Saved for posterity

Remarkable injuryIn 1875 the American surgeon Charles Brigham recorded this wince-inducing case from his practice in San Francisco. The details are contained in a volume he published the following year, Surgical Cases with Illustrations. It’s a notable book, one of the earliest to feature extensive photographs of the cases described. Until the mid-19th century, most medical illustrations were engravings or – from the 1840s – daguerreotypes. The development of a process which made it affordable to reproduce photographs in a mass-produced book made it possible for physicians to gain a far more accurate idea of the cases described.

Case 18 in in Brigham’s Surgical Cases concerns Emile B., a 17-year-old who was helping to work a threshing machine when a ghastly accident befell him. This is how he described it to the surgeon:

“When the machine started up, I went to get my gloves; my shirt was out of my pants so that the straw could not bother me; as I reached for the gloves, my shirt fell over the knuckle of the tumbling rod; the bolt which went through the knuckle was too long, and my shirt catching on the bolt, drew me on to it. When I felt it had hold of me, I braced myself against the derrick wagon. Every stitch of clothing was torn off from my body, the machine also tore off the skin from my penis and testicles and left them naked; my testicles were torn apart and my penis was hanging between my legs.” 

Dear oh dear. 

“I was in a horrible condition, but felt no pain at the time. I left the ranche on Sunday, the 6th of June, the next day after the accident, and traveling on a wagon and by railway, arrived at the French Hospital on the 7th, at noon.”

Just imagine travelling on wagon over bumpy roads with your nether regions in that condition!

When first seen at the Maison de Sante the patient was in this condition; there was a complete skinning of the perinaeum from the anus forwards, to the extent of two inches and a half in width. Both sphincters of the anus were torn apart, and the faeces came away involuntarily; nothing remained of the scrotum, the neighboring skin on either side was torn away nearly an inch in width; the penis, completely deprived of skin, hung down over and beyond the anus. Over the pubes the skin was also torn away, so as to leave but a narrow border of hair above the wound, at either end of which could be seen the inguinal rings with the spermatic cord and vessels passing through them. One of the testicles lay upon the front of the left thigh, while the other was on the abdomen above the wound. There was no haemorrhage from any part of the surface nor had suppuration yet taken place, but the wound was glazed over with dry blood. As the patient was in a feeble condition, it was decided to postpone any surgical interference until the next day.

Very wise. I think a surgeon today would still think this case a significant challenge.

On the 8th of June, 1875, the patient was etherized in the presence of Drs. Hoffstetter, Soule, Vanvlack, and Bucknall. An incision two inches in length was then made on either side of the perineal wound, in such a manner as to leave a narrow isthmus of skin, an inch in width, united at both ends to the surrounding skin: this allowed the free borders to be approximated; two stitches were also taken in the torn issues of the anus. The penis was then lifted from its position over the perinaeum and drawn up over the pubes; this was accompanied by a little haemorrhage, as the parts had already glued together. The testicles were each brought into place under the penis, five sutures held their tunics together, and a narrow band of strong adhesive plaster was put around them; there remained a deep and broad wound over the pubes. In order to fill it in, and to partly cover the cords of either testicle, two flaps were taken from the sides of the wound having a pedicle towards either thigh; these were held in place by silk sutures strengthened by adhesive plaster; over the raw surface of the penis were placed many small pieces of plaster, so arranged as to allow the exit of pus from between their borders. A tent of linen, soaked in a strong solution of carbolic acid wash, was suspended from a cradle over the entire region of the wound; there was but little constitutional disturbance, except that arising from obstinate sleeplessness; this was partly caused by excessive pains coming on at night, which were so violent at times as to make the patient scream aloud.

This is hardly surprising. Though the ‘strong solution of carbolic acid wash’ was an excellent precaution against infection (carbolic acid was the antiseptic introduced by Joseph Lister, which dramatically reduced operative mortality), it must have hurt like hell.

After the first week the pain was much less, the testicles had apparently united together, the lower part of the perineal flaps was united, but towards the testicles it had sloughed away. During one month the suppuration was profuse, on the seventh week, it being much diminished, eight bits of skin were transplanted into the granulations of the penis and scrotum; of these three lived and formed islands which helped considerably the cicatrization.

19th-century surgeons made significant progress in skin grafting – while this never worked when the graft came from a donor, owing to the problem of rejection, in the hands of a skilful operator it often worked wonders with the patient’s own skin.

It was from the glans penis that the new skin formed most rapidly; it would grow irregularly, so as to make the penis look upside down one week and turned sideways another. Meantime the patient had erections at night, which undoubtedly helped to free the penis from the surrounding granulations at its base.

Emile remained in bed for 43 days, and was given bran baths every other day.  He healed slowly and without pain.

As he began to walk, it was noticed that the scrotum became smaller, and two lumps appeared at the base of the penis at either side; these were the testicles. So imperceptibly did this change take place, that its exact time could not be stated.

Amazingly, the patient was discharged from hospital on August 30th, well and in good spirits.

His penis was then three inches long by one and a half wide; the new skin extended without interruption from the gland (inclusive) to a distance of two inches. The largest island of transplanted skin, half an inch square, was on the right side. The few remaining granulations were covered with a dry scab.

Click to enlarge (if you must)
Click to enlarge (if you must)

That’s not quite all. This is, you will remember, an illustrated book. Luckily for medical posterity, the large portion of Emile’s anatomy removed by the threshing machine was preserved and immortalised by the miracle of photography.

Through the kindness of Dr. F. W. Heitman, of College City, the torn scrotum and penis was preserved and sent to me; it is in a single piece; it has an opening above the scrotum some two inches in diameter, with comparatively smooth edges. There was no scratch or laceration of the outside of the skin of the penis or scrotum; the hair remained upon the latter, as in thebnatural state. It seems that the length of the prepuce was the means of saving the body of the penis from being torn away. Plate 11 shows the side view of the specimen.

[This post was prompted by an interesting short article by Ira M. Rutkow, from the Archives of Surgery, published in 1997 – you can read it here.]

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