temporary or permanent, unilateral or bilateral. 
 
 Hemorrhagic infarct may be congenital or acquired, primary or secondary, usually 
 acute, vary m size, location and seventy. 
 
 Cysts may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, in one or both glands, originate in the cortex, the ducts, connect with the 
 peritoneal cavity into w^hich they may discharge, rupture through the external and cutaneous 
 structures, seldom if ever into the urethra, occasionally into the rectum, more frequently 
 into the perineum, contain blood, pus, serum, dermoid material, or echinococci, one or more 
 simultaneously. 
 
 Fistulae may be congenital or acquired, primary or secondary, single or multiple, con- 
 nect with the peritoneal cavity, urethra, rectum or perineum, one or all, at the same time, 
 become closed spontaneously, remain indefinitely, vary in size or course or rupture through 
 the soft structures. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, usually epitheliomatous and vary in 
 size, shape and number. 
 
 Sarcomata may be primary or secondary, vary in location, and in any tissue. 
 
 INJURIES. 
 
 Foreign bodies invariably enter the gland through the overlying soft structures. They 
 may be single or multiple, vary in size, location and character, become encysted, remain 
 permanently, escape into the scrotum where they may remain, or through which they 
 may afterward escape. 
 
 Ruptures, punctures, lacerations, incisions, and contusions may be the result of accident 
 or design, primary or secondary, single or multiple, involve any portion of one or both 
 glands to the degree of functional disturbance or destruction. 
 
 SYMPTOMS. 
 
 Symptoms associated with testicular variations are simple in character, therefore 
 easy to determine when compared to the deeper structures and organs of the perineum. 
 
 Pain is not always confined to these glands because of their inhibition being by 
 branches of the pudic which supplies so generally the perineum. 
 
 The milder forms of testicular conditions usually produce local symptoms, while 
 the more aggravated forms cause both local and general symptoms, severe in character 
 because all of the reproductive and urinary organs are likewise disturbed, especially with 
 the acute form of disease. 
 
 Page Ninety-Six 
 
CHAPTER XVII. 
 
 SPERMATIC DUCTS. 
 
 Epididymis. Vas Deferens. Seminal Vesicles. Ejaculatory Ducts. 
 
 ANATOMY. 
 
 0-tti drtpry of rij> Cefprerrs. 
 
 LRllCAi SECTION Of TCSTICLl SHOWING 
 THE A)!fiANG[M[Nrt)r THE DUCT3 
 
 "fSTtiE AND ihOj'Mii 
 
 Fig. 52. (Deaver.) 
 
 PERMATIC DUCTS are two tortuous canals, one on either side, 
 that connect the epididymi \vith the urethra and thus provide 
 channels for the escape of the products of the sexual glands. 
 Each of these ducts is divided into the vas deferens and its am- 
 pulla and the ejaculatory duct, at the upper end of the latter the 
 spermatic duct is connected with the seminal vesicles. 
 
 The spermatic ducts described by Deaver are pale and as- 
 sociated with pale medullary fibers from the hypogastric plexus 
 of the sympathetic nerve, for involuntary muscle fibres accompany 
 a greater part of the duct as a differential plexus, and the nerves 
 of the testis and epididymis are sympathetic fibers for the walls 
 of the blood vessels which they accompany as the spermatic and 
 the differential plexuses that surround the corresponding arteries. 
 They have been traced into the muscular tissue and the mucosa. 
 Within the muscles they form the dense myospermatic plexus. 
 
 I'iige Ninety-Seven 
 
Epididymis. The greatly convoluted beginning of the seminal ducts, covers the 
 entire posterior border and outer surface of the testis. 
 
 Blood Supply. Principally the deferential vessels, the spermatic emd the cremasteric 
 arteries. ^ 
 
 Nerve Supply. Spermatic and deferential plexuses which surround the correspond- 
 ing arteries. 
 
 Vas Deferens. This tube extends from the epididymis to the ejaculatory duct and 
 includes almost the entire length of the spermatic duct. 
 
 The ejaculatory duct is formed by the union of the ducts of the corresponding seminal 
 vesicles and vas deferens, and empties into the urethra. 
 
 Blood supply of spermatic ducts is chiefly the deferential from the internal iliac. It 
 also receives a branch from the middle hemorrhoidal. 
 
 Lymphatics of the P'as Deferens. The origin of the collecting trunks of the deferens 
 is supposed to be from two net works, viz. : the muscular and mucous. Some doubt, how- 
 ever, exists since the latter has never been injected. These collecting trunks terminate in 
 external retro-crural gland and in the middle chain of the external iliac glands. 
 
 Lymphatics of the seminal vesicles arise from a network, which is formed by the 
 anastomosis of two networks. One originates in the mucous coat, while the other takes 
 its origin in the muscular coat. 
 
 There are Two Collecting Channels. They anastomose with those of the urinary 
 bladder, and also vary much from those from the prostate. A posterior gland of the ex- 
 ternal iliac group, and a hypogastric gland are the terminals. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Df Benign. 
 iseases -I ,,, ,. 
 
 t_ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, single or multiple, primary or secondary, 
 partially or completely absent, long, short, large, small, sacculated, patulous, partially or 
 completely closed, for a short or long period, or they may never become patulous. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Inflammation may be primary or secondary, acute or chronic, involve a part or all 
 of the duct. 
 
 Tuberculosis may be acute or chronic, primary or secondary, single or multiple in 
 any portion, cease, or continue to develop, disappear spontaneouslj% or become perma- 
 nently destroyed. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 involve any portion, continue to develop or disappear spontaneously. 
 
 Cysts may be congenital or acquired, acute or chronic, primary or secondary, single 
 or multiple, gradually or suddenly disappear by draining into the urethra or rupturing 
 into the surrounding soft structures to become absorbed, or through them, externally upon 
 the skin, into the perineum, scrotum, rectum, bladder or peritoneal cavity. 
 
 Page Ninety -Eight 
 
Fistula may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, through the external soft structures, into the perineum, rectum, urethra, or peri- 
 toneal cavity and several channels connect two or more organs or cavities. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple 
 in any portion of the lube, vary in size, shape and number. 
 
 Lipomata may be congenital or acquired, primary or secondary, single or multiple, 
 remain stationary, continue to grow or disappear spontaneously. 
 
 Concretions may be congenital or acquired, primary or secondary, single or mul- 
 tiple, semisolid or hard, vary in size, shape and location, remain or escape into or through 
 the surrounding soft structures. 
 
 Strictures may be congenital or acquired, primary or secondary, single or multiple, 
 anywhere in the ducts, remain temporary or permanent (usually permanent) with loss of 
 function. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary (usually primary) single or multiple, vary 
 in location, involve any portion of one or both at the same time, though it is exceedingly 
 rare to have the two affected simultaneously. 
 
 Sarcomata may be primary or secondary, single or multiple (rarely multiple) and 
 affects any portion of the duct. 
 
 INJURIES. 
 
 Injuries may be contusions, lacerations, incisions, or punctures, by accident or de- 
 sign, partially or completely destroy function and vary in degree and location. 
 
 SYMPTOMS. 
 
 Symptoms. 
 
 Seminal Vesicles. 
 
 Local. Inflammatory, functional, neurotic, reflex. 
 
 General. Fuller says : Tenderness is referred to the lateral hypogastric region over 
 the sac, to the lower back or to the deep perineum. 
 
 Pain intensified by acts of urination and defecation, upright positions and exercise, 
 when severe. 
 
 Pain along cord, into testicle, along the urethra, down the thighs, up toward the 
 kidneys or into the rectum at onset, sexual function is excited, strong and persisting erec- 
 tions, often painful chordee, the latter suggesting anterior urethritis. 
 
 Frequent painful emissions, occasional bloody ejaculations. 
 
 Frequent micturition and tenesmus suggesting involvement of bladder. All of these 
 may exist without cystitis. 
 
 Rectal tenesmus and straining at conclusion of the act of defecation or urination. 
 
 Bladder disturbances become increased with partial or complete retention all due 
 to distention of the duct because symptoms gradually subside with drainage. 
 
 Symptoms of spermatic duct involvement are not altogether determined because of 
 their concealment within the deeper structures and because of their intimate relation with 
 the prostate, urethra and bladder above, and in front, rectum behind and perineum below. 
 
 Neurotic sensations with the penis, testicles and scrotum may exist in the form of 
 pain and retraction. 
 
 General symptoms are neurotic and mental to the degree of insomnia increased or de- 
 creased sexual desire. 
 
 Symptoms of conditions involving the vas deferens like other external genitalia may 
 not be easily defined. 
 
 Page Ninety-Nine 
 
CHAPTER XVIIl. 
 
 SCROTUM. 
 ANATOMY. 
 
 "v ^^ fe^ y\ ^^ SCROTUM, sac-like in appearance, is composed of muscular 
 
 W Is. fl ^ fibers known as the dartos muscle, situated in the superficial 
 
 .^^^ h^>i^>, fascia and skin, containing sweat and sebaceous glands with their 
 
 ducts and areolar tissue, in all of which there is an absence of 
 fat. The tissue within the median line known as the raphe is 
 more dense and capable of contraction. 
 
 Blood supply is from the superficial perineal branches of 
 the internal pudic arteries from behind and the external putic 
 branches of the femoral artery above and in front. 
 Nerves. 
 
 The scrotum in the male and labia in the female aie sup- 
 plied with nerves (Deaver) from the lumbar plexus, which go to 
 the front and sides of the scrotum including cutaneous from the 
 genital branch of the genito-crural nerve usually reinforced by 
 branches from the ilio-inguinal that end in the skin in the vicinity 
 of the root of the scrotum, emd the sacral plexus which supplies the posterior surface of 
 the scrotum and are from the perineal or inferior pudendal branches of the small sciatic 
 nerves, and the anterior or external superficial perineal branches of the pudic nei'ves, 
 sympathetic fibers accompanying the cutaneous nerves for the dartos muscle. Deaver also 
 states that scrotal and labial pain may be due to pressure upon the trunk of the inferior 
 pudendal nerve, the small sciatic or that portion of the sacral plexus or spinal cord from 
 which the filaments arise; while on the other hamd, pressure upon the terminal part of the 
 inferior pudendal may give rise to pain referred to the back of the thigh. 
 
 External L'^mphaiics in the Male. 
 
 Collecting trunks of the scrotum are divided into the superior, and inferior. There 
 are ten or fifteen trunks on each side which form a dense network. 
 
 Superior collecting trunks originate on that part of the scrotum which is a continuation 
 of the penile raphe. They pass upward in a vertical direction to the root of the penis, 
 where they turn obliquely outwards, running parallel with the collecting trunks of the 
 penis. After they cross the spermatic cord they tenninate in the supero-internal super- 
 ficial inguinal glands. 
 
 Inferior collecting trunks originate below and posterior to the superior collecting trunks. 
 They pass to the lateral parts of the scrotum in an upward and outward direction to the 
 lateral part of the scrotum, from whence they enter and follow^ the cruro-scrotal groove for 
 a brief distance, and then pass outwards, terminating in the inferior internal glands. 
 
 Within the pre-symphysical plexus are several glandular nodules. This plexus is 
 drained by a number of collecting trunks, which pass into the inguinal and crural canals. 
 
 One inguinal collecting trunk passes into the spermatic cord, and terminates in the 
 external retro-crural gland, as the inguinal collecting trunk enters the inguinal canal, it 
 usually gives off a small glandular nodule. 
 
 Page One Hundred 
 
The crural collecting lrunl(s are three or lour in number. They pass transversely 
 outwards under the femoral aponeurosis and anterior to the pectineus muscle. At first 
 they are in a single bundle, but after a short distance they diverge in a vertical direction, 
 and terminate at three different points. The lowest terminates in the deep inguinal gland, 
 which is in the crural canal and internal to the femoral vein. A second terminates in the 
 gland of Cloquet, while a third terminates in the internal retro-crural gland, which is on 
 the external iliac vein within the pelvis, 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries of the Scrotum. 
 Anomalies. 
 
 Diseases { ^5";.§"- 
 
 l^ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies of the scrotum may be congenital or acquired, primary or secondary, large 
 or small, short or long, unilateral or partially or entirely absent. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, vary in size and shape, in any tissue or locality, become arrested, con- 
 tinue to grow or disappear spontaneously. 
 
 Lipomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size and shape, in any portion of the scrotum. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 anywhere in the scrotal tissue, vary in size and shape, remain stationary, continue to grow 
 or disappear spontaneously. 
 
 Papillomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size and shape, anywhere upon the cutaneous surface, remain stationary, continue 
 to increase in size and number, or disappear spontaneously. 
 
 Tuberculosis may be primary or secondary, acute or chronic, single or multiple, con- 
 tinue to grow, disappear spontaneously, and appear anywhere in the scrotal structures. 
 
 S\)philis may be congenital or acquired, primary or secondary, single or multiple, 
 anywhere in the scrotal tissues, in the form of chancre, eruption or gumma. 
 
 Foreign bodies enter from without, vary in number, character and extent of penetra- 
 tion, encysted, remain indefinitely without causing serious trouble, infected and expelled, 
 complicated with injury to the testicles or spermatic ducts. 
 
 C^sts may be congenital or acquired, single or multiple, acute or chronic, primary 
 or secondary, contain blood, pus, serum, sebacious matter, dermoid material or echinococci, 
 vary in size, rupture externally through the cutaneous structures, into the perineum, rectum, 
 bladder or into the soft structures of the upper thigh, perineum or groin. 
 
 Fistula may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, penetrate the cutaneous structures, the perineum, urethra, bladder, sper- 
 matic duct, rectum or peritoneal cavity. 
 
 Pase One Hundred One 
 
MALIGNANT. 
 
 Carcinomaia may be primary or secondary, vary in size, shape and location and be 
 in any of the structures usually within the skin. 
 
 Sarcomata less frequent, primary or secondary, vary in size, shape and location and 
 originate in any of the structures. 
 
 INJURIES. 
 
 Lacerations, punctures, incisions, and contusions are the result of accident or design, 
 primary or secondary, vary in number, degree and location, sharp or ragged in any tissue 
 or location. 
 
 SYMPTOMS. 
 
 Symptoms scrotal in character are pain, tenderness and induration, mild or severe, 
 local or general or both, but pain and tenderness may exist in scrotal structures free from 
 disease or injury, because of their richness in sensitive nerve fibers and intimate relation 
 with other structures equally well supplied. 
 
 Each of these symptoms may be primary or secondary to conditions within the struc- 
 tures contained within the sac or tissues far distant to it, especially the prostate, urethra, 
 bladder or rectum. 
 
 Page One Hundred Two 
 
CHAPTER XIX. 
 
 VAGINA. 
 
 ANATOMY. 
 
 ^V >-^ ""^^ /^ HE VAGINA originally the cloacal chamber, contains the clitoris, 
 ^1^ \l ^ external urinary meatus and the cervix uteri with its opening sur- 
 
 C>y> 5^S— ^^ rounded by mucous membrane, deeply folded to form the major 
 
 and minor labiae which form its outlet. 
 
 The hulho cavernous in the female has been termed the 
 sphincter vaginae, the two muscles of opposite sides are v/idely sepa- 
 rated from each other by the vagina which they surround. They 
 arise from the central tendon of the perineum, pass forward invest- 
 ing the bulbi vestibule and are lost in the fascia covering the cor- 
 pora cavernosa and the dorsal surface of the clitoris. 
 
 Vaginal mucous membrane has a stratified scaly epithelium 
 and is corrugated by a number of transverse ridges called rugae 
 vaginales. There is also a transverse rugae on the anterior and 
 posterior wall of the vagina especially seen in young subjects in 
 the lower part of the vagina. Within the mucous coat, nodules 
 of lymphoid tissue are found, and the vaginal wall is surrounded by loose vascular con- 
 nective tissue, containing many large communicating veins. 
 
 The blood supply is mostly from the branches of the vesico-vaginal artery, vaginal 
 branch of the uterine artery, vaginal branches of the middle hemorrhoidal and internal 
 pudic arteries. 
 
 The veins surrounding the vaginal wall drain their contents into the internal iliac vein. 
 Nerves supplying the vagina, according to Piersol, are from the hypogastric sympa- 
 thetic plexus through the pelvis and from the second, third and fourth sacral nerves. The 
 immediate source of the sympathetic fibers is from the cervical ganglia at the side of the 
 neck of the uterus from which in association with the sacral branches, twigs pass to and 
 from each side of the vaginal plexus that embraces the vagina and filaments chiefly for 
 the involuntary muscle of its walls and blood vessels. Sensory fibers are few in the 
 vaginal mucous membrane so that the upper vagina has but slight sensibility though it is 
 greatly increased as the vaginal orifice is approached by the pudic fibers which supply the 
 mucous membrane and which send motor fibers to the striated muscle surrounding the 
 entrance. 
 
 Lymphatics of the Female. The female sexual organs are external and internal, 
 and have their corresponding lymphatics. Therefore, the lymphatics of the external and 
 internal genitalia are considered separately. The lymphatics of the vulva arise from a net- 
 work which is arranged in several planes and which covers the forchette, meatus urinarius 
 vestibule, labia minora, labia majora and clitoris. Drainage of this meshwork is accom- 
 panied by collecting trunks which take an upward and forward direction to the mons 
 veneris where they change abruptly into a transverse direction towards the superficial 
 inguinal glands. The collecting trunks arising from the posterior two-thirds, take an up- 
 ward and outward direction before reaching their tenninal glands. The termination of 
 the vulva glands is the superior-internal group, inferior-internal group or one of the ex- 
 ternal groups. They usually, however, terminate in the former group, rarely in the latter 
 group. 
 
 Page One Hundred Three 
 
Lymphatics of the Vagina. Two kinds of tissue are drained by the vaginal lym- 
 phatics: mucous membrane cind muscular respectively. 
 
 Those which drain the mucous membrane are beneath the epithelium, and are com- 
 posed of a very fine and dense network. The muscular lymphatics are the coarser ftf the 
 two. 
 
 The collecting trunks of the vaginal lymphatics are divided into three groups, viz. : 
 the superior, middle and inferior group. 
 
 The superior group drains the upper third of the vagina. Two collecting trunks arise 
 from this group. One arises anterior to the cervix, while the other arises posterior to the 
 cervix. 
 
 The anterior collecting trunk, after passing upward, outward and anterior to the 
 ureter, receives several cervical trunks and terminates in the middle gland of the middle 
 chain of the external iliac group. ■ 
 
 The posterior collecting trunk takes an upward and outward direction and ter- 
 minates either in the middle gland of the middle chain of the external iliac group, or in 
 the posterior gland of this group. 
 
 The middle group drains the middle third of the vagina. Its direction is upward, 
 backward and outward, and corresponds to the direction taken by the vaginal artery. The 
 termination is a gland of the hypogastric group, which is located in the hypogastric space 
 at the origin of the vaginal artery. 
 
 The inferior group collecting trunks arise in the third of the recto-vaginal septum. 
 
 first — These collecting trunks descend, then pass outward and backward, after 
 which they pass upward into the cavity of the sacrum, internal to the sacral foramen and 
 terminate usually in the glands of the promontory group. Occasionally they terminate in 
 the lateral sacral glands. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 T-N- r Benign. 
 
 Diseases | ^^^^^^,^ 
 
 Injuries. 
 
 Anomalies. A part or all of the vaginal tissues may be absent. The cavity large or 
 small, irregular in shape, entirely absent, septinated, deep, shallow or narrow and have 
 one or more external or internal openings- those internal entering the rectum, bladder or 
 peritoneal cavity. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Vaginitis may be primary or secondary, acute or chronic, mild or severe and involve 
 a part or all of the vaginal mucosa. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, vary in size, shape and depth, in any tissue or portion of the vaginal wall, 
 cease, continue to grow, or disappear spontaneously. 
 
 Papillomata may be congenital or acquired, single or multiple, primary or secondary, 
 in any portion of the mucous membrane, especially upon the muco-cutaneous border, vary 
 in size and shape, usually pedunculated, cease, continue to grow or disappear spon- 
 taneously. 
 
 Page One Hundred Four 
 
Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape and location, have a broad ba^e or pedicle, cease, continue to grow or 
 disappear spontaneously, though such a resolution seldom occurs. 
 
 Fibromata may be congenital or acquired, primary or secondary, usually primary, 
 single or multiple, vary in size and shape, in any portion of the vaginal tissue, especially 
 the muscularis. 
 
 Lipomata may be congenital or acquired, usually primary, single or multiple, vary in 
 size, shape, anywhere in the vaginal tissues. 
 
 Cysts may be congenital or acquired, single or multiple, primary or secondary, acute 
 or chronic, in any tissue or portion of the vaginal wall, rupture into the vagina, rectum, 
 perineum, urethra, bladder, uterus or peritoneal cavity, remain undisturbed, contain blood, 
 pus or serum, urine, echinococci or dermoid material. 
 
 Fistula may be congenital or acquired, primary or secondary, single or multiple, 
 acute or chronic, enter the vagina, rectum, urethra, bladder, uterus, peritoneal cavity, pass 
 into or through the perineal body or soft structures of the upper thigh. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, single or multiple, usually primary ajid 
 single, originate in any tissue or portion of the vaginal wall. 
 
 Sarcomata may be single or multiple, primary or secondary, vary in size and 
 originate in any tissue or portion of the vaginal wall. 
 
 INJURIES. 
 
 Lacerations, incisions, punctures, may be by accident or design, single or multiple, 
 primary or secondary, longitudinal or circular, partial or complete, in any portion of the 
 vaginal wall. 
 
 Foreign bodies may be by accident or design, single or multiple, enter through the 
 vaginal outlet, rectum, perineum, bladder or peritoneal cavity and escape through their 
 outlets. 
 
 SYMPTOMS. 
 
 The many conditions that may exist within the vagina render it productive of a great 
 many local and general physiologic symptoms, very similar in character. 
 
 Local pain, tenderness and induration and general nervous disturbances are of the 
 greatest consideration and probably more definite in this than the other reproductive organs 
 of the female. 
 
 It is only the milder forms of vaginal conditions that produce local symptoms alone, 
 but they often produce rectal or urinary disturbances of an aggravated form, but these 
 two tracts seldom escape the influences of the more severe conditions, especially when they 
 are in close proximity. 
 
 Page One Hundred Five 
 
CHAPTER XX. 
 
 BARTHOLIN GLANDS. 
 ANATOMY. 
 
 J^tl^7tc^.£J^ ^cuu^<^. 
 
 Fig. 53. 
 
 ARTHOLIN GLANDS in the female are the homologues of 
 Cowper's glands in the male. They are a small pair of organs 
 situated one on either side of the vaginal orifice, behind the 
 bulbus vestibuli and about the middle of the base of labium major. 
 The duct merges from the anteromedial border of the gland. It 
 is a small tube about 2 mm. in diameter and about Yl cm. long, 
 and opens into the vaginal orifice between the nymphae cind the 
 hymen. 
 
 Its structure corresponds to the mucous tubo-alveolar type, 
 the small component lobules however, being separated by fibro- 
 muscular tissue, the terminal compartments are lined by columnar 
 epithelium and contain numerous goblet cells. 
 
 The main duct sometimes has ampulary enlargements. The 
 secretion of the gland is whitish in color and viscid. 
 
 Blood Suppl]). The arteries supplying this gland are twigs 
 given off from the bulbar branch of the internal pudic. The veins are tributaries chiefly 
 to the internal pudic but also communicate to the trunks of the vestibular bulb and the 
 vagina. 
 
 Page One Hundred Six 
 
Nerves are very numerous and include sympathetic fibers and twigs from the pudic. 
 Lymphatics. The lymphatics join those of the vagina and rectum that are afferents 
 of the internal iliac nodes. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 Anomalies. 
 
 Diseases ! P5";.g"- 
 
 ( Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies. The glands of the two sides often vary in size and may be asym- 
 metrically placed. The ducts may be double and the lobules so separated that the usual 
 gland mass is replaced by isolated divisions or sometimes seemingly wanting on one or 
 both sides. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Inflammation may be primary or secondary, acute or chronic, unilateral or bilateral 
 and vary in degree. 
 
 Papillomata may be congenital or acquired, primary or secondary, vary in size, 
 number, shape and location. 
 
 Adenomata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Fibromata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number and location. 
 
 Cysts may be congenital or acquired, primary or secondary, acute or chronic, contain 
 blood, pus, or serum, vary m size, shape, number and location, rupture through the cu- 
 taneous structures, their natural course, into the vagina or rectum. 
 
 Fistula may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, vary in size, shape, length, open through the skin into the vagina or rectum. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, vary in size, character, shape, location 
 and rate of growth. 
 
 Sarcomata may be primary or secondary, vary in size, shape, character, location and 
 rate of growth. 
 
 INJURIES. 
 
 Incisions, punctures, contusions may be accidental or induced, primary or secondary, 
 vary in degree and severity. 
 
 SYMPTOMS. 
 
 Symptoms such as pain, tenderness, redness and induration are most prominent. They 
 may vary in degree and severity, local or general in their manifestations, and when gen- 
 eral, are difficult to recognize. 
 
 Page One Hundred Seven 
 
CHAPTER XXI. 
 
 CLITORIS. 
 ANATOMY. 
 
 ^JLijbsyi^ 
 
 Fig. 54. 
 
 VS. (^ rJ) j\ ^^ ERECTILE BODY (clitoris in the female) , is the analogue 
 jpj I J. Ji W of the penis in the male and is therefore to be considered much 
 
 S-vfH K^\^^ in the same manner symptomatically. It is buried in such a 
 
 manner beneath the labia that only its small conical anterior end 
 and the lower vertical ridge of integument over the body appear 
 when the labiae are separated. 
 
 Blood Supply. The vessels supplying blood to the clitoris 
 correspond with those of the penis but are smaller and the same 
 arrangement is found with the veins. 
 
 Nerve supply in its derivation and distribution is the same 
 as found in the penis, being from the sympathetic system for the 
 walls of the blood spaces and from the pudic nerves. The dor- 
 sal nerve is relatively larger and supplies the integument of the 
 glans and prepuce with fibers connected with special sensory end 
 organs (Piersol). 
 
 Clitoris. The lymphatic glands of the prepuce terminate in the superficial inguinal 
 glands. Those of the glands clitoris resemble the lymphatics in the male. Their origin is 
 composed of a network which empties into several collecting trunks. They pass along the 
 dorsum of the clitoris to a point anterior to the symphysis, where in their union the pre- 
 
 pare One Hundred Eight 
 
symphysical plexus is formed. Two collecting find their origin in this plexus. One made 
 up of a small chain of glandular trunks passes along the canal of the neck, beneath the 
 round ligament to the retro-crural glands. The other trunk runs towards the canal of 
 the neck and terminates in the gland of Cloque, the retro-crural and deep inguinal glands. 
 The clitoris has five times as many nerves as the penis and is supplied with sympathetic 
 nerves which are freely anastomosed with the cerobrospinal nerves. 
 
 S\)mf}toms such as pain, tenderness and general sexual irritability are most common 
 and important. The existence of pathology of any kind within or about the clitoris will 
 cause irritation of the sensory nerve fibers which it contains and consequently many ag- 
 gravated general disturbances, such as headache, nausea, vomiting and sexual desire 
 (See Chapter Male Erectile Body.) 
 
 Page One Huiulreil Nine 
 
CHAPTER XXII. 
 
 UTERUS. 
 
 ANATOMY. 
 
 f^ ^rnm^ ^^ j^ HE UTERUS constitutes in weight a larger amount than all of 
 ^^ 1^ f / (^ ^^^ other reproductive organs in the female, and because of this 
 
 \^j^ 5x0^, ^^ ^^ probably more frequently the seat of pathology, especially 
 
 with the addition of pregnaint conditions. It must, therefore, play 
 a prominent role in symptomatology. 
 
 Blood supply is from the two uterine, each a branch of the 
 internal iliac that accompanies the ureter along the pelvic wall, 
 behind and below the ovarian fossa, to the attached border of 
 the broad ligament beneath which it passes in its course to the 
 ureters. 
 
 As it is not necessary to describe in further detail the blood 
 supply of this organ the subject will be concluded by reference 
 to its intimate blood relation to the entire uro-genital and rectal 
 tracts. (See Piersol, pp. 2009-2010.) 
 
 Uterine nerves are large and for involuntary muscles and 
 derived from the sympathetic system, the (utero-vaginal subdivisional) of the pelvic plexus, 
 but directly from the second, third and fourth sacral spinal nerves. 
 
 The utero-vaginal plexus divide into two parts, the smaller for the posterior, and the 
 lateral parts of the uterus. The larger consists of a chain of small ganglia along the 
 cervix and vaginal vault. 
 
 Sympathetic nerves supply involuntary muscular walls of the uterus and tubes so 
 that irritation from the generative organs travels to the abdominal brain by way of the 
 ovarian and hypogastric plexuses. Uterine and tubal neuralgia is thus explained. Lacera- 
 tion of the cervix pathologic in character for five years has been described by Sutton as 
 being the cause of confirmed neurasthenia. 
 
 Lymphatics of the Uterus. The uterine lymphatics originate in the mucous mus- 
 cular and peritoneal coasts respectively. A network is formed by their anastomosis in the 
 sub-peritoneal cellular tissue. The collecting trunks number four or five. The networks 
 which originate at the cervix or corpus uteri are continuous, yet the cervical or corporal 
 collecting trunks are considered separately. 
 
 Cervical collecting trunks number from four to eight. They form the large lymphatic 
 knot after leaving the cervix. This knot is called the juxta-cervical knot, it is often absent 
 in the new-born, but alv/ays present when pregnancy exists. The cervical collecting trunks 
 are subdivided into three groups, viz. : primary, secondary and lateral sacral groups. 
 
 Primary Croups. There are two or three collecting trunks in the primary group, they 
 converge towards the lateral portions of the corpus-uteri. They usually pass upward and 
 anterior to and above the ureter. Occasionally their course is posterior and sub-ureteral. 
 After accompanying the uterine artery for a short distance, the lymphatics leave the 
 uterine artery and pass up the lateral wall of the pelvic cavity internal to the hypogastric 
 artery in the adult, cross it in the foetus. They terminate in the middle and superior gland 
 of the middle chain of the external iliac group. 
 
 The juxta-cervical gland was first discovered by M. Lucas Championniere. It is 
 occasionally found as an interrupting glandular nodule by the side of the cervix. Revnier 
 
 Page One Hundred Ten 
 
"is of the opinion that the juxta-cervical gland is an hypertrophied gland due to a patho- 
 logical process." 
 
 Secondary) or hypogaslr'ic group originates on the same level as the primary group. 
 It passes posteriorly to and below the ureter after which it passes upward, backward and 
 outward terminating in a gland of the hypogcistric group on the anterior surface of the 
 hypogastric artery on a level with the uterine and vaginal arteries. 
 
 The lateral sacral group is composed of two or three collecting trunks which originate 
 on the posterior cervical surface, after which they pass backward and continue across the 
 lateral part of the rectum through the utero-sacral ligaments, from which they pass upward 
 into the cavity of the sacrum. 1 wo terminals, the lateral sacral and the promontory glands. 
 The former receives the external or shorter collecting trunks, while the latter receives the 
 internal or longer collecting trunks. 
 
 Collecting trunks of the corpus uteri are three in number, one primary and two ac- 
 cessory collecting trunks. The primary collecting trunk subdivides into four or five small 
 collecting trunks which originate below the uterine cornu. From their origin their course 
 corresponds to the termmal segment of the uterme artery, after which they pass beneath 
 the ovary to be joined by the ovarian ligament. As they continue in an upward direction 
 towards the lumbar region, they pass around the blood vessels and with them cross the 
 hilum of the kidney, then turn acutely and descend to the juxta-aortic glands. Some how- 
 ever, may terminate in the pre-aortic group. 
 
 Accessory trunks are two in number, viz. : primary and secondary. The primary 
 trunk may be composed of one trunk or be subdivided into two trunks. Just below the 
 uterine cornu is their point of origin. They pass outward and terminate in the middle chain 
 of the external iliac group. This chain therefore receives cervical and corporeal lymphatics. 
 
 Secondary collecting trunlf is difficult to trace to its termination, which is the super- 
 ficial gland of the supero-internal group. 
 
 Infections are carried upward by the retro-peritoneal glands to the thoracic duct frorn 
 the uterus. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 Anomalies. 
 
 Diseases f P/^/.S"" 
 
 ■\ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 Anomalies may be congenital or acquired, single or multiple, primary or secondary, 
 vary in form, number and position, number of cavities or the entire absence of a cavity. 
 The cervix may be long or short, small, irregular in shape, diameter, position, septinated, 
 contain more than one canal, entirely absent (uterusacoulis) , open into the bladder, urethra, 
 rectum or peritoneal cavity. [(See Anomalies of the Uterus) (Ricketts) Cin. Lancet 
 Clinic (xlvii., page 554.)] 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Endometritis may be primary or secondary, acute or chronic, local or general, mild or 
 severe. 
 
 Ulcers may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, vary in degree, in any tissue or portion of the uterus, cease or continue to grow 
 or disappear spontaneously. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple. 
 
 Page One Hundred Eleven 
 
pedunculated, hard or soft, vary in shape or size, in any portion of the uterine wall, at- 
 tached to any of the abdominal viscera or abdominal w^all, become cystic, rupture into the 
 uterine or peritoneal cavity, rectum, vagina or bladder. 
 
 Papillomata may be congenital or acquired, primary or secondary, single^or mul- 
 tiple, vary in size or shape, with or without pedicle, anywhere upon the external or in- 
 ternal surfaces. 
 
 Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size and shape, with or without pedicle (usually without), anywhere upon the 
 external or internal surface. 
 
 Pregnancies may be normal or abnormal, single or multiple, become attached any- 
 where upon the mucous surfaces or upper cervical canal, escape through the cervical canal, 
 uterine wall into the rectum, intestinal canal, bladder, peritoneal cavity, Hfe of the foetus 
 become extinct during any period of development, and the body remain indefinitely within 
 the uterine cavity. 
 
 Procidentia may be congenital or acquired, primary or secondary, vary in degree 
 from slight to complete, return spontaneously to the normal position where it may remain 
 indefinitely, or descend to ciny degree at any age and remain without ever having been 
 impregnated, 
 
 C^sts may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, contain blood, pus, serum, urine, feces, echinococci, dermoid or colloid material, 
 rupture into the uterus, bladder, rectum, peritoneal cavity, intestmal canal or externally 
 through the skin or perineum. 
 
 Fistula may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, enter the bladder, uterus, rectum, peritoneal cavity, intestinal canal, perineum or 
 pass through the external cutaneous structures. 
 
 MALIGNANT. 
 Carcinomata may be primary or secondary, single or multiple, in any tissues of the 
 uterine body, especially the cervix. 
 
 Sarcomata may be primary or secondary, single or multiple, hard or soft, in any of 
 the tissues of the uterine body. 
 
 INJURIES. 
 
 Lacerations, punctures, and ruptures may be complete or incomplete, the result of acci- 
 dent or design, from within or without, single or multiple, longitudional or circular, pene- 
 trate into the peritoneal cavity, bladder, vagina, rectum, the overlying soft structures, or 
 indirectly into the intestinal canal, blood vessels, ureters or Fallopian tubes. 
 
 Foreign bodies may be by accident or design, single or multiple, vary in character, 
 enter through the vaginal and cervical canals, bladder, rectum, or peritoneal cavity, the 
 overlying soft structures or make their exit through these structures. 
 
 SYMPTOMS. 
 
 Symptoms ascribed to the uterus highly dominate the adjacent organs and soft struc- 
 tures because of richness in sensory nerve fibers from the pudic and their coalescence with 
 sensory fibers from the same source. 
 
 The same group of symptoms are manifested with all and probably to the same de- 
 gree throughout their existence whether they be mild or severe. 
 
 This organ normally being the largest of the perineal and pelvic structures, and 
 varying so greatly in size during pregnancy and disease, and possessing such a great blood, 
 lymphatic and nerve supply, places it first in variety of pathology and symptomatology. It 
 must also be the greatest factor in their complications. 
 
 Local manifestations such as pain and tenderness are most prominent and may be 
 more readily defined than other pelvic organs when involved without the manifestations of 
 chill, headache, shock, perspiration, nausea and vomiting. 
 
 The various forms of uterine pregnancies are without doubt the more common ex- 
 citing causes of these manifestations. Next in frequency are accidents incident to preg- 
 nancy, but uterine pathology of any kind may cause similar manifestations. 
 
 Page One Hundred Twelve 
 
CHAPTER XXIII. 
 
 OVARIES. 
 ANATOMY. 
 
 '>^ 
 
 vr''^ 
 
 Fig. 55. — Ovary and Blood Vessels (Kelley). 
 
 ^(il (T) A\^^ normal ovary is about the size of a large almond 
 ^)1. 4v 7 ^^-^^'' ^^ connected with the broad ligament by peritoneal folds 
 
 - />H K\N-/, though not firmly fixed in any definite place. The upper end of 
 
 the ovary is termed the tubal pole as it is more intimately con- 
 nected with the Fallopian tube. The lower end is termed the 
 uterine pole because it is connected with the uterus by a fibrous 
 cord known as the ovarian ligament. The anterior border is 
 termed the hilum of the ovary. 
 
 Ovarian is the only tissue capable of regenerating itself or 
 any other tissue of the body. It has been known to reproduce 
 functional ovarian tissue, muscle, fat, tendon, cartilage, bone, 
 teeth and hair and parts of various organs. 
 
 It is, therefore, important that all ovarian tissue should be 
 
 removed when menstruation is to be prevented, or regeneration 
 
 of such tissue is to be avoided. The benefits to be derived from 
 
 the knowledge of the absence of any ovarian tissue whatever are great from a symptomatic 
 
 point of view, because their symptoms cannot then exist. 
 
 Blood vessels correspond to the spermatic arteries of the male, springing from the 
 anterior aspect of the aorta below the level of origin of the renal vessels, each gaining 
 the pelvis in the fold of the peritoneum forming the suspensory ligament of the ovary, and 
 enters the ovary at its anterior border. These arteries anastomose freely near the hilum 
 with vessels derived from the uterine arteries. 
 
 Page One Hundred Thirteen 
 
The blood is returned by communicating veins similar to the pampiniform plexus in 
 the male. 
 
 Nerves are from a plexus which accompanies the ovarian artery and which is con- 
 tinuous above with the renal plexus. Other fibers are derived from the lower part 
 of the aortic plexus and join the plexus on the ovarian artery. The afferent impulsfe from 
 the ovary reach the central nervous system through the posterior root fibers of the tenth 
 thoracic nerve. 
 
 Ovarian lymphatics form a dense plexus, which when infected overshadows the sub- 
 jacent venous plexus. After the plexus becomes smaller, four to six collecting trunks are 
 formed. They take an upward course with the ovarian vessels, pass anteriorly to the 
 common iliac vessels and ureter accompanying and then anastomose with lymphatics from 
 the Fallopian tube and uterine fundus at the fifth lumbar vertebra, after which they 
 terminate in the lateral aortic glands. One vessel passes downward and slightly outward 
 into the superior part of the ligament and terminates in one gland of the middle chain of 
 the internal iliac group. Marcille, Zeissl and Horowitz have one of the testicular lym- 
 phatics end in the same gland of the abdomino-aortic group. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies, 
 
 Diseases | ^f^"- ^ 
 [ Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 in form, size, shape and position. When single they are invariably of horse-shoe shape. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape and location. 
 
 Papillomala may be congenital or acquired, primary or secondary, single or mul- 
 tiple, vary in size, shape and location, with or without pedicles and disappear spontaneously, 
 though this is a rare occurrence. 
 
 Adenomata may be congenital or acquired, primary or secondary, vary in size, shape, 
 number cind location, with or without pedicles, usually without, and seldom disappear 
 spontaneously. 
 
 Pregnancies of the ovaries are of rare occurrence, with considerable doubt as to the 
 possibility of multiple ovarian pregnancies. They may mature without rupture, become 
 encysted and remain indefinitely, or rupture at any period during development into the 
 peritoneal or intestinal cavity, bladder, uterus, rectum or vagina. 
 
 Adhesions may be congenital or acquired, primary or secondary, single or multiple, 
 with or without disease, to the uterus, Fallopian tubes, bladder, intestines, appendix, rectal 
 or vaginal wall. 
 
 C'^sts may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, contain blood, pus, serum, echinococci, fecal, colloid or dermoid material. 
 
 Page One Hundred Fourteen 
 
rupture into the peritoneal cavity, Fallopian tube, uterus, bladder, intestinal tract, rectum 
 or vagina. 
 
 Hernia of the ovaries may be congenital or acquired, primary or secondary, uni- 
 lateral or bilateral, through the femoral or inguinal ring, into the labia, bladder, rectum or 
 vagina. 
 
 Fisiulce may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, open into the peritoneal cavity. Fallopian tube, uterus, bladder, intestinal 
 canal, rectum, vagina or perineum. 
 
 MALIGNANT. 
 
 Carc'inomata may be primary or secondary, usually primary, involving one or both 
 ovaries, rarely both, in any portion of the gland and extend into the surrounding structures. 
 
 Sarcomala may be primary or secondary, usually primary, involve one or both 
 ovaries and extend into the ovarian ligament first, broad ligament tube, uterus and sur- 
 rounding soft structures like carcinoma. 
 
 INJORIES. 
 
 Ruptures, incisions, punctures and lacerations may be by accident or design, primary 
 or secondary, single or multiple, penetrating or non-penetrating, in any portion of the ovary, 
 extend into the peritoneal cavity. Fallopian tube, uterus, bladder, vagina, rectum, peri- 
 neum, appendix, intestinal canal or externally into the soft structures or through the skin, 
 anywhere about the pelvis. 
 
 SYMPTOMS. 
 
 Symptoms such as obtain with ovaries even when aggravated by profound pathology 
 are very indefinite. This is especially so with the earlier manifestations, which are so often 
 slight in character, and because the nerve fibers are from the same source and intimately 
 associated. 
 
 Pain having its origin in one would be reflected to the other and thus involve the 
 uterus and surrounding structures which are also dominated by branches of the pudic. 
 
 This being so, primary pain of one structure would become secondary with others, 
 especially the Fallopian tubes and uterus. 
 
 Local disturbances in the ovaries are in the form of pain and tenderness, sometimes 
 induced by the sense of touch. Like their analogue the testicles, they are more sensitive 
 than any other tissue in the uro-genital tract, and their sensitiveness increases with pathology. 
 Their irregularities, therefore, are more readily reckoned with and defined, especially when 
 general disturbances are manifested. Pressure upon a normal ovary will Induce tenderness, 
 pain, chill, headache, shock, nausea and vomiting. It is therefore apparent why they 
 are so greatly influenced by pathology within them or their adjacent structures or those 
 far distant within the pelvis or perineum, that possess the same nerve supply. The very 
 great variety of conditions to which the ovaries are subjected, produce symptoms Identical 
 in character thus rendering It impossible to identify any one of them. 
 
 Page One Hundred Fifteen 
 
CHAPTER XXIV. 
 
 FALLOPIAN TUBES. 
 ANATOMY. 
 
 fig,. 56. — Fallopian tube and blood vessels (Kelley). 
 
 ALLOPIAN TUBES are composed of the muscular, mucous and 
 submucous coats, lined with epithelium and covered with peri- 
 toneum. The circular muscle fibers are more numerous near 
 the uterus. The mucous coat is covered with ciliated epithelium, 
 arranged for driving the contents of the tube toward the uterus 
 with which the epithelium is continuous, and extends to the fim- 
 briated end of the tubes where they join the peritoneum. 
 
 Blood vessels are from the uterine artery and branches of 
 the ovarian artery and the veins connect with the uterine and 
 ovarian veins. 
 
 Nerves are derived from the plexus that supplies the ovary 
 and that which connects with the uterus. Afferent fibers appear 
 to belong to the eleventh and twelfth thoracic and the first lumbar 
 nerves. 
 
 The lymphatics join the lumbar group of glands. 
 
 ETIOLOGY. 
 
 Ai 
 
 Diseases and Injuries. 
 
 Anomalies. 
 Benign. 
 Malignant. 
 Injuries. 
 
 D 
 
 { 
 
 Page One Hundred Sixteen 
 
ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 in form, size, length, relation to other structures, entrance into the uterus, blood, nerve and 
 lymph supplies, or one or both entirely absent or imperforate. 
 
 DISEASES. 
 
 Benign. Malignant. 
 
 BENIGN. 
 
 Inflammation may be primary or secondary, acute or chronic, local or general, mild 
 or severe. 
 
 Tuberculosis may be primary or secondary, local or general, single or multiple, acute 
 or chronic, in any of the tissues or portion of the tube, become arrested, disappear or con- 
 tinue to destruction. 
 
 Syphilis may be congenital or acquired, primary or secondary, single or multiple, 
 local or general, arrested, disappear spontaneously or continue in its destruction. 
 
 Papillomala may be congenital or acquired, primary or secondary, single or mul- 
 tiple, with or without pedicle, in any portion of the tube, remain quiescent, disapp>ear or 
 continue to grow. 
 
 Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 usually without pedicle, in any portion of the tube, remain quiescent, continue to grow, 
 or disappear spontaneously, though this seldom occurs. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape and location, continue to grow, remain quiescent or disappear spon- 
 taneously. 
 
 Pregnancies may be primary or secondary, single or multiple, in any portion of the 
 tube, develop to about the sixth week before which time they invariably rupture to escape 
 into the peritoneal cavity, broad ligament, uterus, bladder, intestinal canal, rectum, or 
 vagina, become encysted in the broad ligament where they may die and remain indefinitely 
 or develop to maturity, and then die, and remain indefinitely. 
 
 Cysts may be congenital or acquired, primary or secondary, single or multiple, acute 
 or chronic, vary in size, contain blood, pus, serum, echinococci, colloid or dermoid ma- 
 terial, rupture into the broad ligament, peritoneal cavity, uterus, bladder, rectum, vagina, 
 perineum, intestinal tract or soft tissues, through the cutaneous structures anywhere about 
 the pelvis. 
 
 Fislulcs may be congenital or acquired, primary or secondary, single or multiple, open 
 into the uterus, peritoneal cavity, bladder, vagina, rectum, perineum or through the ex- 
 ternal soft structures. 
 
 Prolapse may be congenital or acquired, primary or secondary, single or multiple, 
 behind the uterus, into the vaginal vault, with other tissues, or complicated with various 
 inguinal, femoral and ventral herniae the same as ovaries. 
 
 MALIGNANT. 
 
 Carcinomata may be primary or secondary, usually primary, in any portion of the 
 tube, unilateral or bilateral, and extend into the broad ligament, uterus, or ovaries. 
 
 Sarcomata may be primary or secondary, usually primary, single or multiple in 
 any portion of the tube, unilateral or bilateral, usually unilateral. 
 
 Page One Hundred Seventeen 
 
INJURIES. 
 
 Incisions, punctures, ruptures may be primary or secondary, single or multiple, vary 
 in size and location, by accident or design, complete or incomplete, extend into th»v peri- 
 toneal cavity, uterus, bladder, rectum, vagina, or the overlying soft structures. 
 
 Foreign bodies, though small, may enter the Fallopian tube through the uterine 
 canal, the w^all of the tube by v^^ay of the peritoneal cavity, the rectum, vagina, or through 
 the overlying soft structures. 
 
 SYMPTOMS. 
 
 Sy^mptoms due to Fallopian tube disturbances are very similar in character to those 
 of the ovaries and uterus because of their close proximity and intimate relation of nerves. 
 Their similarity is so great that instances are few where they can be defined, the element 
 of doubt always existing. 
 
 Local tenderness and pain are the earlier manifestations and while they may grad- 
 ually increase in severity until the general manifestations assert themselves they are not 
 definite. 
 
 Symptoms are alike with all conditions of the tubes and their adjacent structures and 
 for this reason cannot be made specific, nor can they be differentiated from conditions in 
 their adjacent structures except in a few instances when their symptoms predommate 
 
 Page One Hundred Eighteen 
 
CHAPTER XXV. 
 
 RECTUM 
 ANATOMY. 
 
 Fig. 57. — Pelvic organs seen in dissection of male perineum (Deaver). 
 
 HE RECTUM is seven inches long and extends from the sigmoid 
 to the external sphincter ani, and its first portion ending in front 
 of the tip of the coccyx and bending somewhat backward. In 
 front of the upper portion of the rectum are the perineum, blad- 
 der, seminal vesicles, vasa deferentia emd prostate in the male 
 and vagina in the female. 
 
 The second portion extends from the tip of the coccyx and 
 is almost entirely encircled by the internal sphincter am muscle, 
 and not covered with peritoneum. The distance from the interna] 
 sphincter to the meso-sigmoid is four inches. 
 
 The cylinder in the upper portion though about two inches 
 in diameter may be distended to four or five inches with feces 
 or the hand without rupture. 
 
 External sphincter ani muscle arises from the coccyx and 
 extends to the anus, sometimes to the bulbocavernosi muscle. It 
 
 Page One Hundred Nineteen 
 
is composed of striated fibers which lie directly beneath the skin and its purpose is to open 
 and close the anal orifice and to fix the anterior tendon of the perineum during contraction 
 of the bulbocavernosi, some fibers completely surrounding the anus. In the female a few 
 decussate with those of the sphincter vaginae and nearer the outside circles than the internal 
 sphincter. The anterior fibers pass along the sides of the prostate and vagina. The middle 
 fibers blend with the longitudinal fibers of the rectum and extend to the sphincter ani and 
 the posterior fibers join the other lavatori to become inserted at the tip of the coccyx. 
 
 Blood supply is the superficial perineal artery which is a branch of the internal pudic, 
 given off just before it enters the space between the layers of the triangular ligament of 
 the perineum. It is sometimes termed the transverse artery of the perineum. 
 
 The fourth sacral and inferior hemorrhoidal nerves supply the external sphincter ani 
 muscle. Some fibers coming from the pudic and inferior mesenteric and pelvic plexuses, 
 arise from the fourth sacral and inferior hemorrhoidal branch of the pudic and they in 
 turn connect with the small sciatic, pudic and fourth sacral nerves. 
 
 The inferior hemorrhoidal nerve usually branches off the pudic after it peisses through 
 the lesser sacro-sciatic foramen and supplies the external sphincter, cutaneous filaments to 
 the perineal integument and communicating branches of the inferior pudendal and super- 
 ficial nerves. 
 
 It is thus seen that it has three important branches, the inferior hemorrhoidal, perineal 
 and dorsal nerve of the penis and clitoris, the main trunk having passed forward in Al- 
 cock's canal in the obturator fascia. With the change from cloacal to the true mammalian 
 condition, the pudic trunk was necessarily split into many twigs, it no longer answering the 
 purpose for which it was first intended. 
 
 Levator ani muscle is composed of three sets of fibers. 
 
 Anterior, pass along the side of the prostate and vagina. 
 
 Middle, blend with the longitudinal fibers of the rectum and extends to the sphincter 
 ani. 
 
 Posterior, join the other levator ani to be inserted into the tip of the coccyx. The 
 entire muscle is supplied by the inferior hemorrhoidal and fourth and fifth sacral nerve, 
 and its function is to raise the pelvic floor and fascia. 
 
 Blood Supply. The levator ani, obturator internus, pyriformis and coccygeus mus- 
 cles are in part supplied by the gluteal. The pyriformis and coccygeus also receive 
 tranches from the lateral sacral artery. The sciatic artery also sends branches to the 
 pyriformis, levator ani and coccygeus muscles, and the obturator receives a branch from 
 the internal pudic artery. 
 
 The recto vesical fascia's principal function is to prevent pus and extravasated urine 
 from passing from the perineum to the pelvis. 
 
 Blood supply of the rectum is from three hemorrhoidal and middle sacral arteries, 
 the m.ost important of which is the superior hemorrhoidal, which is the prolongation of the 
 inferior messenteric trunk, which after reaching the rectum from the meso-colonic root, 
 divides into two chief branches which course around the sides of the rectum anteriorly. 
 Many of its small branches then perforate the rectal muscular fibers to supply their 
 mucous membrane. The superior and middle hemorrhoidal anastomose both externally 
 and internally to the rectal wall. 
 
 The inferior hemorrhoidal artery pierces the inner wall of Alcock's canal, and runs 
 obliquely forward and inwards. It soon divides into two or three main branches, which 
 sometimes arise separately and pass across the space to the anal passage. The artery 
 anastomoses in the walls of the anal passage with its fellow on the opposite side and with 
 the middle and superior hemorrhoidal arteries. It also anastomoses with the transverse 
 perineal arteries and supplies cutaneous twigs to the region of the anus, and others turn 
 around the border of the gluteus maxims to supply the lower part of the buttock. 
 
 Nerve supply is from the sympathetic twigs which are derived from the inferior mes- 
 senteric and hypogastric (sometimes called pelvic plexus) and cerebrospinal system, fibers 
 of which arise from the second, third and fourth sacral nerves. Fibers of the inferior 
 hemorrhoidal branch of the internal pudic nerve (third and fourth sacral) are also dis- 
 
 Page One Hundred Twenty 
 
tributed to the lower part of the anal canal and external sphincter. The second, third and 
 fourth sacral nerves convey motor impulses to the longitudinal fibers but also inhibits im- 
 pulses to the circular muscular fibers. 
 
 Fibers from the sympathetic also convey motor impulses to the circular muscle and 
 inhibitory fibers to the longitudinal muscles of the rectum. 
 
 The reflex center which governs the action of the sphincter and the muscular fibers 
 of the rectum (defecation center) is situated m the lumbar region of the cord and appears 
 to be capable of carrying out the whole act of defecation even when separated from the 
 brain. 
 
 Lymphatics of the rectum pass to the glands on the front of the sacrum and some in 
 the lower portion of the anal canal join the lymphatics around the anus and pass with 
 them to the oblique set of the superficial inguinal glands, a few from the lower portion of 
 the rectum are said (Quenu) to jom the iliac glands but these are not constant according 
 to Gerota. 
 
 ETIOLOGY. 
 
 Anomalies, Diseases and Injuries. 
 
 Anomalies. 
 
 Dr Benign, 
 iseases - i\ ^r i • 
 
 ( Malignant. 
 
 Injuries. 
 
 ANOMALIES. 
 
 Anomalies may be congenital or acquired, primary or secondary, single or multiple, 
 in any portion, vary in length, diameter and uniformity of lumen, position and relation to 
 other structures, a part or all of the rectum absent, and the anal opening behind, in the 
 vagina, bladder, urethra, uterus, peritoneal cavity or absent. 
 
 DISEASES. 
 
 Benign. Malignant. 
 BENIGN. 
 
 Benign diseases are of many kinds and varieties and may occupy any portion of 
 the cylinder. They may be congenital or acquired and vary in size and rate of growth. 
 
 Proctitis may be primary or secondary, acute or chronic, local or general, mild or 
 severe. 
 
 Ulcers may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, result from infection or pressure, necrosis, extend partially or completely 
 through any portion of the rectal wall especially in the lower third of the cylinder. 
 
 Fissures may be congenital or acquired, primary or secondary, acute or chronic, sin- 
 gle or multiple, vary in depth, length and width in one or all of the tissues of the wall, 
 location, almost invariably external or between the sphincters. Their most frequent cause 
 is the passage of such a mass through one of normal tension, or the presence of cicatricial 
 tissue. 
 
 Fistulce may be congenital or acquired, primary or secondary, acute or chronic, single 
 or multiple, extend into and through the perineum, posterior soft structures, urethra, blad- 
 der, prostate, vagina, uterus, or peritoneal cavity, vary in size, length and location, straight 
 or tortuous. 
 
 Page One Huiulivil T\vent\-One 
 
Varicosities such as hemorrhoids, angiomata and aneurysms may be congenital or ac- 
 quired, primary or secondary, acute or chronic, in one or more vessels or any portion of 
 the rectum, vary in size and sometimes disappear spontaneously. ^ 
 
 Papillomata are of the more common varieties found within the rectum and they 
 may be congenital or acquired, primary or secondary, single or multiple, usually multiple, 
 located anywhere upon the mucous membrane and develop to a considerable size, usually 
 with pedicle. (See Papillomata and Adenomata of the Rectum, A^. Y. Med. Jour., 
 Vol. LXXX, 1907, also Papillomata and Adenomata, Hist. Review, Amer. Jour. 
 OF Dermatology, March 1, 1908. (Ricketts.) 
 
 Adenomata may be congenital or acquired, primary or secondary, single or multiple, 
 upon any portion of the inner surface of the rectum, vary in size and shape, remain quies- 
 cent, continue to grow or disappear spontaneously. They usually have a broad base and 
 appear most frequently in the lower half of the cylinder. 
 
 Tuberculosis may be primary or secondary, acute or chronic, single or multiple, vary 
 in size, be upon any portion and in any tissue, but usually in the lower third of the cylinder 
 and extend into the surrounding tissues. 
 
 Syphilis may be congenital or acquired, primary or secondary, acute or chronic, 
 single or multiple, vary in size, in amy tissue or location and usually in the lower third 
 of the cylinder, sometimes disappears spontaneously or cause total destruction of any part 
 or all of the rectal wall in the form of gumma. 
 
 Fibromata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, location, in any tissue, usually in the lower half of the cylinder. 
 
 Lipomata may be congenital or acquired, primary or secondary, single or multiple, 
 vary in size, shape, location, in any tissue but usually about the middle of the cylinder. 
 
 Prolapsus may be congenital or acquired, primary or secondary, acute or chronic, one 
 of four degrees. Hyperexertion to stool when the lumen of the rectum has been lessened 
 by any cause and when the sphincters have relaxed unduly are the most common causes. 
 
 Infection may be primary or secondary, bacterial or parasitic, local or general, mild or 
 severe, acute or chronic, and result in abscess within the rectal wall or any of the adjacent 
 tissues or organs. 
 
 Cyds may be congenital or acquired, primary or secondary, acute or chronic, single or 
 multiple, in any portion or tissue, contain blood, pus, serum, echinococci or dermoid ma- 
 terial, rupture posteriorly through the soft structures, into the vagina, rectum, perineum, 
 urethra, uterus or peritoneal cavity. 
 
 Strictures may be congenital or acquired, primary or secondary, acute or chronic, 
 partial or complete, single or multiple, in any portion of the rectal wall. 
 
 Parasites may be congenital or acquired, primary or secondary, single or multiple, re- 
 main indefinitely with or without producing inflammation, encysted or within the open cavity. 
 
 Foreign bodies may enter from without or within, through the anus or mouth, vagina, 
 bladder, uterus, peritoneal cavity or external soft structures. 
 
 Feces may be hard or soft in consistency and either form cause great rectal or con- 
 stitutional disturbances. If the normal diameter of a mass normal in consistency, is less- 
 ened from any cause at a given point distant to the sphincters, the pressure upon them will 
 not be normal in uniformity or degree because the line of perpendicular will have been 
 changed. Thin or watery stools are probably exceptions to this rule and an empty gut 
 significant of quietude. 
 
 These remarks apply to both sexes but because of the difference in. their anatomical 
 relations the same rules for classification do not obtain. In the male the fecal mass is 
 pushed forward against the prostate, seminal ducts and urethra while in the female this 
 force is forward against the vaginal wall and uterus. 
 
 MALIGNANT. 
 
 Malignant diseases are of two kinds with their respective variations. Those sar- 
 comatous in character are less frequent and usually of secondary origin. The carcinomata 
 are more common eind as a rule primary in origin. Either variety may occur upon any 
 
 Page One Hundred Twenty-Two 
 
portion of the rectal wall or mucous membrane, always smgle and more frequent m the 
 lower half of the rectum and more often in the male in whom ulcer is more common. 
 
 Carcinomala may be primary or secondary, single or multiple, in any tissue or portion 
 of the rectum, usually single, and appear most frequently on the mucous membrane imme- 
 diately overlying the tip of the coccyx. 
 
 Sarcomata may be primary or secondary, single or multiple, usually single, in any 
 tissue or portion of the rectal wall. 
 
 INJURIES. 
 
 Ruptures. 
 
 Laceration. 
 
 Incision. 
 
 Puncture. 
 
 Rupture of the rectum may assume one of three varieties, laceration, incision and 
 puncture and each vary in extent, number and position, partial or complete, through the 
 rectal wall or when complete, extend into the surrounding soft structures, vagina, uterus, 
 bladder, peritoneal cavity, urethra, seminal vesicles or prostate. 
 
 SYMPTOMS. 
 
 Rectal Reflexes and Neuroses. (By H. C. Von Dahm, M. D.) 
 
 The consideration of rectal reflexes and neuroses leads to anatomical fields sometimes 
 far removed from the rectum, and again to fields so intimately associated with that organ, 
 not only anatomically, but from symptomatic and pathologic standpoints, that the subject 
 becomes a vast one and of no little importance. 
 
 The close association of the rectum with the genito-urmary system makes the success- 
 ful study of either one necessarily lead to a consideration of the other. Especially is this 
 true as to the neurotic manifestations of their pathology. 
 
 A review of the nerve supply of the rectum shows its innervation derived from both 
 the sympathetic and spinal systems with a predomination of the sympathetic. 
 
 This system supplies numerous filaments from the hypogastric, sacral and mesenteric 
 plexes, while the spinal element is derived from the third, fourth and fifth sacral nerves. In 
 their distribution the two nerve elements become intimately interwoven. The spinal nerves 
 in their course to the rectum, pass through the sacral plexus of the sympathetic and are dis- 
 tributed to the striated muscles, the levator ani and external sphincter, thence to the peri- 
 neal skin and the modified epithelium of the anorectal region as far up as the anorectal 
 line. Above this line we find only sympathetic distribution, the voluntary control of the 
 rectal function ceases and becomes an automatic one, entirely under the control of the 
 sympathetic. 
 
 The perineum, prostate, urethra, bladder and vagina receive a great part of their 
 spinal and sympathetic nerve supply from the same source as the rectum and anus, \\'hich 
 fact accounts for the various reflexes between the rectal and genito-urinary systems. Any 
 pathological condition of the rectum may give rise to genito-urinary symptoms, while many 
 times genito-urinary lesions have their symptoms referred to the rectum. 
 
 This rule obtains with both sexes though more frequently and numerous in the male 
 and of a more severe and complicated character because the genito-urinary system of the 
 female is less complicated in its arrangement. 
 
 Rectal disturbances are factors that always necessitate consideration, especially when 
 the male reproduction organs are disturbed. They are so intimately associated and com- 
 plex, that it is often impossible to discover their cause or origin, but such a difficulty is 
 not so likely to be encountered when the rectum in the female is primaiily disturbed, because 
 for want of so close a proximity of the two tracts as exists in the male. The same might 
 he said about the urinary apparatus in the female because of the absence of complexity. 
 
 While symptoms of rectal conditions are quite significant, those of the sigmoid are 
 intimately associated because their distinction is but imaginary, one being an extension of 
 the other. 
 
 Page One Huiulred Twenty-Throe 
 
From the studies of various investigators and anatomists, we draw the conclusion (a) 
 that the innervation of the pelvic viscera is derived chiefly from the sympathetic or is 
 greatly controlled by it. <!v 
 
 (b) That the innervation for both automatic rectal and automatic vesical function 
 is situated entirely in the sympathetic ; 
 
 (c) That the spinal cord in its relation to the pelvic viscera is simply the pathway 
 for sensory) impulses to the brain and for cerebral impulses controlling their voluntary 
 functions. 
 
 (d) That the two systems are intimately joined by the rami-communicantes of the 
 lumbar and sacral segments of the cord. 
 
 Only by the consideration of these facts, are we able to grasp the far-reaching but 
 withal closely related reflexes and neuroses of the pelvic viscera. 
 
 Rectal reflexes may arise from (a) areas innervated by the spinal nerves, (b) by 
 the sympathetic, or (c) by both systems. 
 
 The close association of the two systems often makes it impossible to definitely state 
 that a reflex arises entirely from one system or the other. Generally speaking, however, 
 we may say that the spinal factor is represented in all areas where stimuli can be recognized 
 and localized by the patient, while the sympathetic factor may affect distant points, the local 
 stimulus not being recognized except as referred pain at some point of spinal distribution. 
 
 We may conclude, therefore, that these reflexes may be manifested by (a) motor 
 spasms, (b) by sensory disturbances, (c) by alterations in secretion or (d) by any com- 
 bination of these three results. 
 
 The most familiar rectal reflex and the most neglected one is that of defecation. Here 
 we have the motor element represented by the contraction and relaxation of the striated 
 muscles of the pelvis and the abdominal muscles; the sensor]^ disturbance manifested by 
 peripheral nerve stimulation at the anal papillae from contact -with the feces ; and the 
 secretory element by a further secretion by the rectal mucosa. The desire for stool comes 
 on when pressure on the muscular coats of the rectum, on the levator ami and pelvic wall 
 creates a sense of fullness; this is sent to the sympathetic ganglia as an afferent impulse, is 
 returned as a strong efferent impulse and causes contraction of the involuntary muscles of 
 the rectum. 
 
 In addition to this impulse another is created at the anal papillce. by the mass coming 
 in contact with their extremely sensitive surfaces. This generates the motor impulse and the 
 voluntary muscles do their part. This short reflex would result in automatic evacuation 
 were it not overcome by the voluntary contraction of the external sphincter and levator ani 
 muscles. The reflex is kept up however, to exhaustion, and as it becomes exhausted, the 
 desire passes. Neglect of this reflex demand of nature, we know is one of the basic causes 
 of so-called "habit"' constipation. 
 
 As said before, were it not for the po\ver of voluntary inhibition, the act of defeca- 
 tion would be entirely automatic, the rectum emptying itself as soon as the efferent sym- 
 pathetic impulses were of sufficient strength to generate motor impulses. In addition to 
 this automatic power the rectum exhibits a marked tendency to periodicity in the exercise 
 of its function. 
 
 If inhibition of the efferent motor impulse is the basic cause of "habit'' constipation, 
 here then we have the simplest cure. Coincide with the reflex of automaticity and peri- 
 odicity, thus creating a "habit action' and the "habit constipation" is removed. This, 
 of course, is true only when the reflex arc is unimpaired by lesions of its centers. 
 
 Anal fissure is a condition giving rise to many neuroses. There is at first a spinal 
 reflex evidenced by the contraction of the external sphincter at the time of defecation or 
 upon digital examination. (The spasm is much more marked than the simple anal reflex 
 — this latter, after a short time, becoming much accentuated) . Later when the irritation 
 from the fissure becomes more severe a mixed reflex is developed, with much pain either at 
 the time of stool or immediately following. This causes an involuntary reflex contraction 
 of the sphincter, which cannot be voluntarily relaxed. We must remember that the ex- 
 ternal sphincter must be relaxed reflexly, but that it may be contracted both reflexly and 
 voluntarily. 
 
 Paffe One Hundred Twenty-Four 
 
The spasmodic contraction of the sphincter so depletes the blood supply of the fissure 
 and irritates the exposed nerve endings to such a degree that reverse reflexes are set up. 
 The pain may now be referred to the sacrum, prostate, the ovaries or the bladder. It may 
 even travel down the thigh, or follow the distribution of the fourth and fifth sacral nerves. 
 Intestinal disturbances may arise such as flatulence, or vague diffuse pain. These reflexes 
 may be explained as may all complex neuroses of this region by the contiguity of their 
 spinal and sympathetic centers. A thrombotic hemorrhoid may give rise to similar symptoms. 
 
 One of the common reflexes of internal hemorrhoids is a pain and sense of rvcight 
 in the floor of the pelvis, or sometimes it is referred to the sacrum. This may be explained, 
 as the result of the congested rectum pressing upon the levator ani muscles or upon one 
 of the nearby sacral nerves. 
 
 Anal pruritus gives rise to a number of neuroses, of which itching is the most promi- 
 nent. This reflex is observed in the perineal skin and in the modified skin lining the anal 
 canal as far up as the crypts. This symptom is due to irritation of those nerves capable 
 of carrying tactile sensation and not those which convey painful stimuli. Local anes- 
 thetics will neutralize painful skin sensations in this region but will not stop the itching of a 
 true pruritus. Another neurosis in this condition is a sensation of crarvling. This is due 
 to irritation of the same nerve endings. An illustration of the secretor]) f^pe of reflex some- 
 times present in anal pruritus is perineal sweating. This symptom has also been noted in 
 cases of great nervous excitement and in fecal impaction. 
 
 Ordinarily, sensations of moisture or dryness are felt only in the anal and perineal 
 skin. However, when the pathology causing these conditions is situated either in the rectal 
 ampulla or at the anorectal line, the sensation to the patient is at the point of irritation 
 and not where the moisure or dryness exists. 
 
 A cryptitis may produce more disturbances of spinal sensation and motor function 
 than any other rectal lesion. The resulting neuroses are legion and may be explained by 
 the complicated and interwoven nerve supply to the crypts and to the papillae in immediate 
 relationship. So profound does this irritation become that a mental exhaustion or extreme 
 emotional irritability has been noted and from no other cause. 
 
 Persistent vomiting is a neurosis, which may result from impacted feces in the rectum 
 or colon. Retained flatus, tumors and strictures of the rectum, especially when they are 
 high enough to press upon the peritoneum, may give rise to pain which may be referred to 
 the appendix, the bladder or ovaries. 
 
 Lesions above the ano-rectal line are not so liable to cause so many complicated 
 neuroses as are those situated belorv this highly sensitized region. This is true also of 
 extra-rectal lesions involving the loose tissue immediately around that organ. It has been 
 a much discussed question, if the mucosa of the rectum proper is at all supplied with 
 sensory nerve endings. It has been demonstrated that ulcers may be cauterized without 
 localized pain to the patient; that hemorrhoids may be removed without an anesthestic and 
 that sensations of heat and cold cannot be detected unless they come in contact with the 
 spinal innervation at the ano-rectal line. Carcinoma of the rectum develops no pain that 
 can be localized until it involves the voluntary muscles of the pelvis or pelvic wall. This 
 may be why so many rectal carcinomas reach an inoperable stage before their presence is 
 discovered. This absence of localized pain is noted also in suppurations outside the rec- 
 tum. Unless they involve some one of the structures named or press upon a nerve fila- 
 ment their presence is often unsuspected. 
 
 There are a number of neuroses that occur without the presence of pathology in 
 tissue. A patient may complain of vagus symptoms of uneasiness or pain in the region of 
 the anus and upon examination we find everything normal. Perhaps a few minutes later 
 another examination \vi\\ disclose a sphincter in the extreme spasm. We must necessarily 
 account for this as pain due to muscular contraction from some central lesion and not to 
 peripheral irritation. This may in time produce marked systemic and mental phenomena. 
 Or on the contrary, undue sphincteric dilation may produce phenomena just as profound. 
 It is not uncommon in highly sensitive individuals to find a condition bordering on nervous 
 exhaustion following a constipated stool. The systemic effect of divulsion of the sphinc- 
 ters is very evident. The heart action is increased, blood pressure is raised, the respirations 
 
 Page One Hundred Twenty-Five 
 
become deeper, the capillaries are flushed through excitation of the vaso-motor center and 
 profound nervous phenomena are produced. 
 
 Following divulsion of the sphincters, we sometimes find the internal sphincter in a 
 state of contraction and doing the work of both. Sahli calls this condition "vicarious con- 
 traction," while Cook gives it the name of "compensatory contraction." It may be ex- 
 plained by the voluntary contraction of the levator ani and glutei stimulating a sympathetic 
 reflex which is referred to the internal sphincter. 
 
 In a consideration of neuroses of the rectum, we must differentiate between diseases 
 of that organ with referred pain in extra rectal structures and pathological conditions, which 
 are extra rectal, but producing rectal symptoms. In addition to their local symptoms, 
 peculiar to the lesion, prostatitis, seminal-vesiculitis, urethral stricture, various lesions of the 
 bladder, renal calculi, and ovarian or uterine inflammations may exhibit a very marked pain 
 in the rectum or sacrum. These symptoms are often ascribed to some slight rectal lesion 
 and the real cause overlooked. Especially is this true of uterine or ovarian displacement. 
 Illustrative of this, a retroverted uterus may produce a mucoid proctitis or hemorrhoids. 
 Treatment of these conditions would afford only temporary relief at best while correction 
 of the displacement would bring about permanent benefit. 
 
 Lesions of the central nei-vous system, which interfere with the transmission of motor 
 or sensory impulses are often exhibited in the rectum. AUingham says: "In the beginning 
 of various forms of mania one often observes that the patient has severe pains in the rectum 
 without any pathological lesion to account for the same/' Locomotor ataxia shows ear/jj 
 rectal symptoms such as constipation, paroxysmal pain, lessened irritability of the sphmcters 
 and loss of sensation in the perineal skin. Later we may have a loss of the voluntary 
 or reflex control of the bowel. When this last occurs, a vicarious condition is produced, 
 as the automatic control is not lost so early, and we have a constipation with incontinence. 
 Acute transverse myelitis results in early paralysis of the rectum and bladder, while in the 
 lateral sclerosis, we observe increased sphincteric rigidity and reflexes. 
 
 A review, such as this paper is intended to be, would be far from complete without 
 a reference to the effect of rectal pathology on the general health of the individual. There 
 is hardly a lesion of the rectum that does not have its effect on the general nutrition. Many 
 of them go farther and make their influence felt on the mind as well. Especially is this 
 true in individuals of a nervous temperament. It is surprising the amount of mental relief 
 afforded by a successful treatment or operation upon a rectal lesion. Whether the con- 
 dition before treatment v/as psychical or physical, the feeling of depression is thrown off 
 and the patient is afforded mental and physical relief sometimes out of all proportion to the 
 pathology removed. 
 
 A rectum distended with gas or feces may cause painful disturbances alike through- 
 out the uro-genital and rectal tracts, because of the excessive pressure upon the seminal 
 vesicles and prostate glands, so rich in sensory nerve filaments. 
 
 Highly acidulated feces or a bladder distended wth urine, or containing a highly 
 acid urine, will cause the desire to urinate, defecate or copulate. Constipation and diar- 
 rhea may be the result of such a condition and is, no doubt, frequently the cause of the 
 uterus discharging prematurely its fetal contents. 
 
 Rectal irritation in certain individuals of either sex, may produce greater sexual ex- 
 citability thaui the same degree of irritation to the sexual organs alone, and irritation of 
 the sexual organs may cause a desire to defecate and irritation to either may cause frequent 
 desire to urinate, thus demonstrating the intimate relationship of their nervous impulses in 
 both health and disease. 
 
 It may cause the loss or increase of sexual desire and sometimes be associated with 
 dull pain of a bearing-down character, which is so frequently reflected to the coccyx and 
 pain in the loin about the buttocks and sometimes down the thigh. 
 
 Alimentary function may remain normal or be disturbed by the various rectal condi- 
 tions and their compHcations in the form of nausea, vomiting, eructation, acid stomach, 
 flatulence, constipation, diarrhea and distention. 
 
 They may be mild or severe or of short or long duration. 
 
 The appetite may be impaired by infection due to any cause and its impairment in- 
 creases with the degree of infection or irritability. 
 
 Page One Hundred Twenty-Six 
 
CHAPTER XXVI. 
 
 PERSONAL BIOGRAPHY. 
 
 1. The Negligence and Result of Vaccination, Iionton, O., June 1, 1882 (pamphlet). 
 
 2. Lynx Rufus, Journal Cincinnati Nat. Hist. Soc, April, 1882. 
 
 3. Construction of Sewers, Ironton, O., June, 1882, (pamphlet). 
 
 4. A Case of Scarlatina, Med. Soc. Columbus, O., Col. .Med. Journal, January, 1884. 
 
 5. Internal Urethrotomy, January 2, 1893, p. 195, Bound, Vol. 5. 
 
 6. A Case of Ichthyosis Sebacea, Lancei-Clinic, Cincinnati, 1885, x, p. 312. 
 
 7. Clinical Use of Chrysarobin. Lancet-Clinic, Cincinnati, 1885, xiv, 312. 
 
 8. Pityriasis Rosea, Lancet-Clinic, Cincinnati, 1885. 
 
 9. A Case of Lichen Scrofulosis. Lancet-Clinic, Cincinnati, 1885, x, p. 427. 
 
 10. Pyrogallic Acid, Its Preparation and Uses. Lancet-Clinic, Cincinnati, 1885, x, p. 39. 
 
 11. Three Cases of Carcinoma. Lancet-Clinic, Cincinnati, 1885, x, p. 398. 
 
 12. Case of Epithelioma Monographia Syphilitica, 1885. 
 
 13. Lupus Vulgaris, Columbus (O.) Med. Journal, May, 1885. 
 
 14. Treatment of Ulcer (Chronic) Leg, Virginia Med. Monthly, 1885. 
 
 15. Cincinnati Med. Soc. Discussion Plastic Surgery. Lancei-Clinic, Cincinnati, March 23, 1886. 
 
 16. -Abscess Cerebellum (Case Specimen). Lancet-Clinic, Cincinnati May 4, 1886. 
 
 17. Sponge Grafting. Lancet-Clinic, Cincinnati, April 13, 1886. 
 
 18. Epithelioma- Aetology, Diagnosis and Treatment. Lancei-Clinic, Cincinnati, June 12, 1886. 
 
 19. Thermocautery in Treatment of Herpes. Lancet-Clinic, Cincinnati, October 13, 1886. 
 
 20. A Case of Morphia. Cincinnati Med. Journal, Sept., 1886. 
 
 21. Psoriasis. Lancet-Clinic, Cincinnati, xviii, p. 265, 1887. 
 
 22. Onochogriphosis. Lancet-Clinic, Cincinnati, xviii. p. 303, 1887. 
 
 23. Rodent Ulcer, Papillomatous Epithelioma and Lupus Eiythematosis, Lancel-Climc, Cincinnati, 
 March, 1887. 
 
 24. Oidium Albicans. Lancea-Clinic, Cincinnati, xviu, p. 393, 1887. 
 
 25. Management of Eczema. Lancei-Clinic, Cincinnati, July 30, 1887. 
 
 26. Urticaria (Copaiba). Lancei-Clinic, Cincinnati, Dec. 19, 1887. 
 
 27. The Relation of the Red Corpuscles to the Brain. Jour. Nat. Hist. Soc, Cincinnati, April, 
 
 1887. 
 
 28. Surgical Treatment of Tubercular Glands. Cincinnati Journ. Med., 1888. 
 
 29. Sundry Articles. Cincinnati Med. Journ., 1888. 
 
 30. Circumcision from a Dermatological Standpoint. Lancet-Clinic, Cincinnati, xx, p. 40, 1888. 
 
 31. Syphilitic Ulceration of Nose. Lancet Clinic, Cincinnati, July, 1888. 
 
 32. Use of Arsenic in Dermatology. Lancei-Clinic, Cincinnati, May 8, 1888. 
 
 33. Squamous Eczema. Lancei-Clinic, Cincinnati, xxi, p. 493, 1888. 
 
 34. Psoriasis Nummularis. Lancei-Clinic, Cincinnati, Dec. 11, 1888. 
 
 35. Dermatological Coverings of Animals and Plants. Cincinnati Nat. Hisl. Soc. Journ., January, 
 1888. 
 
 36. Treatment of Acne. Trans. Ohio Stale Med. Soc, 1888. 
 
 37. Eczema Infantile. Trans. Ohio Stale Med. Soc, 1888. 
 
 38. Naevoid Elephantiasis (Case), Cutaneous Journal, 1888. 
 
 39. Rhinoplastes and Extrophy Bladder. Lancet-Clinic, Cincinnati, Nov. 9, 1889. 
 
 40. Eruption (Hydrastus and Laudanum) Lancet-Clinic, March 18, 1889. 
 
 41. External Urethrotomy. Lancei-Clinic, Cincinnati, xxiii, p. 583, 1889. 
 
 42. Plasto-Cosmetics in Surgery of Face. Lancet-Clinic, Cincinnati, xxiii, 303, 1889. 
 
 43. Pemphigus Vulgaris. Lancet-Clinic, Cincinnati, xxiii, 470, 1889. 
 
 44. Cremation. Med. & Surg. Reporter, Phila., March, 1889. 
 
 45. Lymphangitis. Lancet-Clinic, Cincinnati, xxv, 597, 1889. 
 
 46. Fifteen Cases of Gonorrhea. Lancet-Clinic, Cincinnati, xxv. 11, 1890. 
 
 47. Copaiba Eruption Herpes Lumbricales. Lancet-Clinic, Cincinnati, xxv, 72, 1890. 
 
 48. Extensive Naevus in a Child Three Months Old. Lancei-Clinic, xxv, 75, 1890. 
 
 49. General Alopecia. Lancet-Clinic, Cincinnati, xxv, 132, 1890. 
 
 50. Excision of the Knee. Lancet-Clinic, Cincinnati, xxv, 537, 1890. 
 
 51. Surgical Treatment of Epilepsy. Lancei-Clinic, Cincinnati, xxv, 73, 1890. 
 
 52. Radical Operation for Hernia. Lancet-Clinic, Cincinnati, xxvi, 41, 1891. 
 
 53. The Use and Abuse of Soap and Water. Cutaneous Journal, May, 1890. 
 
 54. Atypic Herpes Zoster Gangrenosa. Jour. .4m. Med. Ass'n, May, 1890. 
 
 Page One Hundred Twenty-Seven 
 
55. External Surgery of the Nose. Jour. Am. Med. Ass'n, May, 1890. 
 
 56. Indications for Infernal Urethrotomy. Trans. Ohio Slate Med. Soc, May, 1890. 
 
 57. Large Doses of Kali lodidum, St. Louis Med. Mirror, 1893, also South West. Ohio Med. 
 Soc, 1890. 
 
 58. Experimental Research in Bone Grafting. New York Slate Med. Assoc, Nov. 5, 1890. 
 
 59. The Removal of Lymphatic Glands. Cincinnati Med. Journ., March, 1890. 
 
 60. Osteo-penthesis Reprint from Jour. Am. Med. Ass'n, xii, 277, No. 2, B. Vol. 6, 1891. 
 
 61. A Case of Talipes Eqquino- Varus. Jour. Am. Med. Assn., August 20, 1892, p. 305; also 
 Vol. xii, No. 2, Bound, Vol. 6. 
 
 62. Scrotal Hernia. Lancet-Clinic, Cincinnati, Vol. 7, p. 16. 
 
 63. Early Removal of Tubercular Foci of the Bone. Jour. Mat. Med., xxi, 217, No. 1, Bound 
 Vol. 6. 
 
 64. 150 Circiimcisions. Lancet-Clinic, Cincinnati, Feb. 9, 1892, Bound Vol. 5, p. 135. 
 
 65. 150 Circumcisions, Lancet-Clinic, Cincinnati, v, 241, 1892. 
 
 66. Large Doses of The Iodides. Lancet-Clinic, Cincinnati. Vol. 7, p. 247. 
 
 67. The Surgical Treatment of Epilepsy. Lancet- Clinic, Cincinnati, vii, 1891, 241. 
 
 68. A Case of Sarcoma Axilla. Lancet- Clinic, Cincinnati, xxvi, 470, 1891. 
 
 69. Vesical Calculus. Lancet-Clinic, Cincinnati, xxvi, 471, 1891. 
 
 70. Fracture of the Skull and Restoration of Fragments. Lancet-Clinic, Cincinnati, xxvi, 729, 
 1891. 
 
 71. Treatment of Chronic Gonorrhea with Yellow-Oxide. Lancet-Clinic, Cincinnati, xxvi, 1891. 
 
 72. Osteo-Penthesis, Washington, D. C, May, 1891. 
 
 73. The Surgery of Cleft Palate. Miss. Valley Dental Assoc. Trans., March, 1891. 
 
 74. Observations on Koch's Lymph in Sixty-Three Cases. Cincinnati Academy of Med., Jan., 
 1891, also Lancet-Clinic, Feb., 1891. 
 
 75. 150 Circumcisions. Lancet-Clinic, Cincinnati, xxviii, 359, 1892. 
 
 76. Abscess of Cerebellum (6 cases) Following Caries Middle Ear Disease. Lancet-Clinic, 
 Cincinnati, xxviii, 818, 1892. 
 
 77. Neurectomy Great Sciatic, Talipes, Correction (Photo). Jour. Am. Med. Ass'n, May, 1892. 
 
 78. Internal Urethrotomy (36 cases). New York Med. Journ., July, 1893. 
 
 79. Niagara's Water Power. Journ. Cincinnati Nat. Hist. Soc, January, 1893. 
 
 80. Intestinal Anastomosis (Maunsell). Jour. Am. Med. Ass'n, August 26, 1893. 
 
 81. Lupus, Its Extirpation. A^en; York Med. Journ.. September 23, 1893. 
 
 82. Varicocele (19 Operations). New York Med. Jour., June 17, 1893. 
 
 83. Early Removal of Tubercular Foci of Bone. Jour. Mat. Msdica, May 12, 1893. 
 
 84. Primary Gonorrhea and Syphilis in Children. Jour. Am. Med. Ass'n, December 16, 1893. 
 
 85. Excision of Hip-Joinl in Tubercular Disease. Jour. Cyn. & Pediatrics, January, 1894, 
 also Cincinnati Acad. Med., November, 1893. 
 
 86. Obliteration of Pigmentation. Jour. Am. Med. Ass'n, January 20, 1893. 
 
 87. External Urethrotomy. Med. Record, N. Y., June, 1893. 
 
 88. A Staff of Consultants. Times Star, December 15, 1893. 
 
 89. Traumatic Periostitis. Railway Age, March 7, 1894. 
 
 90. Circular Saw Injury (Photo). Med. News, Phila., January 1. 1894. 
 
 91. Tubercular Syphilis Nose (Photo) Sarcoma General (Photos). Cutaneous & Cenito-Urin. 
 Journ., April 1, 1894. 
 
 92. Intestinal Anastomosis. Ann. Surg., April 1, 1894. 
 
 93. Omental Tumor, St. Louis, 1894. 
 
 94. Enchondroma of Neck (Photos). Times & Register, January 6, 1894. 
 
 95. Last 30 of a Series of 200 Circumcisions. A^en. York Med. Journ., March, 1894. 
 
 96. Six Thigh Amputations and Hydrocele. IVest Va. Med. Journ., September 1, 1894. 
 
 97. Small-pox and Vaccination. Cincinnati Med. Journ., March, 1894. 
 
 98. Epithelioma of Lower Jaw. St. Louis Med. Mirror, April, 1894. 
 
 99. Extrophy of Bladder. A^en; York Med. Record, April 14, 1894. 
 
 100. An Interesting Case (Tubercular Foci). Mo. Med. Monthly, April 1, 1894. 
 
 101. Epithelioma Over Sternum. Med. Progress, Louisville, Ky., May 1, 1894. 
 
 102. The Surgical Uses of Cocaine. Med. & Surg. Reporter, April 14, 1894. 
 
 103. Fifty Cases of Rectal Surgery. Journal Rectal Surg., Louisville, Ky., July 1, 1894. 
 
 104. Hip- Joint Amputation. West Va. Med. Jour., November, 1894. 
 
 105. The Lengthening and Shortening of Bones. L. Oilier, Lyons, France. Translated by 
 B. M. R., Cincinnati Med. Jour., March 1, 1894. 
 
 106. The Removal by Trephine of Fluid as the Result of Acute Cerebral Meningitis, with 
 Report of a Case and Experiments Upon the Lower Animals. New York State Med. Ass'n, October, 
 1894. 
 
 107. New Surgery in the So-Called Medical Cases. Marion, Ohio, December 21, 1894. 
 
 108. Ccistration for Hypertrophied Prostate. December 2, 1894. 
 
 109. Removal of Head of Femur From Lesser Sciatic Notch. December 15, 1894. 
 
 110. Trephine in Acute Cerebral Meningitis. December 8, 1894. 
 
 111. Colotomy and Kraske Operation. Cincinnati Lancet-Clinic, xxxiii, 679. 
 
 112. Hydrocele Radical Operation. IVest Va. Med. Jour., October, 1894. 
 
 113. Hygroma. Cincinnati Acad. Med., December 11, 1895; also Lancet-Clinic, xxxv, 724. 
 
 Page One Hundred Twenty-Eight 
 
114. The ManaRemenI of Tubercular Subjects. Penna. Soc, May 14, 1895. 
 
 115. Dislocation and Double Fracture of Upper Third of Humerus. Jour. Am. Med. Ais'n. 
 May, 1895. 
 
 116. Malignant Growths of Superior Maxillary Bone. 5/. Louis Med. Mirror, March I, 1895. 
 
 117. Modern Surgery of Serous Cavities. Nat. .'\ss'n Railway Surgeons Centr. Ohio, Med. Soc, 
 Columbus, Ohio, February 7, 1895. 
 
 118. Cerebral Cyst Removal Typhoid Ulcer Operation. Cincinnali Lancet-Clinic, April 6, 1895. 
 
 119. Flat Foot, Its Correction and Comparative Study With the Foot of the Orang, Chimpanzee, 
 Gorilla and Baboon. Am. Med. Ass'n, August 3, 1895. 
 
 120. Double Club Fool and Hands, Children's Section. Am. Med. Ass'n Journal, October 10, 
 
 121. Lupus Treated by Galvanism. Am. Med. Assn. Journ., May 7-10, 1895. 
 
 122. Reply to Medical Record Editorial on Circumcision. Med. & Surg. Reporter, Phila., 
 February 21, 1895. 
 
 123. Site of Inoculation (Vaccinia) Lancel-Clwic, Cincinnati, April 20, 1895. 
 
 124. Neuralgia of the Fifth Nerve. Cincinnati Acad. Med., March, 1895. 
 
 125. Rupture of the Left Lateral Ventricle. Cincinnati Acad. Med., April, 1895. 
 
 126. New Operation for Hemorrhoids and Prolapsed Rectum. Ph};s. & Surgeon, Ann Arbor, 
 
 October, 1895. .„ , - c ,. .one 
 
 127. The Cranectomies. Brain Surgery. Read Before Detroit Med. hoc, Sept. 16, 18^:3. 
 
 128. Exsection of Head of Humerus and Jaws for Ankylosis. Lancet-Clinic, Cincinnati, Oct. 20, 
 
 129. The Removal of Lymphatic Glands. Cincinnali Med. Journ., March, 1890. 
 
 130. A Radical Operation for Prolapsed Rectum and Hemorrhoids. Chicago Academy Medicine, 
 Feb. 14,' 1896. 
 
 131. The Advantages of the Bicycle. Cincinnati Tribune, Oct. 6, 1895. 
 
 132. Enchrondritis, Surgical Treatment. Journ. Am. Med. Assn., Aug. 22. 1896. 
 
 133. Sanitation of Workshops and Public Conveyances. Lancet-Clinic, Cincinnati, 1896, xxxvi, 396. 
 
 134. Vivisection. Cincinnali Commercial Gazelle, November 10, 1895. 
 
 135. Anal Fistula Peritonitis Laparotomy Recovery. Lancel-Clinic, Cincinnati, April 7, 1896. 
 
 136. Surgery of the Chest. Report of Cases. Lancet-Clinic, Cincinnati, 1896, xxxvii, 237. 
 
 137. Twelve Deaths. — Total Number of Fatalaties in 12 Years (1) Strangulated Omental Tumor; 
 (2) Sarcoma of Lower End of Femur; (3) Colotomy; (4) Intestinal Anastomosis; (5) Post. Dislocation 
 of Femur; (6) Typhoid Ulcer; (7) Appendicitis; (8) Cystic Kidney; (9) Tuberculosis Sacro- Iliac; 
 (10) Hip-Joint Amputation; (11) Two Trachectomies, Lancet-Clinic, Cincinnati, 1896, xxxvii, 264. 
 
 138. Trifacial Neuralgia, Ligation of CommoiT and External; Cartoid Report of Case 97 Years 
 of Age; Virginia State Med. Soc, Rockbridge. Alum Springs, September 8-10, 1896. 
 
 139. Sulgical Melange: (1) Ligation of Brachial; (2) Gunshot "Wound of Facial Artery; (3; 
 Talipes; (4) Hyperlrophied Prostate, 3 cases; (5) Sarcoma of Sacrum, Miss. Valley Med. Assn., 
 September 15, 1896. 
 
 140. Eczema Chronicum and Ethyl Chloride (Bougie). Lancel-Chmc, Cincinnati, 1896, xxxvu, 
 
 141. Brachial Cysts, Extirpation, Recovery. Lancel-Clinic, Cincinnati. 1896, xxxviii, 36 Dis- 
 cussion 40. o n/I 1 D 
 
 142. Surgical Melange. (1) Craniotomes; (2) Thacheolomy Lacehook; (3) Murphy Button 
 Gut Strangulation; (4) Appendicitis Suppuration, 4 Cases; (5) Tubercular Fibula .Amputation; (6) 
 Amputation Middle Thigh. Read before North East Med. Assn. Kentucky, Carlisle, January 21, 1897. 
 
 143. Ligation Common Cartoid for Trifacial Neuralgia. Surg. Seel., Jour. Am. Med. Assn., 
 June 1-5, 1897. 
 
 144. Cranectomies, Report of Four Cases. Lancel-Clinic, Cincinnati, July 10, 1897. 
 
 145. Removal of Upper and Lower Jaws Through the Mouth Without Incision. Railway Surg., 
 Chicago, 1897-8, IV, 337. 
 
 146. Appendicitis, 4 Cases. Lancel-Clinic, Cincinnati, July 17, 1897. 
 
 147. Rectal Prolapse Hemorrhoids. Mitchell Dist. Med. Soc, July 8-9. 1897. 
 
 148. Appendicitis. Olympic Springs Bath Co., Ky., July 10, 1897. 
 
 149. Brain Surgery for Epilepsy. Milrvaukee Med. Jour., 1896, iv, 92-94. 
 
 150. Trifacial Neuralgia, Ligation of Common Cartoid and External Cartoids. Report of a 
 Case aged 97 years. Virginia Med. Semi-Monthlv, Richmond, 1896-7, i, 326-328. 
 
 151. Three Cases of Appendicitis. Lancel-Clinic, Cincinnali, 1897, xxxix, 330-332. 
 
 152. Lace Hook in Trachea, Tracheotomy. Columbus Med. Journ., 1897, xviii, 586. 
 
 153. Foreign Body in Trachea. Lancet-Clinic, Cincinnati, 1897, xxxviii, 139. 
 
 154. Abdominal Incision for .Ascites. Lancet-Clinic, Cincinnati, 1897, xxxix. 347. 
 
 155. Aneurism of Aortic Arch. Surgical Treatment by Ligation of Right Common Cartoid and 
 Sub-Clavian Arteries. Journ. Am. Med. Assn., August 13, 1898. 
 
 156. Deaths, Surgical Causes: (I) Gangrene, Thigh Amputation; (2) Brain .Abscess; (3) 
 Ovarectomy, Double; (4) Intestinal Obstruction; (5) Fibro-Sarcoma of Uterus; (6) Lithotomy; (7) 
 Gall-Bladder Rupture; (8) Brain Abscess; (9) Fracture Base of Skull; (10) Meningitis Cerebral. 
 /.ance/-C/m/c, C.ncmnati, 1898, xl, 571-575. .- , o 
 
 157. Trifacial Neuralgia, Ligature Externa! and Common Cartoid. Ohio State Med. Soc, 
 May 4-6, 1898. 
 
 Page One-Hundred Twenty-Nine 
 
158. Hypertrophied Prostate, Nine Cases. Lancel-Clinic, Cincinnati, 1898, xl, 481. 
 
 159. The Dermal Coverings of Animals and Plants. A Short Resume of Various Authors, 
 Lancet-Clinic, Cincinnati, August 20, 1898. 
 
 160. Serpents and Their Venom, Copperhead, Corral and Rattlesnake. Lancet-Clinic, Cincinnati, 
 
 1898, xli. 491-494. "^ 
 
 161. Surgical Melange; (I) Empyema of Chest; (2) Empyema of Chest; (3) Abscess of 
 L.ung; (4) Ununited Fracture of Humerus; (5) Septum Nasi Protrusion; (6) Septum Nasi Protrusion; 
 (7) Sarcoma of Neck; (8) Sarcoma Popliteal Space; (9) Anal Fistula; (10) Anal Fistula; Lancet- 
 Clinic, Cincinnati. 
 
 162. Case History, Photograph. Dermatological Section, .'\m. Med. Assoc, June 6-9, 1899. 
 
 163. Surgical Appendicitis. Ohio Stale Med. Soc. May, '899, Vol. xii, p. 221. 
 
 164. Heart of Tortoise. Virginia Med. Monthlv, March 10, 1899. 
 
 165. Rectal Sarcoma, Excision and Subsequent Colotomy. Am. Proctological Assoc, June 6, 
 
 1899. 
 
 166. Cranial Injuries of Childhood, Their Treatment. Ohio Pediatric Soc, May 9, 1899. 
 
 167. Cholangiostome, Presented to New York Soc. Med, Assoc, December 25, 1899, Vol. v, 
 
 No. 12, p. 895. 
 
 168. Femora! A.rtery and Vein, Their Destruction With Loss of Leg. Journ. Am. Med. Assn., 
 August, 1899. 
 
 169. Dermatology, A Record of Clinical Cases, Cincinnati, 1893. A Report of 300 Dermatological 
 Cases, 1899; Record of Smallpox Cases in Ironton, March 15, 1881 to June 15, 1882. Notes of 
 Lectures on Medicine, Translation of Dr. Ollier's work. 
 
 170. Handbook: What To Do In Case of Accident. 1893. 
 
 171. An Operation for Inguinal Hernia. Lancet-Clinic, 1898, ns. xli, 508. 
 
 172. Sarcoma in Patients With a History of Syphilitic Infection. Lancet-Clinic, Cincinnati, 1898, 
 ns. xli, 456-458. 
 
 173. A Case of Ununited Fracture of the Humerus. Lancel-Clinic, Cincinnati, 1898, ns. xli, 508. 
 
 174. Translation of Dr. OHiers Work. Bone Resection. 
 
 175. Specimens Demonstrating the Operation of Gastro Cholecystotomy ; End to End Anastomosis 
 of Gut, etc., Bound Vol., ii, p. 302. 
 
 176. Report of a Case of Talipes Equino-Varus. Jour. Am. Med. Assn., Vol. 9, No. 8, d. 
 219, Bound Vol. ii. 
 
 177. Circumcision, Last 50 of Series of 200. New York Med. Journ., April 7, 1894, p. 431. 
 Bound Vol. 49. 
 
 178. Bloodless Amputation at the Hip-Joint. Bound Vol. iii, p. 32, 1898. 
 
 179. Direct Fixation of Fractures. Medical Age, Detroit, 1894, 1.717. Railwa]) Surgeon. 
 Chicago, 1894, 1. 351. Times Register, Phila., xxviii, 306-308, 1894. Also Reprint. 
 
 180. Operations for Gall-Stones. Lancet-Clinic, Cincinnati, 1899, ns. xiii, 237-239. 
 
 181. Sarcome de la Resion anlerieure du Thorax et de I'aisse lie droit, J. Am. Med. Assn., 
 1900, xxiv, 76-77, 1 fig. 
 
 182. Ovarian Pregnancy. Report of a Case at Full Term. Am. J. Surg. & Gynecol., St. Louis, 
 1900, xiii, 146-148. 
 
 183. Specimens of Gall-Stones. Lancet-Clinic, Cincinnati, xliv, 369-370. 
 
 184. Specimens of Gall-Stones. Lancet-Clinic, Cincinnati, 1900, xlv, 594. 
 
 185. Case of Ectopic Pregnancy. Lancel-Clinic, Cincinnati, 1900, xliv, 370-371. 
 
 186. Sarcoma of the Kidney. Lancet-Clinic, Cincinnati, 1900, xliv, 364. 
 
 187. Submucous Ligature For Rectal Hemorrhoids and Prolapse. Med. Rev. of Rev. N Y 
 
 1900, vi, 512-519, 6 fig. 
 
 188. Some Anomalies of the Uterus. Lancel-Clinic, Cincinnati, 1901, xlvii, 554. 
 
 189. Hernia, Radical Operation with Wire Mattress (Phelps) Trans. New York State Med 
 Soc, 1901. 
 
 190. Inguinal Hernia. Lancet-Clinic, Cincinnati, 1901, ns. xlvi, 105. 
 
 191. Appendicitis (Surgical Treatment). Lancet-Clinic, Cincinnati, 1901, ns., xlvi, 189-192. 
 
 192. The Appendix Veriformis and Caecum. A Comparative Study. 1814-1901 / Am Mpd 
 Assn., 1901, xxxvi, 1556. ■ •'■ ■ 
 
 193. Discussion on Specimens of Tubercular Kidney and Bladder. Lancet-Clinic, Cincinnati, 1902 
 ns. xlix, 39. 
 
 194. A Brief Resume of the Treatment of Tuberculosis. Lancet-Clinic, Cincinnati, 1902 ns xlix 
 
 140-141. ' ' • . 
 
 195. Surgery of the Prostate and Diaphragm. Lancel-Clinic. Cincinnati, 1902 ns xlix 369-376- 
 
 399-405; 431-434. . , , 
 
 196. Appendicitis. Lancet-Clinic, Cincinnati, 1902, ns. xlviii, 573-576. 
 
 197. Surgery of the Heart. Lancet-Clinic, Cincinnati, 1902. 
 
 198. Ligation of Arteries, Cocaine Anaesthesia. Interstate Med. Journ., St. Louis, 1902, ix. 
 
 199. Ligation of Arteries, Cocaine Anesthesia. Lancet-Clinic, Cincinnati, 1902, ns. xlviii, 403-405. 
 
 200. Surgery of Penetrating Wounds of Lungs and Heart (Experimental) Virginia Med. Semi- 
 Monthly, Richmond, Va., 1902-3, vii, 508-511. 
 
 201. Exhibition of a Patient Upon Whom Operation for Floating Kidney Was Performed. 
 Lancet-Clinic, Cincinnati, 1903, ns. 50, p. 63. 
 
 Page One Hundred Thirty 
 
202. Specimen of Foreign Body Removed From ihe Intestine, Supposed to be a Piece of Carbon. 
 /.anccl-Clinic, Cincinnati, 1903, ns. 50, p. 63. 
 
 203. Lung Surgery. Laiicel-Clinic, Cincmnati, 1903, ns. \'oi. 50, p. 1-9. 
 
 204. Lung Surgery, Historical and Experimental. Abstract Med. News, New York, 1903, Ixxxiii, 
 683-699. 
 
 205. Surgeiy of the Pancreas (Historical and Experimental). Med. Forlnightly, St. Louis, 1903, 
 xxiii, 299-305. 
 
 206. The Surgery of the Heart. N. Y. Med. Journ., 1903, Ixxvii, 918-963; 1148-1204. 
 
 207. Typhoid Gangrene of the Lower Extremities, 134 Cases of Spontaneous and Surgical Am- 
 putations; An Flistorical Resume. Lancet-Clinic. Cincinnati, 1903, ns. Vol. 51, pp. 553; 580. 
 
 208. Surgery of the Thyroid. Kansas Cr/p Med. Index,— Lancet, 1903, xxiv, 389-436. 
 
 209. Surgery of the Diaphragm. Virginia Med. Semi-Monlhl\j, Richmond, 1903-4, viii, 87-90. 
 
 210. Typhoid Gangrene of the Lower Extremities, 134 Cases, Spontaneous and Surgical Am- 
 putations; An Historical Resume. Buffalo Med. Journ., 1903-4, ns. xliii, 361-364. 
 
 211. Ibid-Columhus Med. Journ., 1904, xxviii, 11-13. 
 
 212 Ibid-Med. & Surg. Monitor, Indianapolis, 1904, vii, 28-30. 
 
 213. Ihid-Am. journ. Surg. &■ Cynec, St. Louis, 1903-4, xvii, 117. 
 
 214. I bid -Denver Med. Times, 1903-4, xxiii, 382-385. 
 
 215. Ibid- Virginia Med. Semi -Monthly;, Richmond, Va., 1903, xiii, 562-564. 
 
 216. Surgery of the Prostate, Pancreas, Spleen, Diaphragm, Thyroid Gland and Hydrocehpalus 
 (Volume) 1904. 
 
 217. Surgery of Hydrocephalus. An Historical Review. Am. Med., Philadelphia, 1904, vii, 
 783-787. 
 
 218. Surgery of Hydrocephalus. Col. Med. Journ., 1904, xxviii, 64-67. 
 
 219. The Surgery of the Heart and Lungs, etc., New York, 1904, pp. 562, 132 plates. 
 
 220. Cholecystotomy. Lancet-Clinic, Cincinnati, 1904, ns. liii, 432. 
 
 221. Excision of Elbow Joint for Traumatic and Inflammatory Arthritic Ankylosis. Am. Journ. 
 Surg. &• C^nec, St. Louis, 1904-5, xvii, 134-138; also Louisville Journ. Med. & Surg., 1904-5, xi, 318. 
 
 222. Fracture Deformities of the Lower Leg in Childhood. Illustrated by Skiaeraphs. 5/. Louis 
 Med. Rev., 1905, lii. 524-544. 
 
 223. Rupture of the Gall-Bladder, Spontaneous and Traumatic, With and Without Operation. 
 An Historical Review of 273 Cases. 5/. Louis Med. Rev., 1905, li, 108-233-276-456-476-497; lii, 4. 25. 
 
 224. Excision of the Elbow Joint for Traumatic and Arthritic Ankylosis. Abstract. 5/. Louis 
 Med. Rev., 1905, li, 437, also Trans. West Surg. & Cynec. Assoc, 1905. 
 
 225. Cholecystotomy and Nephrectomy for Gall-Stones and Pyonephrosis (Tubercular). Lancet- 
 Clinic, Cincinnati, 1905, ns. liv, 139. 
 
 226. Vesico-Rectal Anastomosis. New Y or\ Med. Journ., 1905, Ixxxi, 162. 
 
 227. Ovarian Angeioma. A'en; Y or}( Med. Journ., 1905, Ixxxi, 163. 
 
 228. Dr. Tuholske's Case of Malformahon of the Bladder. Si. Louis Med. Rev., 1905, li, 178. 
 
 229. Specimens of Tubercular Kidneys. Lancet-Clinic, Cincinnati, 1905, ns. liv, 532. 
 
 230. Haematoma of the Ovary. Lancet-Clinic, Cincinnati, 1905, ns. liv, 687. 
 
 231. Diagnosis and Treatment of Gall-Stones. Kentucify Med. Journ., Louisville, 1905-6, iii, 550. 
 
 232. Cardiac Stimulation for Suspended Animation by Direct Digital Manipulation. .A Supple- 
 mentary Report to Surgery of the Heart and Lungs (Abstract). Col. Med. Journ., 1906, xxx, 308-311, 
 also Colorado Med. Journ., 1906, xii, 325-328. 
 
 233. Cardiac Stimulation for Suspended Animation by Direct Digital Manipulation, Illustrated 
 by Diagrams and Case Reports. Am. Med. Comp., Toledo, 1906, xix. 177-180, Buffalo Med. journ., 
 1905-1906, Ixi, 708. 
 
 234. Trigemnial Neuralgia, Surgical Treatment. An Historical Resume. Lancet-Clinic, Cincinnati, 
 1906, ns. Ivi, 597-608; also Nashville Journ. Med. & Surg., 1906, xcviii, 97-101; also Virginia Med 
 Semi-Monthly, Richmond, 1906-7, xi, 12-14. 
 
 235. The Diseases Diagnosis and Surgical Treatment of the Right Upper .Abdominal Cavity. An 
 Historical Resume. Lancet-Clinic, Cincinnati, 1906, Ixvi, 201-242. 
 
 236. Cardiac Stimulation for Suspended Animation by Direct Digital Manipulation. Med. Rev. 
 of Rev., New York, 1906, xii, 848-850. 
 
 237. Ibid — Trana. Surg. Sect. Am. Med. Assn., 1906, Volume. 
 
 238. Feminalities. Lancet-Clinic, Cincinnati, 1907. 
 
 239. Limiting Population. Lancet-Clinic, Cincinnati, 1907. 
 
 240. Villous Papilloma of the Rectum. New Ynrl( Med. Journ., 1907, Ixxx. 
 
 241. Surgery of the Ureter. St. Louis Med. Rev.. 1907-8, Serial Bound Volume, 300 Copies. 
 An Historical Review. 1908. 
 
 242. An Historical Review of Papilloma and Adenoma. American Journ. Dermatology March 
 
 1, 1908. 
 
 243. Appendicitis and Typhoid Fever, Four Cases. Lancet-Clinic, Cincinnati, February 22, 1908. 
 
 244. The Disposition of the Appendicular Stiimp. Lancet-Clinic, Cincinnati, March 28, 1908. 
 
 245. Intestinal Obstruction Exploration, Western Surgical and Gynecological .A.ssociation (trans.), 
 St. Louis, Mo., December 30-31, 1907. 
 
 246. Capillary Varicosity of Rectal Mucosa. .Am. Proctologic .A.ssn. (Trans.), Chicago, June I. 
 1908. 
 
 Page One Hundred Thirty-One 
 
247. Surgery of Hare Lip and Cleft Palate (Illustrated). Trans. Ohio Valley Med. Assn., 1908. 
 
 248. Protracted Birth of Second Intra-Uterine Twin. A Resume, Biologically Considered. Trans. 
 Miss. Valley Med. Assn., 1908. 
 
 249. Surgery of the Prostate, Pancreas, Spleen, Diaphragm, Thyroid and Hydrocephalus (A 
 Resume) 500 Bound Autograph Copies. 250 pp. each, 1904. ^ 
 
 250. Radical Cure for Hernia. Lancet-Clinic, ns. xxvi, 1891. 
 
 251. Eczema Infantile. Journ. Am. Med. Assn., xix, 1892. 
 
 252. Report of Twelve Cases of Herniotomy. Lancel-Clinic, ns. xxviii, 1892. 
 
 253. Psoriasis, Forty Cases Treated With Arsenious Acid. Journ. Am. Med. Assn., xx, 482, 1892. 
 
 254. Direct Fixation in Fractures. Times and Register, Philadelphia, xxviii, 1894. 
 
 255. Prostate. Times and Register, Philadelphia, xxix, 1894. 
 
 256. Typhoid Perforation, Cerebral Cyst. Lancet-Clinic, ns. xxiv, 1895. 
 
 257. Brain Surgery for Epilepsy. Lancet-Clinic, ns. xxxv, 1895. 
 
 258. Case Reports. Lancet-Clinic, ns. xxxv, 1895. 
 
 259. Removal of the Head of the Femur From the Lesser Sciatic Notch. Med. Fortnightly, St. 
 Louis, vii, 1895. 
 
 260. Rectal Carcinoma with Subsequent Cololomy; Normal Prophylactic Appendectorr.y. Si. 
 Louis Med. Revierv, xli, 1900. 
 
 261. Surgery of Congenital Dislocation of Head of Femur. Western Surg. & Gyn. Assn. Trans. 
 December 20-21, 1909; also New York Med. Journ., January 4, 1910, p. 1154. 
 
 262. Spastic Contraction of Uterus. Lancet-Clinic, October 16, 1906. 
 
 263. Local Versus General Anaesthesia. Miss. Valley Med. Assn., St. Louis, Oct. 12-14, 1909, 
 also Lancet-Clinic, Oct. 23, 1909, pp. 235-247: also Tables in Medical Review of Reviews, Dec, 
 
 1909, pp. 828-834. 
 
 264. The Prostate. Dark County Ohio Med. Soc, Seot. 9, 1909, also A'en; York Med. Jour., 
 Jan. 29, pp. 225-227, 1910. 
 
 265. Civilization, Yesterday, Today, Tomorrow. The First of a Series of Addresses Delivered 
 Before the Medical Dept. of Barnes University, St. Louis, Mo., Oct. 13, 1909; also 5/. Louis Med. 
 Rev,, Dec, pp. 393-399, 1909. 
 
 266. Surgery of Cirrhosis of the Liver. Cincinnati Acad. Med., Feb. 18, 1909; also New York 
 Med. Journ., Feb. 18, 1909. 
 
 267. Odontomata. Cincinnati Acad. Med., Nov., 1908; also Lancet-Clinic, Jan. 9, 1909. 
 
 268. Anatomy and Pathology of Ureter. New York Acad. Med., Dec. 17, 1908; also Virginia 
 Semi-Monihly Med. Journ.; also New York Med. Journ., Jan., 1909. 
 
 269. Malformation and Amputation of Sigmoid and Lesions to and Behind the Left Broad Liga- 
 n,ent; Illustrated. Ohio State Med. Soc. Trans., 1909; also Ohio State Med. Soc. Journ., May 15, 1910. 
 
 270. Sterilization for Crime. May 15-28. Sent this Paper to Literary Digest, Saturday Evening 
 Post and New York Med. Journ. (all refused it). Published in Med. Review of Reviews, New York, 
 Nov. 25, p. 755, 1909. 
 
 27 i. Local Versus General Anaesthesia. Kentucky Med. Soc, Torrent, Ky., June 20-21, 1909; 
 also Piqua, Ohio, Sept. 20, 1909. 
 
 272. Surgery of Cleft Palate. Read French Lick Springs, Indiana, Oct., 1909; also Ohio 
 Valley Med. Assn.; also Lancet-Clinic, Aug. 28, 1909. 
 
 273. Surgery of the Thorax and Its Viscera. Second Address, Barnes Med. College, St. Louis, 
 Dec, 1909; also Virginia Med. Semi-Month., Richmond, Va., May 13, p. 65-70, 1910. 
 
 274. Case Reports of Multiple Surgical Operations. Indianapolis Med. Jour., May, p. 212, 1910. 
 Haematoma Right Broad Ligament Complicating Three Months' Gestation. St. Louis Med Review 
 
 Oct. 1, 1910. 
 
 275. Anomalous Kidney (Nephrectomy) ; Illustrated. Jour. Surg. Cvn. & Ohsi Tune n 637- 
 638, 1910. ^ •' J ' P- u^/ 
 
 276. Community Education. Lancet-Clinic, June 25, 1910. 
 
 277. The Newer Surgery. An Address Before the Tri-State Med. Soc, Iowa, Illinois Missouri 
 St. Louis, Mo., Sept. 13-14, 1910; also Lancet-Clinic, Oct. 15, 1910. 
 
 278. Surgery of Aneurysm of the Aortic Arch and Its Branches; Illustrated. Read Before Chicaoo 
 Med. Soc, Feb. 16, 1910; also Lancet-Clinic, Aug. 27, p. 196-207, 1910. 
 
 279. Discussion of Dr. Deaton's Paper, Rectal Colonic Tube. fourn. Ohio State Med Soc 
 Jan., p. 29, 1910. 
 
 280. Surgery of the Posterior Urethra, and Prostatic Abscess and Their Consequent Fistulac. 
 Read Before the North Central Soc. of the Am. Uroloeical Assoc. With the Chicano Uroloc Soc 
 March 24, 1910; also Am. Journ. Surg., p. 214, July 10,''l910. 
 
 Two Cases of Twenty-Pound Sarcoma of the Left Ovary. St. Louis Med. Review, Oct. 1, 1910. 
 
 281. Surgery of the Great Sciatic Nerve, Including Two Cases of Complete Severance with Sub- 
 sequent Anastomosis. Miss. Valley Med. Assn., Detroit. Sept. 13-15, 1910- also Lancel-Clinic Oct 1 
 
 1910. ' ■ ' 
 
 282. Intra-Peritoneal Exploratorv Hysterotomy. Read Before Cincinnati Acad. Med fan 17 
 1910, also Lance/-C/mi'c, March 26. pp. 339-341, 1910. ' ' 
 
 283. Surgical Contraindications. Read Before the Union Med. Assn., Richmond Ind April 
 27, 1911; also Lunce(-C/ini'c, May 6, 1911. 
 
 284. Naphtha Soap, Its Dangers. 5/. Louis Med. Rev., Aug. 1, 1911. 
 
 Page One Hundred Thirty-Two 
 
285. Civilization Yesterday, Today, Tomorrow. An Address. 5/. Louis Med. Rev., Dec, 1900. 
 
 286. Thoracic Surgery. Lancet-Clinic, Nov. 26, 1910. 
 
 287. The Thorax. Lancci-Clinic, July 29. 1911. 
 
 288. Surgery of the Pleura. Lancet-Clinic, p. 310-320, Sept. 23. 1911. 
 
 289. Naphtha Soap. Its Dangers. St. Louis Med. Reviem, July 1, 1911. 
 
 290. Surgery of the Lung. Lancet-Clinic, pp. 393-398, Oct. 14. 1911. 
 
 291. Surgery of the Lung. Lancet-Clinic, pp. 441-443. Oct. 28. 1911. 
 
 292. Surgery of the Lung. Lancet-Clinic, pp. 503-504, Nov. 4, 1911. 
 
 293. Surgery of the Bronchus. Lancet-Clinic, pp. 603-607. Dec. 9, 1911. 
 
 294. Thymus, Vagi and Ductus Thoracicus. Demonstrated on a Dog by Intratracheal Insufflation 
 Before The Western Surgical and Gynecological Association. Kansas City, Mo., Dec. 19, 1911. Trans- 
 action for same, and International Clinics, Vol. iv. 22nd Series. 1912. 
 
 295. Surgery of the Pericardium, Lancet-Clinic, Cincinnati, 1912. 
 
 296. The Coccyx as a Causative Factor in Genito-Urinary Diseases. Read Before The North 
 Central Branch of The .American Genito-Urinary Association, St. Louis, Mo., Feb. 5, 7, 1912. 
 
 297. Intratracheal Insufflation. Medical Record, Sept. 19, 1914. Delivered at the New York 
 Polyclinic. International Congress of Brussels of 1914. 
 
 298. Suprapubic Cesarian Section for Puerperal Eclampsia. Trans. West. Sur". and Cyn. Asso., 
 1913; also Reprint The American Journ. of Surgerv, Sept. and Oct., 1914. 
 
 299. Intratracheal Insufflation Anesthesia Demonstration on Dog. Alabama State Med. Soc, 
 Montgomery, Ala., Transactions, 1914. 
 
 300. Surgery of the Thorax and Its Viscera. .A Volume of 700 pages. 1916. 
 
 301. Intratracheal Insufflation (History). Amer. Jour, of Surg., Oct., 1915. 
 
 302. Anesthesia From the Dawn and Its Relation to Surgery. Lancet-Clinic Cincinnati Nov 
 28, p. 484, 1915. (An Illustrated Address.) 
 
 303. Chloacal Morphology. Amer. Genito-Urinary .Asso., Chicago, Nov. I2-I3tli, 1915. (Trans- 
 actions.) 
 
 304. Local Anesthesia. An Illustrated Address. West Virginia State Med. Asso Huntinofon 
 W. Va., May 12th, 1915. nungton, 
 
 Page One Hundred Thirty-Three 
 
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