Reprinted from the 
TRANSACTIONS OF THE PHILADELPHIA COUNTY 
MEDICAL SOCIETY. 
Vol. I.—1887.  
DR. WILLARE. FOREIGN BODIES IN THE URETHRA AND BLADDER. 
REMOVAL BY THE LITIIOLAPAXY EVACUATOR 
WITH LARGE, STRAIGHT, OPEN- 
ENDED CANULA. 
DE FOREST WILLARD, M.D. 
[Read November 9, 1887.] 
My object in bringing before you the subject of urethral and vesical 
foreign bodies is simply to emphasize the value of the evacuator 
(ordinarily used in rapid lithotrity to extract the calculous fragments) 
for removing other more or less solid substances that have found their 
way into the urinary tract, either by accident or design. 
Foreign bodies enter by various routes. Projectiles may reach the 
viscus and remain in its cavity ; bones may be driven in by crushing 
forces; foetal remains may ulcerate through from extra-uterine cavities; 
intestinal contents may occasionally make their way into the bladder, 
but all these are either rare, or are accompanied by such traumatism 
that death frequently ensues. 
The bodies that we will especially consider are those introduced 
through the meatus urinarius, urinary calculi being only incidentally 
considered. 
The strong tendency for manipulation of this part of the body that 
exists from early childhood to decrepit old age, leads to many 
instances of misadventure. Think of a lad actually sliding a watch- 
chain down his urethra. Examples of inserted beads, pebbles, sticks, 
etc., are numerous in childhood. After puberty the tendency becomes 
more marked as the sexual desire increases. A few years later we 
find the morbid recluse, especially among the shepherds and monks of 
former centuries, resorting to intra-urethral stimulation with sticks or 
other hard substances to arouse the over-exhausted functions, waning 
from excessive masturbation or venery. Yielding himself to his 
vile erotic feelings, the instrument often slipped from his fingers 
and was lost in the canal. Sexually insane must have been the shep- 2 
WILLARD, 
herd who had used for this purpose his pocket knife, after manual 
friction and urethral stimulation had proved unsatisfactory, until 
little by little, through hundreds of these indecent acts he had laid 
open the entire penis along its dorsal aspect until the pubis was 
reached, and the penis hung in two halves, united only by the lower 
wall of the urethra. Then with a short stick he was able to tickle 
the very orifices of the ejaculatory ducts. This stick slipping into 
his bladder, became encrusted, and it w'as not until the pain became 
torturing, that he confessed the cause. Pipe-stems, pencils, ther- 
mometer tubes, glass rods, straws, needles, wires, twigs, hairpins, 
fruit stones, and even forks and lockets, have all been found in the 
urethra, after introduction for stimulative purposes, or to relieve 
dysuria from stricture or other causes. In one instance1 a man 
introduced the sewing needle of the girl whom u he desired to fall in 
love with him.” 
At the present time we have fewer of these lecherous accidents, 
save from drunken debauchees, but the majority of instances occur 
from the use of old or improper catheters or bougies. Of course, these 
accidents are more frequently found in men than women, as the 
former are more subject to urethral disease, and are also more erotic, 
but there are instances in both sexes. 
In children, small round bodies, as beads, etc., are found in the 
anterior part of the canal, while the longer instruments at all ages 
slip back to the membranous portion of the tube, or into the bladder. 
Usually a long foreign body will find its way into the bladder in a 
few hours; rarely, two or more days may be required. In exceptional, 
rare cases, rounded bodies remain a long time in the urethra, the urine 
following a tortuous course around them, and, becoming encrusted, a 
pocket ultimately forms, or suppuration ensues. 
It is not strange that catheters and similar instruments are broken 
off in the canal when we learn of the recklessness of a man who used 
one gum catheter for twenty years, or of another who attached two 
portions of a silver tube simply with sealing wax. 
A too short instrument has often eluded the grasp of the surgeon 
and slipped bladderward. 
As to this recedence of instruments, which is strong and actual, 
there have been many theories. It does not seem strange to me that 
the compressor muscular fibres of the urethra, when stimulated to 
action by a body applied in front, should reverse their usual action 
1 Poulet: Foreign Bodies in Surgery. FOREIGN BODIES IN URETHRA AND BLADDER. 
3 
as easily as do the muscles of the pharynx, oesophagus, intestines, 
etc. This act of swallowing a hard substance is aided by the erection 
of the penis, which in its subsidence (should the anterior end of the 
object become engaged) drives it further and further back with each 
successive engorgement. Tending to this same unfortunate end are 
all the manipulations of the part, in the patient’s endeavor to extract 
the offending body. 
Unfortunately for the safe extraction of these bodies, the surgeon 
has to meet with a large amount of deception upon the part of the 
patient, when the object has been self-introduced, and it is often im- 
possible to obtain any reliable information either as to the presence of 
the foreign mass or as to its conformation. In broken bougies the 
surgeon should, if possible, have the other remaining fragment in his 
hand for measurement, or else secure one of similar size. Any 
object of peculiar shape should be accurately described, or duplicated. 
It must be remembered, that while a patient may confess to the intro- 
duction of but one body, there may be several. The position in the 
canal must be thoroughlv fixed. In the ante-scrotal region this is 
easily accomplished, and with the aid of a sound and a finger intro- 
duced into the rectum even the posterior urethra can be well 
examined, provided inflammation be not too severe. When possible, 
no manipulations should be attempted for extraction without the body 
being firmly secured from further recedence. 
Ether is of the greatest value, but cocaine injections may answer 
for urethral work. 
Treatment.—About one-tenth of inserted foreign bodies will be 
spontaneously expelled, but when the vis a tvrgo of the urine fails to 
wash out either a calculus or an object inserted through the meatus, 
the safest and surest plan is to attach to an ordinary litholapaxy 
evacuator (Bigelow’s or other improved pattern) a large, straight tube, 
which is open at both ends. It contains a movable stylet for ease of 
introduction. The size should be the largest that the urethra will 
possibly admit (after nicking the meatus, if necessary), say French 
No. 29 or 30; American, No. 19; English, No. 16, for adults; chil- 
dren in proportion. The possibility of the passage of the body through 
the tube should be determined, if possible, by actual trial, provided a 
similar piece can be obtained. Rarely will any bougie larger than 
the above-named size be found in the bladder or urethra. 
The method has been so satisfactory in my hands, as is proven by 
the collection of objects before you, that I always resort to it with 
confidence, to the exclusion of all other primary devices. 4 
WILLARD, 
If lodgement has occurred in the urethra, the canal must be firmly 
closed by finger pressure behind the object, while the metallic tube is 
slid down and carefully caused to engage the catheter or other mass 
within its calibre, when the bulb of the instrument is slowly com- 
pressed until the water has distended the urethra to its fullest limit, 
thus liberating the body, when suction is suddenly applied while the 
penis is stretched forward. Unless the mass be firmly caught and 
imbedded in a pocket, this manoeuvre rarely fails after a few trials. 
The quantity of water that can be contained in the urethra is so small 
that the body may require two or three efforts to withdraw it the whole 
length of the instrument. The water should be injected very slowly, 
but the suction current must be made forcibly. Inspection of the 
rubber tube can be made through the upper opening without detach- 
ment of the catheter. 
Avoid employing forceps until unsuccessful with the above method, 
but when necessary to be used, the superiority of the canula again 
asserts itself. The forceps can be manipulated through its calibre, 
and if the object be compressible enough to pass the bore, withdrawal 
can be accomplished without the slightest injury to the mucous mem- 
brane. Objects of larger size than this tube can seldom be with- 
drawn with safety by any method save cutting. Hairpins can be 
compressed through the walls of the urethra, and their points passed 
into the calibre, when they can be completely pushed within the bore 
and easily withdrawn. 
Beads, peas, pebbles, etc., will easily enter the canula by suction. 
Catheters, wires, etc., will usually require the assistance of forceps. 
Barbed heads of grain can also be ensheathed and withdrawn by this 
device. 
If the object has passed into the bladder, the evacuator becomes an 
even more essential aid. A straight instrument is not always easy of 
introduction, but the security gained against subsequent urethral 
injury abundantly repays for the trouble. If a flexible or spirally 
cut obturator is used, the introduction is rendered much easier. The 
tube is used first as a sound to discover the offending body, when the 
bulb of the evacuator is first slowly compressed, so as not to disturb 
the fragment. Suction should always be made quickly, so as to draw 
the body with force. Failing, the water is next ejected with more 
energy, so as to move the fragment into better line with the calibre, 
suction being again rapidly applied. The hard substances will not be 
driven against the sides of the bladder with any more power than are 
calculous fragments, and unless consisting of broken glass will not be FOREIGN BODIES IN URETHRA AND BLADDER. 
5 
as angular. If the body is rounded, and of size that can pass the 
bore, it will in a few moments be found in the bulb. If very long, like 
a catheter, or pencil, or wire, the chances are not so good that it can 
be brought into line with the calibre of the tube. As a bougie ordi- 
narily breaks at or near the eye, however, its passage is more than 
probable. Failing, after ten minutes of gentle trial, a lithotrite should 
be introduced if the body is a bougie or pencil, and is capable of being 
cut or pinched in two, and the division made. A cutting lithotrite, like 
Caudemont’s, is manufactured, but I presume is seldom found among 
the paraphernalia of surgeons, and the fenestrated instrument of 
Thompson is far safer. If the bougie is old and brittle, as is pre- 
sumptively the case, such division with a lithotrite is easily accom- 
plished. The segments can then be sucked out, and their total length 
carefully compared with the remaining portion or lost body. Every 
particle must be secured, lest it form the nucleus of a future calculus. 
Even the broken jaw of a lithotrite might be drawn into the bore. 
If the surgeon has not the straight tube with open end, which I 
advise, he may use the ordinary straight evacuating tube. Rounded 
bodies, and pieces of bougie small enough and flexible enough to enter 
the side opening can often be secured with ease, but long or rigid 
pieces can only be drawn through the open-ended tube. This tube 
has the disadvantage that the point must be kept just inside the neck 
of the bladder. If pushed too far, the posterior bladder wall flaps 
against it; if withdrawn too much, it is concealed in the prostatic por- 
tion, and makes no suction upon the vesical contents. Its safety from 
impaction of fragments in the eye, however, more than counterbalances 
this slight trouble; since, in the ordinary evacuating tube, a large 
fragment often cannot be dislodged from the eye, and lacerates the 
urethra during withdrawal. 
Should these manipulations fail (and if they have been carefully 
conducted, no injury need have been done to the bladder), I show 
you now two forms of forceps which I have had made of just sufficient 
length to be slightly protruded from the end of the tube. In the one, 
the jaws open by a spring, as in the old Halles’ forceps; and in the 
other, the jaws are worked by handles, as in the Mathieu and Gross, 
and “alligator ” patterns. 
Careful attempts can now be made to seize the body and extract it 
through the catheter. If small enough to be brought through, it is a 
great satisfaction to know that no possible injury can be done to either 
the neck of the bladder or the urethra, as is so likely to occur when a 
body is extracted in the jaws of a lithotrite. Necessarily only a small 6 
WILLARD, 
proportion of introduced objects can be removed per urethram, and 1 
should lay it down as a rule that any foreign body too large to pass 
the calibre of this No. 29 tube, unless it be very soft and pliable, should 
be removed by lithotomy, either perineal or suprapubic. Lithotomy 
has its dangers, but laceration is worse. 
The suprapubic is at present the fashionable operation, and it cer- 
tainly presents many inducements in its favor. The median perineal 
operation, however, is a safe one, and gives excellent results. No im- 
portant structures are severed, and there is seldom troublesome hemor- 
rhage if the raphe is closely followed. By either of the routes great 
care must be exercised in the search, if the object be sharp-pointed, lest 
a perforation be made. The inflation of the rectum in order to lift the 
bladder, must be dispensed with if the object is sharp-pointed. The 
upper route gives more room, and while there is a slight risk of wound- 
ing the peritoneum, yet we must remember also, in the extraction of 
large objects, as well as calculi, by the perineal route, that the recto- 
vesical fold of the peritoneum is in close proximity to the neck of the 
bladder, and may not escape involvement in the subsequent inflamma- 
tory action. 
If the walls of the bladder were only of sufficient strength to warrant 
their immediate sewing with catgut or silk, and permit primary union 
under strictly antiseptic dressings, while the urine were drained off 
below, the suprapubic route would certainly be decidedly the better 
one; but as this is not the case, there is still room for honest differ- 
ences of opinion in the selection of an operation. For the present, 
we must be content to drain the suprapubic wound. 
In the absence of an evacuator, the expulsive force of the urine is 
often sufficient to dislodge a urethral impaction, especially if the meatus 
is closed for a moment, so as to obtain the full dilating power of the 
water. Failing in this effort, if the foreign body can be located and 
the urethra closed, a large injection of sweet oil may be thrown in, 
after a hot bath, and the largest possible bougie carried down to the 
body to stretch the membrane, while pressure from behind is made 
either by the surgeon’s finger or by the expulsive efforts of the patient’s 
bladder. 
Should lodgement be made in the fossa navicularis, the spoon of the 
ordinary pocket-case can often be hooked behind the object and assist 
in coaxing it forward. A hairpin, or wire doubled upon itself and 
slightly bent, or a blunt curette, makes also a valuable extractor. An 
excellent instrument also is the articulated scoop of Leroy d’Etiolles, 
which, being introduced past the foreign body, has a mechanism by FOREIGN BODIES IN URETHRA AND BLADDER. 
7 
which its tip is then bent at right angles to the shaft, and is capable of 
making strong but dangerous traction. The abruptly short-beaked 
sound which I always use for sounding the has fond of the bladder, 
can sometimes also be “wormed” past the obstruction, and effect its 
dislodgement. I show you here seven prostatic stones that I have thus 
extracted, aided by the force of the urine. Long urethral forceps are of 
great service, as they serve partially to protect the canal during extrac- 
tion, but they do so far less effectually than does the straight tube before 
described, which should be placed in every evacuating set. Hunter’s 
or Civiale’s three-bladed forceps are occasionally used, but I always 
look with abhorrence upon dragging any object forcibly through the 
canal. A dangerous instrument is the urethral lithotrite of Reliquet, 
as incision is infinitely safer for all rough and large bodies. 
When the substance lies posterior to the triangular ligament, gentle 
attempts should be made to push it into the bladder, only after the 
evacuator has failed to dislodge it. If necessary to operate, the raphe 
should be closely followed, while a large staff is held in position to indi- 
cate the location of the obstruction and of the tube. 
An incision in front of the scrotum is easily made, and should be 
closed after the removal of the body by catgut or quilled sutures. 
Treated antiseptically, and with either a retained catheter, or with 
frequent catheterizations, immediate union may be confidently expected. 
The quilled suture gives more perfect rest by its splint action. 
If a stricture exists, and the foreign body is lodged behind it, dila- 
tation or free external incision of the stricture should be practised. 
In former days, the instruments for search and removal of these 
objects, greatly exceeded those of the present day, when operative pro- 
cedures are more common. The “duplicators” of Mercier, and of 
Charriere, were intended to fold up any soft substance, as a very flexible 
bougie. Long stiff bodies were seized by “redressors” or “bascu- 
leurs,” forceps with bevelled blades, constructed so as to rotate the body 
so that its long axis would correspond with that of the instrument. 
Occasionally a small lithotrite will answer for either of these purposes, 
but the great danger of laceration during withdrawal through an un- 
protected canal, must never be lost sight of. 
The curved forceps of Cusco or Voillemier are, perhaps, as useful in 
the bladder as in the membranous urethra; but I am afraid to use them 
for the reasons already named, especially since I have found suction so 
much safer and also more effectual. 
For the removal of pins, bonnet pins, or needles, from the urethra, 
the point can sometimes be imbedded in a wax or gum bougie, but it is 8 
FOREIGN BODIES IN URETHRA AND BLADDER 
easier washed out with the evacuator. If immovable, the point can be 
pushed through the walls of the urethra, and by sharply bending the 
penis, the head after reversal drawn through the tube by suction or 
by forceps. It is seldom necessary to cut the pin when this method is 
used. 
If a piece of nitrate of silver is lost from a porte-caustique, the 
evacuator, charged with salt water, should be at once used if the force 
of urination does not expel the mass. 
Many ingenious devices have been practised in the absence of instru- 
ments, to rid the urethra of impacted bodies, but the knife is far safer 
than rough instrumentation. In the absence of the straight evacuating 
tube, an extra sized catheter, with open end, and a large syringe, 
might prove useful. 
Blood-clots in the bladder are practically foreign bodies, and are 
best removed by gentle suction through the curved evacuator, or 
through the blood catheter, which 1 here show, the large eye of 
which is closed down during introduction by a spirally cut obturator. 
Catheter accidents are so frequent that instruments should be 
often examined. Only recently I found that the distal extremity of 
my much-used pocket case instrument could be slipped from its screw- 
thread by a very small amount of traction. Old gum bougies should 
be thrown away as soon as they begin to lose their elasticity. 
To summarize: 
1. The litholapaxy evacuating tube, large, straight, and with open 
end, is the surest and safest instrument for the removal of foreign 
bodies from either urethra or bladder. 
2. The fenestrated lithotrite should be employed to break up all 
bodies capable of division. 
3. Incision of urethra or bladder is safer than a tear of the neck of 
the viscus or of the canal. 
4. The suprapubic and median perineal are the safest routes of 
entrance to the bladder when suction fails. 
5. Forceps should be used with the greatest care, and always through 
a straight tube, which insures protection both to the urethra and neck 
of the bladder during both exploration and extraction.