CORNELL UNIVERSITY LIBRARY GIFT OF Mr. Vale Cornell University Library RC 871.V22 A practical treatise on the surgical dis 3 1924 012 159 830 Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012159830 A PEACTICAL TEEATISE SUEGIOAL DISEASES GENITO-UEOARY ORGANS, INCLUDING SYPHILIS. DESIGNED AS A MANUAL FOR STUDENTS AND PRACTITIONERS. WITH ENGRA VINGS AND OASES. BT W. H. JAE BTJEElSr, A. M., M. D., PBOFEBSOE OP THE PEINCIPLES OP STTKGBKT, "WTm DISEASES OF THE GENITO-lJEmAEY SYSTEM AHD CLINICAL SUBGEEY, IN BELLETITB HOSPITAL MEDICAL COLLEGE; CONSULTING BUEGEON TO THE NEW TOEE: HOSPITAL, THE BELLEVUB HOSPITAL, THE CHAEITY HOSPITAL, ETC. : E. L. KEYES, A.M., M. D., PK0FES80E OP DEEMAT0L06T IN BELLEVTTE HOSPITAL MEDICAL COLLEGE; SUEGEON TO THE CHAEITY HOSPITAL, VENEEEAI. DIVTSION; CONStTLTING DEEMATOLOGIST TO THE BUKEATT OF OtTT-DOOE BELIEF, BBLLETUE HOSPITAL, ETC. NEW YORK: D. APPLETON AND COMPANY, 1, 3, AND 5 BOND STREET, 1880. 1 E>TEEED, according to Ac^f Congress, in the year 18T4, By D. APPLETON & COMPANY, In the Office of the Librarian of Congress, at 'Washington. PEEFAOE. The steady growth of tlie science and art of sui-gery has in- volved a corresponding increase in bulk of the text-books in which its principles and practice are set forth — an increase abeady sug- gestive of either a limit in bulk soon to be reached, or the omission or slurring over of special subjects. In this alternative the prepara- tion of text-books on special subjects would seem to be the appro- priate remedy. The tendency of mankind to aggregate in large and constantly- increasing cities has led to a corresponding tendency to the growth of specialists in the different departments of medicine and surgery ; and the development in large cities of hospitals and schools, and opportunities for teaching, would seem to render them the natural repositories of accumulating experience and the sources of advan- cing knowledge. It is from city practice and hospital experience, therefore, that the materials for the preparation of text-books on special subjects would be naturally sought, and from these sources the substance of the present work has been mainly derived. Its object is to present to the student and general practitioner a suc- cinct account of the nature and treatment of the diseases incident to the genito-urinary organs as they are encountered in private and hospital practice by those engaged in their daily and especial study. The literature of this department of surgery has been carefully studied with the purpose of reproducing every fact of p^^actical value. It is hoped that the reader will recognize a conciseness in the grouping of these facts which will save him the necessity of ref- erence to the numerous monographs and essays from which they have been collected. On account of the general character of the work as a text-book, .t has been impossible to refer very largely to personal authority and experience, and this has been for the most part avoided except in reference to mooted points and exceptional or noteworthy phe- nomena. The extent of the subject-matter treated of, and the ne- cessity for compression, will be regarded, it is hoped, as a sufficient iv PREFACE. apology for terseness and directness of expression or defect iii style, while tlie circumstance of joiat-authorship will explain any lack of uniformity in manner througliout the work, of which the prepara- tion for the press has devolved mainly upon the junior author. The plan of the work is based upon an anatomical classification of the tissues and organs of which the diseases and deformities form the subjects of description. This necessitates some repetition and fi"ec[uent reference to facts, cases, or illustrations already given, or to be given, in connection with other anatomical divisions of the genito-urinary tract. These references are usually made thus : (E"ephralgia), (Plate XX.), (Case 45), the page not being specified, as the constant appearance of signs scattered through a page tends to confuse the reader. No difficulty need be experienced in turning to these references promptly, as the parenthetical word, case, or plate, may be f oimd at once credited to its proper page in the general in- dex at the end of the book, or in the index to plates, or list of cases, at its commencement. The terms of measurement employed are uniformly English, with the exception of the centimetre and millimetre, which fre- quently occur in the text. These may be readily reduced to their equivalent in inches by computation fi-om the subjoined table.' The subject of syphihs is included, of necessity, in a treatise like the present. Opportunities for the observation and study of this disease on a large scale fall mainly to the share of the metro- politan hospital-surgeon and special practitioner. Although prop- erly belonging to the department of Principles of Surgery, there is no disease falling within the limits of this work concerning which clear and correct ideas as to nature and treatment will, at the pres- ent time, so seriously influence success in practice. Chapter VIII., Part II., " On Syphilitic Diseases of the Eye," has been kindly furnished, at the request of the authors, by Prof. H. D. Xoyes, M. D., whose authority on this subject is undisputed. They beg leave to thank Dr. Eoosa for aid, both personally and through his excellent work " On Diseases of the Ear," in the prep- aration of Chapter IX., " On Syphihs of the Ear." Acknowledgments are also due to Dr. Partridge and Dr. Mor- rison-Fiset, of the house-staff of the Charity Hospital, for kind assistance ; and to Dr. L. A. Stimson for aid in many ways. ' 1 centimetre — 4.433 lines, or .393708 inch ; 1 millimetre = .443 " .03937 inch ; or, roughly, 1 millimetre equals half a line— about one twenty-fifth of an inch OOITTEITTS. PART I. DISEASES OF TSE GEmTO-UEmARY ORGANS. CHAPTEE I. DISEASES OF THE PENIS. inatomy.-Aiiomalies; Double Penis; Absence of Penis.-lnjuries, Fraoture.-Cutoneous Affections - Tmnora.-Cancer.-Aniputation of Penia.— Tlie Prepuce; Circumcision.-Phimosis ; Kemote Eesulta of Phunosis.— Paiaphimosis.-The Glans Penis; Herpes Projonitalis, Balanitis, and Posthitis, Tege- tatiODS, EpitbeEoma.— The Corpora Cavernosa; Inflammation, Oalcifloation, Gummy Tumor Circum- scribed Chronic Inflammation p^u j, j CHAPTEE II. DISEASES OF THE FEETHEA. Anatomy.— Natural Curve of the Urethra.— Proper Curve for Instruments.- Oatheterism; Obstacles to Catheterism In Che Healthy Urethra.-Deformities of the Urethra; Imperforation, Atresia, Hypospa- dias, Hermaphrodiam, Epispadias. — Urethral and Sexual Hygiene.— Injuries of the Urethra.— Urethral Fever. — Foreign Bodies ... t .... 27 CHAPTEE III. DISEASES OF THE UBETHEA. Inflammation. — Causes. — Subdivisions: Gonorrhoea; Bastard Gonorrhea; Urethritis. — Symptoms. — Du- ration. — Course. — Gleet. — Complications of Urethral Inflammation. — Treatment; Method of per- forming Injection ; Abortive Treatment. — Methodic Treatment of Increasing Stage, including De- scription of "Wrappings ; of Stationary Stage, including Chordee ; of Decreasing Stage, including Copaibal Erythema. — Gleety Stage ; Treatment of Gleet. — The Endoscope. — Kare Sequelae of Gon- orrhoea 02 CHAPTEE IT. COMPLICATIONS OP GONOKKHffiA. Folliculitis. — Inflammation of Lacuna Magna. — Cowperitis. — Peri-urethritis. — Adenitis.— Lymphitis.— Gonorrhoea! Eheumatism ; Hydrarthrosis inflammatory; affecting Sheaths of Tendons ; Burste.- Diag- nostic Table of Simple and Gonorrhceal Eheumatism. — Gonorrhoea! Ophthalmia.— Gonorrhcea! Con- junctivitis.— Diagnostic Table of Gonorrhceal Conjunctivitis and Gonorrhojal Ophthahnia . 77 CHAPTEE T. BTEICTUEB OF THE ITEETHEA. Beflnttlon.- Tarietles ; Muscular, Organic— Organic Stricture.— Form.— Number.— Seat.— The Lesion In Stricture Causes.- Time of Occurrence of Stricture.- Irritable and Eesillent Stricture . . 99 ^ CONTENTS. CHAPTER VI. BTEICTUBB OF THE TJEETHEA. Instrmiients and their Use,— Filiform Bougies with Manoeuvres alone, and as Guides.— Bougies.— Bulbous Eougies.-Catheters.-Sounds.— Scale.— Advantages of Steel Instruments.— Instruments for Divul- flion with Manoeuvres. — Instruments for Internal Urethrotomy with Mano9Uvres. — Perineal Ure- throtomy with and without a Guide.— Eectal Puncture.— Supra-pubic Puncture.— Dieulafoy's As- pirator PAGE 102 CHAPTER Til. STEIOTUEE OF THE TTRETHRA. Diagnosis. — Use of Bulbous Bougie.— Symptoms of Stricture and its Results as affecting the Urethra, Bladder, Kidneys, Testicles, Rectum, Nerves, etc, Including a Consideration of Infiltration, and the Harmlessness of Healthy Urine in contact with the Tissues.- Causes of Death from Stricture.— Recapitulationof Symptoms and Effects of Stricture 134 CHAPTER YIII. TEEATilE^fT OF 8TEICXUEE OF THE UKETHEA. With Details for all Complications, and a Recapitulation 148 CHAPTER IX DISEASES OF THE PEOSXATB. Anatomy. — Function. — Deformities. — ^Injuries. — Atrophy. — Hypertrophy. — Ear at the Neck of the Blad- der.— Symptoms and Results of Hypertrophy. — Course of Symptoms from commencing Imtability up to Retention, Atony, Stone, Uraemia, Death , 170 CHAPTER X. DISEASES OF THE PEOSTATE. Hypertrophy (continued).— Diagnosis ; Description of Instruments and Manosuvres employed in their Use. — ^Examination of Patient — ^Methods of retaining Catheters in the Bladder. — Methods of deciding upon the Character and Extent of Prostatic Deformity as affecting the Course of the Urethra. — Treat- ment. — ^Treatment of Complications. — Internal Remedies in Prostatic Disease. — ^Natural Mode of Death due to Hypertrophied Prostate 185 CHAPTER SI. DISEASES OF THE PEOSTATE. Congestion.^Parenchymatous Prostatitis.— Terminations : in Resolution, Chronic Prostatitis, Abscess. — Treatment. — Gonorrhceal Prostatitis. — Prostatic and Peri-prostatic Abscess. — Ti-eatment'of all Forms of Abscess.^Follicular Prostatitis.— Its Liabihfy to be mistaken for Stone in the Bladder. — Treat- ment.— Tubercular Prostatitis.— Cancer of the Prostate.— Prostatic Concretions.— Prostatic CalcuU.— Neuralgia of the Prostatic Urethra,— Syphihs of the Prostate 205 CHAPTER XII. DISEASES OP THE BLADDER. Anatomy.— Anomalies and* Deformities, Exstrophy.— Hernia of Bladder. — Hypertrophy.— Atrophy .— "Wounds.— Rupture of the Bladder.— Foreign Bodies.— Retention of Urine.— Incontinence : in Chil- dren, In Adult8.—Tenesmus.— Chorea.— H£6mataria.—JTeuralgia of the Vesical Neck.— Cause.— Sjrmptoms. — Diagnosis. — Treatment 218 CHAPTER XIII. DISEASES OP THE BLADDER. Acute Cystitis.— GonorrhoBal Cystitis.— Diagnostic Table of Cystitis of the Neck and Prostatis.— Pathologi- cal Lesions in Cy8titi8.—Treatment.— Chronic Catarrh of the Bladder.— Atony of the Bladder.— Paral- ysis, Heterologous Deposits, and Tumors, in the Bladder-Walls , 240 CHAPTER Xiy. STONE IN THE BLADDEE. Materials of which Calculi are formed.— Causes of Stone, Internal and external.— Number —Size.— Shape —Weight.— Degree of Hardness.— Possible Consequences of Stone, including Symptoms, Pathology, and Modes of Death,— Symptoms considered in relation to Diagnosis and Selection of Mode of Cure. —Sounding. — Circumstances prejudicial to a Choice of IJthotrity 268 CONTENTS. ^jj CHAPTER XT. LTTHOTEITT. Preparatory Treatment.— Instniments required for the Operation, with the Manoeuvres employed in using them. — Impaction of Fragments in the Urethra, with Methods of remoYing the same . page 280 CHAPTEB XTI. LITHOTKITY, Lithotrity continued.— Position of the Patient.— Introduction of the Lithotrite.— Method of catching the Stone.— Precautions la crashing.- ManoeuTres for catching Stone not easily seized.— Subsequent Crushings after one Successful Effort.— How to find Last Fragments.— Complications in Uthotrity, their Significance and Management ... 297 CHAPTER XVII. LITHOTEITY. lilthotrlty continued. — After-Treatment. — Precautions and Care after Crushing Operations, with Con- sideration of Complications liable to arise, and the Methods of meeting them. — Lithotrity in Chil- dren. — ^Lithotrity in "Women 811: CHAPTER XTin. LITHOTOIIT. Preventive Treatment of Stone, General and Local. — Solvent Treatment of Stone.- Electrolytic Treat- ment. — Lithotomy. — Selection of Cases based on Statistics ; the Condition of the Patient ; the Condi- tion of the Stone. — Choice of Operation. — Description of Operations. — The Lateral Operation.— In- Btruments employed. — Modification required for very Large Stones. — ^After-Treatment. — Lateral Operation in Children. — ^The Median Operation. — Supra-pubic Operation.— Complications of Lithot- omy.— Relapse after Lithotomy 324 CHAPTER XIX DISEASES Off THE TTEETBES. Anatomy.— Anomalies.— Chronic Inflammation.— Dilatation.— Stricture.— Wounds .... 349 CHAPTER XX. DISEASES OF TEE KIDHET, Anatomy.-AnomaUes.-Injuries.-Suppression of Urine.— Nephralgia.-Phosphatic Urine.-Oxaluria.- Gravel and Kidney-Stone.— Nephritic CoUc— PyeUtis, PyelonephritlB, and Peri-nephritic Abscess.— PyeUtis Pathological Lesions.-Couses.-Calculous PyeUtis.^Peri-n6phritio AbsoesB.-Treatment of PyeUtis (calculous). Solvent Treatinent^ Nephrotomy.-Hydronephrosis^Kidney CystSr-Hydatids.- Tuberole.— Cancer.— Ablation of Kidney.— SypMUs of the Kidney ...... 860 CHAPTER XXL DISEASES OF THE BOEOTUM. Anatomv-Iniurie8.-(Edema.-Emphysema.-Eczema.- Intertrigo.- Pityriasis-EczemaMarginatum -iriiritus GenitaUmn.-PedicuU Pubis.-Phlegmonous Erysipelas.-Elephantiasis.-Tumors and Cancer of Scrotum.— EpitheUoma CHAPTER XXIL DISEASES OF THE TE3TI0LE. Anatomy.-Anomalies.-Cryptorchidism.-Hypertrophy-Atrophy.-Injnne,.-Ha>matocele.-H»mato. cele of tiieCord.-Free Bodies in the Tunica TaginaUs CHAPTER XXIIL DISEASES OF THE TESTICLE. cyated yiii CONTENTS. CHAPTER XXrV. DISEASES OF THE TESTICLE. Inflammation.— OrcMtis.— Causes.— Symptoms.— Pathological Changes.— Prognosis.— Treatment— Epi- didymitis. — ^Frequency and Date of Appearance in Gonorrhoea. — Causes. — Symptoms. — SterjKtyas a Eesult of Epididymitis.— Diagnostic Table of Orchitis and Epididymitis. — Treatment of Epididy- mitis !•-*■«= 411 CHAPTER SXT. DISEASES OF THE TESTICLE. Pseudo-tubercular Epididymitis.— Tubercular Testis.— Symptoms.— Pathology.— Treatment— SyphiUtic Epididymitis.— Syphilitic Orchitis ; Interstitial; Gummy.— Cancer.— flarcoma.— Diagnostic Table of Syphilitic Testis, Tubercular Testis, Cancer, Sarcoma, including Diagnostic Features of Different Eongi. — Castration.— Dermoid Cyst.— Irritable Testis. — Neuralgia Testis 423 CHAPTER SXVI. MALADIES INVOLVING THE GENITAL FUNCTION. Impotence.— True Impotence, its Causes and Treatment. — False Impotence, its Causes Mid Treatment.— Sterility.— Masturbation. — Pollution, Nocturnal and Diurnal. — Sperinatorrh(Ba.—Erotomania.— Saty- riasis. — Priapism. — ^Aspermatism 446 CHAPTER SXVII. DI6£LASE3 OF TKE COED. Anatomy.- Spasm of Cremaster. — Yaricocele, mild, severe 46T CHAPTER XXVIII. DISEASES OP THE VAS DEFERENS AND SEiUNAL VESICLES, Anatomy.— In^mmation, acute and chronic 472 PART II. CHANCROID AND SYPHILIS. CHAPTER I. CHANCSOZD. Definition. — ^Transmissibility to Animals.— Cause of Chancroid.— Indefinite Inoculability. — Relative Fro- quency. — ^Methods of Contagion-^Explanation of Apparent Long Period of Incubation. — Situation of Chancroid.— Symptoms. — Course. — Character of Scar. — ^Variation of Chancroid fi^m Type, in Ini- tial Form, In Shape, in Number, in Size, in Duration, in Pain, in Condition of Base, in Course (Re- lapse). — CorapUcation by Yegetations, by Syphilitic Chancre, by Inflammation, by G-angrene and Gan- grenous Phagedena, by Pultaceous Phagedena, by Bubo, by Lymphitis. — Diagnosis of Chancroid.— Prognosis ... 476 CHAPTER II. OHANOBOtD. Prcphylactic Treatment. — Local Treatment of Chancroid.^Local Treatment of Phagedena.— General Treatment of Chancroid. — Bubo; simple; virulent— Treatment of Bubo. — ^Lymphitis; simple; virulent ; syphilitic. — Treatment of Lymphitis 494 CHAPTER III. BYP11ILT8. Nature.— Unity and Duality.— Length of Time required for Absorption of Virus.- Analogy with Vaccine Virus. — Second Attacks of True Syphilis. -Transmissibility to Animals.— Incubation of SyphiUtio (JUiMJiiN IB. Jy Chancre.— Induration, parchment-like, split-pea, diflfuae.—tnceration.— Secretion.— Pain.— ITatare of Soar.— Auto and Hetero-Inooulation.- Yacoinal Syphilid.- Multiple Inoculation.— Fluids capable of transmitting Syphilis by Inoculation.- Methods of Transmission of SyphiUs.— Duration of Chancre— Number.-Size.— Situation. — rorm.— Symptoms of Urethral Chancre.- Course of Chancre.— Compli- tions.— "Mixed Chancre."— Transformation into Mucous Patch.— Phagedena and Gangrene- Treatment of Chancre.— SyphUitic Bubo.— Lymphitia PiSE 506 CHAPTEE IV. BYpniLIS. Diagnostic Table of SyphiUtio Chancre, Chancroid, Herpes, and Ulcerated Abrasion.— Of Syphilitic Bubo and thoBubo of Chancroid. — Of Syphilitic Lymphitis and the Lymphitis of Chancroid.- General Syph- ilis. — Secondary, Tertiary, Malignant, Irregular, and Intermediary Syphilides. — Prognosis of Syphilis.— Duration. — Influence of Gout and Scrofula upon the Course of Syphilis. — The Ten General Character- istics of Syphilides. — Concomitant Symptoms of Secondary Syphilis. — Secondary Incubation, Syph ilitic Fever, Alopecia, Indolent Glandular Engorgement, Sore-Throat, Analgesia D31 CHAPTEE V. GENERAL TBEATMENX OF SYPHILIS. Hygienic, Tonic, Spectflc Treatment.— Syphilization. — Treatment of Early Syphilis.— Bad Effects of Mer- cury. — ^Methods of administering Mercury. — Treatment of I.ate Syphilis.— Mixed Treatment. — ^Treat- ment by the Iodides.- Methods of Administering Iodine In SyphiUs.— Quantity of Iodide which may be required.— Duration of General Treatment ... 652 CnAPTEE VI. BTPHII.I8 OF SKIN AITO MUOOTTS MEMBEANES. Syphilides Secondary and Tertiary.- The Secondary Syphilides.— Concomitant Symptoms on Mucous Membranes 672 CHAPTEE VII. 8TPHILI8 OF SKIN AND MUCOUS MEMBEANES. The Tertiary Syphilides.- Concomitant Symptoms on Mucous Membranes 690 CHAPTEE VIII. SYPHILIS OF THE EYE. The EyeUds: Chancre; Mucous Patches; Gummy Tumors; Ptosis.-TheConjanctiTa.-The Coraea.-- Thelria- Mydriasis; Iritis, Varieties and CompMcations, acquired and hereditary.-Prognosis.-Treat- ment -Vitreous Humor, Hyalitis.-CrystalUne Lens, Cataract.-CycUtis.-ChoroidiHs, exudative and atrophic— Ee«niUs.-N6Uritis0ptica.-Paralysis of Muscles.-Periostitis 600 CHAPTEE IX. SYPHILIS OF THE JIAE. Syphilis as affecting the Externa; Middle, and Internal Ear .... .... 619 CHAPTEE X. SYPHILIS OF SPECIAL TISSUES AITO OKGASS. Svnbilis of the Nails -Daotynti8.-Syphilis of Tendons.-Sheaths of Tendons and Aponeuroses^Syphifls "^M^ciIXmHs 5 Joints.^yphilis of Bonc^yphilis of Cartilage.-Byphilis of Lymphatic Glands.- SyphihsoftheMammaryGland CHAPTEE XI. VieOEEAL SYPHILIS. Thymus.— Syphilis of the Genito-Urlnary System • * X CONTENTS CHAPTEE XII. STPniLIS Off THE NEBVOTTS STSTEir. The Lesions, Symptoms, Prognosis, Treatment. — General Characteristics of Nervous Symptoms In aH Cases.— Syphilis of the Brain.— Syphilis of tho Cord.— Syphilis of Special Nerves . . fagb 644 CHAPTEE Xm. INHERITED BYPHILISi Inheritance from either Parent, the other remaining sound-— Abortion due to Syphilis. — Date of Appearance of Symptoms.— Symptoms.— Visceral Syphilis.— The Syphilitic Countenance.— Treatment of Inherited Syphilis 660 LIST OF OASES. I. — ^Double penis , II. — Rupture of healthy corpus spongiosum ij III- — Dilatation of lymphatic trun]£ ' _ ij IV- — Irritability of the bladder from phimoses j 5 V- — Chronic circumscribed inflammation of corpora cavernosa 25 VI. — Chronic circumscribed inflammation of corpora cavernosa 26 VII. — Chronic circumscribed inflammation of corpora cavernosa 26 Vni. — Chronic circumscribed inflammation of corpora cavernosa 26 IX- — Chronic circumscribed inflammation of corpora cavernosa 27 X. — Urinary fever _ 4g XI. — Urinary fever 49 XII. — Urinary fever [ 5q XIII. — Head of wheat-straw in the urethra 51 XIV. — Urethral neuralgia due to stricture 76 XV. — Resilient stricture — ^failure of divulsion 116 XVI. — ^Pysemia after divulsion 117 XVII. — Infiltration after supra-pubic puncture 131 XV 111. — Stricture of meatus, producing vesical irritability 135 XIX. — ^Narrow meatus, producing vesical irritability 135 XX. — Hsematuria with stricture 139 XXI. — Traumatic stricture cured by divulsion 156 SXn. — Chorea of the bladder 230 XXin.— Chorea of the bladder 231 XXrV.— Chorea of the bladder 231 XXV. — Acute haematuria 234 XXVI. — ^Paralysis of the bladder, without cystitis 253 XXVII. — Stone in the bladder, complicating stricture 277 XXVIII.— Syphilitic testis, with hydrocele 403 XXIX. — Hydrocele, with calcified walls 405 XXX. — Orchitis, from cold 412 XXXI.— Orchitis 412 XXXn.— Orchitis 412 XXXni. — Double simultaneous epididymitis 416 XXXIV.— Epididymitis from cold 417 XXXV. — Pseudo-tubercular epididymitis 429 XXXVI. — Pseudo-tubercular epididymitis 429 XXXVII. — Tubercular testis, with urethral haemorrhage 432 XXXVm.— Dermoid cyst 443 XXXIX.— Neuralgia testis 445 XL.— Masturbation 458 xii LIST OF CASES. CASE FAGB XLI.— Priapism 466 XLn.— Aspermatism 465 XLm.— Aspermatism 466 XLIV. — Spasm of the cremaster 467 XLT.— Chancre of the arm 5 14 XLVI.— Chancre of the Up 622 XLVIL— Chancre of the lip 623 XL Vm.— Tertiary ulcer of the penis 637 XLIX. — Syphihtic roseola, complicated with copaibal erythema 546 L. — Effect of hygiene upon syphilis 553 LI. — Tertiary ulcer, mistalsen for lupus 599 TiTT. — Syphilitic cycUtis 613 Lin. — Syphilitic arthropathy. 625 LFV. — Gummy tumor of the tongue 639 LV. — Syphilitic hemiplegia 650 II^fDEX TO PLATES. PAGE nOTTRE 1. Transverise section of penis (flaccid) 2 2. Transverse section of penis (erect) 2 3. Forceps for circumcision \ lo 4. Method of reducing paraphimosis , 16 5. Method of reducing paraphimosis 17 6. Method of reducing paraphimosis lY 7. Diagram of the urethra 29 8. Lacuna magna 29 9. Tertieal section of fossa navicularis 30 10. Transverse section of spongy urethra 30 11. Transverse section of prostatic urethra 30 12. Proper curve for urethral instruments 31 13 ^. Faulty curve 31 13 5. Faulty curve 31 14. Correct curve 32 13. Passing the sound, first position 33 16. Passing the sound, second position 33 17. Passing the sound, third position 34 18. Passing the sound, fourth position 34 19. No. 1 A, American hard-rubber syringe 60 20. Proper method of injecting urethra 60 21. Faulty method of injecting urethra 60 22. Bumstead's deep urethral syringe 72 23. Bigelow's deep urethral syringe 72 24. Linear stricture of the urethra 95 25. Annular stricture of the urethra 96 26. Soft catheter for introduction on two-foot guide 104 27. Soft catheter, with screw-tipped guide 104 28. Tips of whalebone guides 10* 29. Urethral lacunae catching small instruments 106 30 A. Olivary bougies, properly made 107 30 £. Olivary bougies, improperly made 107 31. Head of bulbous bougie 10"? 32. Silver catheter 108 33. Thompson's probe-pointed catheter 109 34. Thompson's probe-pointed catheter, modified by Otis 109 35. Thompson's probe-pointed catheter, modified by Bumstead 109 36. Conicity of sound ^^^ 37. Small tunneled steel sound ^' xiv INDEX TO PLATES. FIGUEE not 38. American scale, front. 112 39. American scale, back 112 40. Thompson's diviilsor, tunneled 115 41. Holt's divulsor 118 42. Voillemier's dlTulsor 119 43. Civiale's concealed bistoury. 120 44. Civiale's urethrotome. 121 45. MaisormeuTe's urethrotome, modified by Bumstead 122 46. Maisonneuve's urethrotome, modified by Toillemier 122 47. Dilating urethrotome — Otis 123 48. Blunt-grooved staff for perineal section 124 49. Blunt-grooved staff for perineal section, with guide 124 60. Gouley's catheter-stafiF. 124 61. Tube to be worn in supra-pubic puncture 131 62. Dieulafoy's aspirator 133 53. Pocket at inferior commissure of meatus 136 64. Dilatation of urethra behind stricture 136 55. False passage 16Y 56. Short, straight, conical steel sound 165 57. Hypertrophy of the prostate 175 58. Posterior median hypertrophy 177 59. Posterior median hypertrophy 178 60. Healthy prostate '. 178 61. Sacculated bladder 180 62. Long curves for silver catheters 187 63. Thompson's curve for soft prostatic catheter 188 64 A. Mercier's elbowed catheter 189 64 £. Mercier's catheter, with two elbows 189 65. Soft rubber catheter 189 66 A. Holt's self-retaining catheter 189 66 £. Modified self-retaining catheter 189 67. Catheter-holder..- 190 68. Squier's jointed catheter 191 69. Mercier's false-passage catheter 191 70. Thompson's searcher 192 71. Posterior median prostatic hypertrophy 192 72. Rubber bag for vesical injection 197 73. Rubber urinal 199 74. Hot- water bag, with perineal prolongation 202 75. TJrinal for exstrophy 223 76. Thompson's searcher 271 77. Mercier's elbowed sound 271 78. The "trilabe"— Hunter's forceps 284 79. Jacobson's lithotrite, shut 284 80. Jacobson's lithotrite, open 284 81. Heurteloup's lithotrite 285 82. Fergussou's lithotrite , . . 285 83. Thompson's lithotrite 287 84. French lithotrite 287 86. Female blade of Thompson's lithotrite 287 86. Male blade of Thompson's lithotrite 287 87. Jaws of heavy lithotrite 288 87 bis. Handle of Thompson's lithotrite 289 INDEX TO PLATES. ^ wia-iTRs pj^aj 88. Evacuating catheter, stylet and bag 291 89. Clover's apparatus 291 90. Nekton's "evacuateur" 291 91. Mercier's double evacuating catheter 292 92. Thompson's long urethral forceps 294 93. Urethral forceps, Collin & Co 294 94. Urethral forceps, Mathieu 294 96. Leroy d'Etiolles'a scoop 295 96. Urethral stone-crusher 296 97. Urethral stone-crusher in action 296 98. Method of catching a stone in the bladder 306 99. Position of the stone before crushing 306 100. Staff for lateral lithotomy 333 101. Scalpel for lithotomy 333 102 A. Blizard's knife 333 :02 £. Blizard's knife 333 103. Blunt gorget 333 104. Scoop 334 106. Lithotomy-forceps, with crossed handles 834 106. Lithotomy-forceps, with curved blades 834 107. Crushing-forceps, with extra piece 834 108. Maisonneuve's perforating crusher 335 109. Tube for washing the bladder, 335 110. Bulbous tube, with Davidson's syringe 335 111. Shirted canula 336 112. Keith's tenaculum 336 113. Prichard's anklets and wristlets 336 114. Bony outlet of the pelvis SSY 115. Diagrammatic outlet of the pelvis 338 116. Civiale's stone-crusher. 341 117. Gross's artery-compressor. 842 118. Markoe's median Hthotomy-staff. 3*4 119. Little's median lithotomy staff. 344 120. Little's director 346 121. Aponeurotome ^* ' 122. Sondes dard ^^'^ 123. Hooked gorget ^*'' 124. Cancer of the kidney. ^'^ 126. Pediculus pubis ^°* 126. Section of hsematooele 127. Section of hydrocele ^^^ 128. Simple hydrocele, with hernia ■*"* 129. Congenital hydrocele, with congenital hernia 406 130. Cupped sound -. 131. Maury's fumigator 132. Pumigator ^^g 133. Syphilitic dactylitis 134. Syphilitic dactylitis PAET 1. DISEASES OF THE GENITO-URIMRY ORGAJ^S. CHAPTEE I. DISEASES OF THE PEmS. Anatomy.— Anomalies; Double Penis; Absence of Penis.— Injuries, Fracture.— Cutaneous Affections,— Tumors.- Cancer.- Amputation of Penis.- Tlie Prepuce; Circumcision.- Piimosis; Eemote Eesults of Phimosis.— Parapliimosis.— The Glans Penis; Herpes Progenitalis, Balanitis, and Posthitis, Vego tations, Epithelioma. — The Corpora Cavernosa; Inflammation, Calcification, Gummy Tumor, Circum- scribed Chronic Inflammation, The penis is a genital organ. Its urinary function is purely sec- ondary. It is conformed anatomically to subserve the genital function. In the adult it measures, when at rest, from the root of the scrotum to the meatus urinarius, from two and a half to four inches ; when erect, from five to seven inches. It consists essentially of three segments — the two corpora cavernosa, lying together like the barrels of a gun, and the corpus spongiosum — like the ramrod — beneath them — the whole surrounded by integument. The Coepoea Oaveenosa arise on either side from the tuberosi- ties and ascending rami of the ischium. They come together under the symphysis pubis, and continue side by side, forming the main bulk of the penis. They terminate anteriorly in a conical extremity, over, which the glans penis (the terminal expansion of the corpus spongi- osum) fits like a cap. There is no vascular communication between the tissue of the corpora cavernosa and that of the glans penis, nor with that of any part of the corpus spongiosum. Each corpus cavernosum is surrounded by its own fibrous sheath — tunica albuginea — which, together, are so dense and strong, that they will support the weight of the cadaver without giving way." The ' CrweUhier, "Traitfi d'Anatomie descriptive," Paris, 1865, vol. ii., part i., p. 386. 1 DISEASES OF THE PENIS. sheath is, however, plentifully supplied with elastic fibres, which allow it to accommodate itself to the variable size of the organ. The parti- tion between the corpora cavernosa is perforated by numerous aper- tures, to insure thorough and symmetrical erection. The tissue proper of the corpora cavernosa is known as spongy, or erectile. Erection takes place when the areola of this tissue become distended with blood, as shown in Fig. 1. The Coepus Spongiosum Ueethejs is also composed of erectile tissue. It suiTOunds all that portion of the urethra lying in front of the triangular ligament, anteriorly form- ing the cap over the conical extremity of the united corpora cavernosa — known as glans penis — posteriorly terminating in the bulb, which lies just in front of the triangular ligament in the angle of the converging crura penis. The Glans Penis is covered by a semi-mucous membrane endowed with peculiar sensibility, especially around the raised posterior border — the corona glandis. The epithelium covering the glans is fine ; the papillse minute (Home) ; the sebaceous glands (of Ty- son) large and numerous, and most plen- tiful about the frsenum. These glands secrete the white, badly smelling mate- rial which collects, in uncleanly persons, behind the corona. The function of the glans penis is to furnish a soft-skinned expansion for the distribution of the terminal filaments of the nerves of sexual sensibility. One important function of the corpus spongiosum is acquired through its bulb — namely, that of assisting in the expulsion of the last drops of urine or semen from the urethra. The prostate, levator ani, and deep urethral muscles — especially the compressor urethriE — contract upon the fluid remaining in the canal after micturition, in that spasmodic eifort called by the French the " coup de piston." This forces the last few drops beyond the bulb of the urethra. Now the middle fibres of the accelerator urinje — those which surround the bulb and adjacent portions of the corpus cavernosum — contract and forcibly drive the blood, which was contained in the areolae of the bulb, forward along the corpus spongiosum, forcibly dis- tending that body, and thus bringing the walls of the urethra more closely into contact in a progressive wave. This helps to explain, as 1. Figs. 1, 2.—{Cry/veilMer.) TaANSTEESE Section op Penis. — F Fiaccid ; Fiff. 2. In Erection ; 1, 2. Dor- sal Vein and Artery ; 3. Erectile Tissue ; 4. Tunica Albuginea; 5. Integrunient; 6. Tunica Albuginea of Corpus Spongi- osum; T. Erectile Tissue; 8. tXretbra. BUCK'S FASCIA. „ shown by A. Guerin/ why the last few drops of urine do not escape promptly, but dribble away in cases of organic stricture of any severity ; for, with such a stricture, the areolae of the erectile tissue become more or less obliterated at the constricted point, and an obstacle is formed to the free passage of the wave of blood forward along the corpus spongiosum. The three erectile bodies which have been briefly described are sur- rounded by the sheath proper of the penis— a membrane important in its pathological relations, and sometimes known as Buck's fascia, from the distinguished surgeon who first accurately described it." This fascia may be said to arise from the linea alba and symphysis pubis by a tri- angular bundle of fibres known as the suspensory ligament of the penis. The fibres spread out upon the corpora cavernosa, extend over the conical head of these two bodies, and are, at this point, firmly attached to the under surface of the glans penis, which may be removed entire with the fascia. The sheath, after enoirchng the corpora cavernosa, splits into two layers, to embrace and form a sheath for the corpus spongiosum. The fascia is attached behind along the rami of the pubes, and is identical with the deep layer of the superficial fascia of the peri- naeum, curving under the transverse muscles, and finally losing itself in the anterior layer of the triangular ligament. The cavity of this fascia is bounded anteriorly by the under surface of the glans penis, and pos- teriorly by the triangular ligament. Its boundaries have a practical bearing upon the burrowing of infiltrated urine. Urine may escape out of the urethra, and yet be prevented by this fascia from passing the limits above described for an indefinite time, unless Richet' is correct in stating that, at the root of the penis above, the fascia cannot be distin- guished from that covering the pubes — that it is here loose in character — and that urine may escape at this point out of the sheath into the areolar tissue of the abdominal wall. The lymphatics and veins of the penis run along the dorsum of the member, and receive in their course branches from the corpus spongio- sum, which encircle the penis between the folds of Buck's fascia. The lymphatics lead mainly to glands lying along and above Poupart's liga- ment on either side. The arteries come from the internal pudics. The connective tissue which attaches the integument of the penis to the fascia is very loose and elastic, and, like that of the eyelids, does not contain fat. The skin of the penis, except that it tends to become pigmented af- ter puberty, does not differ essentially from ordinary integument. Over the glans penis it folds back upon itself, forming a non-adherent sheath for the glans (the prepuce), evidently intended to preserve the delicate sensibility of this portion of the member. ' " Deg Retrdcissements du Canal de I'Ur^tre." M6m. de la Soc. de Chir., vol. iv., 1867. '■" Ti-ans. Am. Med. Ass., vol. i., p. 367. " " Traite d'ADatomie M6dico-Chlrurgicale," Pans, 1873. A DISEASES OF THE PENIS. The Peepuce is composed of two layers, a cutaneous (external), and a more delicate semi-mucous (internal). The point of junction of these two is called the orifice of the prepuce. Between these layers is a very loose and elastic connective tissue, without fat, which allows the two surfaces to be entirely separated from each other, and the pre- puce effaced, by drawing back the integument of the penis until the glans is entirely uncovered. The mucous layer of the prepuce is sup- pKed with the glands of Tyson. It is much less elastic than the cutane- ous layer. The prepuce is attached to the lower angle of the meatus urinarius, or orifice of the urethra, by a triangular fold of mucous membrane called the freenum preputii— analogous to the frsenum linguffi. ANOMALIES OF THE PENIS. Deformities of the penis are constituted by abnormalities in some of its constituent parts. The most common examples will be mentioned in connection with these parts. As anomalies of the penis, two condi- tions demand especial notice — double penis and absence of the penis. Anomalies in size occur, as when the penis is nine or ten inches long when at rest, or only a couple of inches long when erect ; but these variations are very uncommon. Double Penis is excessively rare. It is analogous to double uterus and vagina in the female, but by no means so common. Undoubtedly it is not so uncommon as the records of surgery would seem to imply, for the existence of this deformity is naturally accompanied by an ex- cessive sensitiveness on the part of the patient which leads him to shun observation and comment ; and, as the defect is not necessarily accom- panied by any symptoms affecting the general health injuriously, the patient does not voluntarily subject himself to the inspection of a phy- sician, and thus keeps himself out of the books. Case I., reported by the authors, exemplifies this fact, and chance alone allows it to be placed on record. A case of this anomaly is reported by Mr. Ernest Hart ' (with sev- eral plates of ±he patient in different positions), in the person of a well- formed, healthy man, the victim of a monstrosity by foetal inclusion. Between his thighs there grew a third thigh, terminating in a leg and double foot, all small and deformed. In front of this thigh there was a shrunken, empty scrotum, bordered on either side by a well-developed scrotum, each containing one testicle. The penis was double, each organ being well formed and perfectly developed. They were both in proper po- sition, each measuring four and a half inches when pendant, being larger than normal. The left was the larger in circumference, and appeared to have become so by being used in preference to the other. Both be- ' London Lancet, January, 1866, p. 1\. DOUBLE PENIS. same erect at the same time under excitement. The urine or the semen as the case might be, was discharged simultaneously by both organs. The^ following (personal) case is more strictly typical of double penis, since it shows no evidence of so-called foetal inclusion : Case I.— In 1873, a stout, healthy-looking man, of forty-two, applied for advice as to what form of truss he should wear for a rupture. A portion of integument some three inches in diameter, cicatricial in aspect, situated in the median Ime, just below the umbili- cus, and not protruding noticeably as he lay on his back, was pointed out by the patient as the seat of rupture. There was distinct prominence of this portion of the abdominal wall in the upright position, increased on effort, by coughing, etc. The difficulty was congenital and caused but slight inconvenience. The general appearance of the deform- ity suggesting extrophy of the bladder, an attempt was at once made to expose the genitals, which the patient had thus far kept scrupulously covered by his clothing. This movement the patient resisted, insisting that he desired advice about his rupture only, and was unwilUng to e.xpose himself further. After overcoming his reluctance, the gen- ital organs were uncovered, revealing two distinct male organs of normal size, and appar- ently well formed, lying side by side, each attached by its root to the pubic symphysis. Each penis was well developed, the right rather the larger of the two. Their integu- mental covering was common up to the base of the glans; here each was entirely distinct and perfect as to external appearance, but the meatus of the left glans was impervious. The right meatus was nprmal, and the patient stated that his urine passed through this opening mostly, some always escaping from a point behind in the peri- nseum. Here, just where the root of the scrotum should have been attached, was seen, on lifting the double-barreled penis, the orifice of a canal, lined by healthy mucous membrane, and large enough to admit the finger, funnel-shaped, and, in general appeav- ance, recalling the ostium vaginas of a child. What proportion of the urine passed through this orifice the patient could not state, but he was compelled always to let down his trousers and sit, when he made water. On the right side of this orifice was an elongated, rounded prominence, recalling in its outline the labium majus. This contained a testicle, normal in shape and sensibility, and but slightly under-sized, surrounded, as was evident from its mobility, by a tunica vaginalis. The left testis lay over the tendon of origin of the adductor longus in the left groin. It was not fully developed. There was no prominence on the left side of the perinseum. The patient had sexual desires, erec- tions, and emissions. Both penes became simultaneously erect, the right more vigor- ously. The sexual propensity seemed rather deficient. There was a feminine breadth about the pelvis. The mammillae were normal. There had never been any periodical phenomenon of the nature of menstruation. The left lower limb was several inches shorter and smaller than the right. This was congenital. Health had always been unusually good. The patient left with an unsolicited promise to return — a promise which he failed to keep. There was great difficulty in getting at any of the facts of the case, on account of the mauvaise lionte of the patient. Abseitce of the Penis. — A case of congenital absence of the penis has been observed by N6laton.' The scrotum was well developed, and contained testicles. The child urinated through the rectum. Another similar case has been reported by Goschler." ' Oaz. des Hdp., 28, Jan., 1854. " Vierteljahrschrift fur practische Heilkunde," Prag, part iii., 1857. 6 DISEASES OF THE PENIS. ACCIDENTS TO THE PENIS AS A "WHOLE. Contusions. — The escape of blood under the skin in superficial con- tusions of the penis is often excessive, on account of the laxity of the connective tissue, and the large size of the superficial veins. Deeper contusions give rise to localized swelling from circumscribed effusion of blood, which fluctuates, increases in size on erection, and may cause the penis to deviate more or less from its normal aspect. Opening into such a collection of fluid is not to be thought of, as it might give rise to suppurative inflammation. If the contusion be severe enough, inflam- mation of the corpora cavernosa results, ending in suppuration or gan- grene. Severe contusions involving the urethra may lead to infiltration of urine, and loss of substance, with urethral fistula. Treatment of contusion consists in combating inflammation, employ- ing cold, evaporating, astringent lotions; later, perhaps, compression, and in giving the absorbents time to remove the effusion. Wounds. — The penis is liable to be wounded by accident or design. In the latter case insanity, or the melancholy depression often attending the loss of self-respect produced by masturbation, is apt to be at fault, and to induce the patient to mutilate himself: or, the injury may be inflicted by a woman, jealousy being the motive. Superficial cuts are unimportant ; but wounds extending within the sheaths of the corpora cavernosa may give rise to troublesome, possibly fatal hemorrhage, while the cicatrices left on healing may distort the penis, and render erection imperfect and painful. Treatment. — Clean the wound. If a large artery is spirting, tie it, but let the oozing points alone. Join the edges as accurately as pos- sible, with points of fine suture not introduced deeper than through the fibrous sheath. Employ moderate pressure in dressing. Erections, which are sure to occur since the local inflammation induces an afilux of blood, always retard healing. (For injuries involving the urethra, refisr to diseases of that canal.) PEACTTJEE OF THE PENIS. V/hen the fibrous sheaths of the corpora cavernosa are ruptured by sudden forcible flexion of the erect penis, a sort of fracture of the mem- ber is produced, with extensive extravasation of blood — sometimes amounting to traumatic aneurism. The late Valentine Mott ' reported two interesting cases of this accident, where the only treatment em- ployed was rest and cold locally. Both oases recovered, with a useful organ and no deformity. Treatment. — A silver or stout woven, elastic catheter, strong enough to resist lateral compression, is first passed into the bladder to insure ' TranBaotions of the New York Academy of Medicine, vol. !., part i., 1851. FKACTUKE OF THE PENIS. right of way to the urine. Over this the penis is firmly compressed by adhesive straps or collodion, or both, and cold applied locally. Pitha^ states that, if speedy relief be not afforded, the tension of the blood, effused in great excess, may bring on rupture of the sheath of the penis or gangrene, demanding amputation. , ,^' a rule, patients recover more or less perfectly. A lumpiness may be left behind at the point of injury (nodes or ganglia of the corpus cavernosum) which makes ereotior. i-mperfect and painful, and interferes with sexual intercourse. No^ttempt has yet been made to relieve this latter condition, when follQjt^ng fracture. The only other for^^ fracture to which the penis is liable is, rup- ture of the inflamed ^gbrpus spongiosum urethra. When this ereq^iie body is inflamed, as it often is in gonorrhoea, a painful curving dj^vvnward of the penis during erection is the result, and there exists a vi:^lgar superstition that, if this chordee be "broken," the gonorrhoea wi;^ get well. A patient breaks his chordee by violently straighteninn^ the organ, when it is erect.. The result is a free flow of blood from J^jjg urethra, and, after a time, inevitably, traumatic stricture. Inat rapture of the healthy corpus spongiosum may occur is shown by the ^[lowing case : _ II. — A middle-aged Irishman, attempting intercourse while intoxicated, sus- tained a rupture of the corpus spongiosum urethras, which led to abscess, urinary fistula, land subsequent traumatic stricture. The patient had no gonorrhoea, stricture, or other I lesion of the urethra, or of the corpus spongiosum, before the accident. CTJTANE0X7S AFFECTIONS OF THE PENIS. .The integument of the penis may be the seat of most of the ordinary cutf»jjQQyg affections, which present no very special peculiarities in this ^'^'Ipation. Venereal sores and eruptions will be described in their proper Elephantiasis usually involves the scrotum primarily. In phleg- aonous erysipelas of the penis, free incisions should be made early, to l^revent gangrene and save the organ from becoming denuded. Lym- hiangitis may complicate a variety of inflammatory lesions. It will be described in connection with its most common causes — chancre and chancroid. The following case illustrates a peculiar and rare affection of the lymphatics : Case III. — A middle-aged man presented himself with a painless, compressible swelling behind the corona glandis, partially encircling the penis, with one thiolcened cord-like lymphatic, extending from it along the dorsum of the penis to its root. The condition was chronic, and did not interfere with the function of the organ. Its origin was idiopathic, and unconnected with inflammation. TUMORS OF THE PENIS. Fatty, fibrous, cystic, erectile, and other tumors, are occasionally, > " Krankheiten der miinnlichen Geschlechtsorgane," Erlangen, 1864. Tirchow Hdbch. d. sp. Path, und Ther., p. 13. g DISEASES OP THE PENIS. but very rarely, found on the penis. Their removal is a question of judgment involving a recognition of the function of the penis as an intromittent organ, and the possible loss of this function, from the for- mation of cicatrix. Caitoee of the penis, except epithelioma, described under diseases of the glans penis, is exceedingly rare. The medullary variety is some- times seen, especially in boys, following injury of the part. It grows rapidly in a lobular form, unequaiiy jn^the corpora cavernosa, it in- volves the glans, and sprouts out under t*lie prepuce. The vems ot the penis become larger and tortuous. The^^ -^jstention of the common fibrous sheath of the penis, by the rapid gro^ of the new formation within it, may compress the urethra, and make iretention of ""ne im- minent, caUing for external perineal urethrotomy to\relieve the bladder, as occurred in the case of a boy under the charge o^, Dr. , Weir, at St. Luke's Hospital, in this city. The pain of this form of^c^^cer is severe. Some of the bulging prominences along the penis areSj^ery soft, and give a fallacious impression of fluctuation, which is very m^^'^^"- •^'Oc^'i heat is increased, and, as the disease may develop not long?i ^"^^ ^^WJ to the part, the question of suppuration of the corpora cav^°°^^ ™^y present itself to the young surgeon. The inguinal glands sooffJ^®°°'"® involved, the patient emaciates rapidly and dies. Prognosis is the worst, and amputation, the only resource, is not^ be thought of, unless the growth be very recent, and involve only t' fore part of the member. Relapse would even in such cases be almot inevitable. AMPUTATION OF THE PENIS. In amputating the penis, as much of the organ should be spare possible. If it is divided too near the root, it will retract behind laor'''^ symphysis, unless care be taken to prevent it, and render it difficult ' control hsemorrhage. Therefore, where the section must be low, stout ligature may be passed behind the proposed limit of operatioij through some part of the sheath of the penis, as a preliminary step^ before cutting into the corpora cavernosa. When the amputation is made near the suspensory ligament, the j patient can no longer throw a stream of urine forward, and the habitual use of the catheter may be required to prevent soiling the clothes. The steps of the operation are as follows : The skin should be incised at a point somewhat lower than it is desired to divide the body of the penis, as the latter shrinks after section. The corpora cavernosa should be severed with one stroke of the knife. The haemorrhage is free, and many spirting points will require ligature. The arteries are liable to retract into the tissue of the corpora cavernosa, and the forceps must be slender-pointed and grasp well to seize them. Sometimes they cannot be pulled out. Pressure and cold will arrest oozing, but some Missing Page Page Missing in Printing and Binding Page Missing in Printing and Binding Missing Page Missing Page Missing Page Missing Page Missing Page Missing Page Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding Page Missing in Printing and Binding DISEASES or THE URETHRA. ^h both corpora cavernosa, and is evidently situated beneath the sheaths. It measures one and a quarter inch antero-posteriorly, three-quarters of an inch laterally. Four months afterward the patient returned to say that erections were still more interfered with, rendering intercourse impossible. The lump was extending somewhat anteriorly and laterally. This case presented no evidence or suspicion of any venereal taint. Case IX.— In 1872, a perfectly healthy merchant from the West, aged- forty-eight and married seventeen years, presented himself with a hard, semi-elastic patch of indura! tion across the root of the dorsum penis, about one and a half inch each way, the whole giving the idea of two thm plates jomed in the middle hue of the dorsum, 'with some mobUity at the line of junction. The edges were slightly thickened and sensitive. The induration had advanced forward one inch in six months. Sexual intercourse was not prevented, but some management was necessary m its performance. No possible cause could be assigned. CHAPTER II. DISEASES OF TEE USETHRA. Anatomy.— -Natuial Curve of the Trrethra.— Proper Curve for Instmments.— Catheterism ; Obstacles to Caiheterism in the Healthy Urethra.— Deformities of the Urethra; Imperforation, Atresia, Hypospa- dias, Hermaphrodism, Epispadias.- Urethral and Sexnal Hygiene.— Injuries of the Urethra.— Urethral Fever. — Foreign Bodies. The urethra is the common duct for the escape of urine and semen, and, in considering its diseases, this double function must not be lost sight of. It is always a shut canal throughout its whole course, except when distended by some foreign substance. Commencing at the neck of the bladder, it tunnels the upper part of the prostate, perforates the triangular ligament, and terminates at the end of the penis. Its size varies greatly, and, like the penis and testicles, it remains com- paratively very small untU after puberty. Its size is not constant for a given size of penis, a small member being sometimes provided with a large urethra, and vice versa. Its length has been estimated at all points between five and fourteen (Pitha) inches. The length varies with the condition of erection or flaccidity of the organ. In may be lengthened by disease (enlarged prostate). In round numbers, the length of the urethra of a well-proportioned adult is eight inches, six lying in front of the triangular ligament (spongy portion), a little less than one inch be- tween this and the apex of the prostate (muscular or membranous por- tion), a little more than one inch surrounded by the prostate (prostatic portion). The spongy portion is surrounded throughout by the erectile corpus spongiosum, terminating below in the bulb. Here the canal pierces the triangular ligament — that firm, fibrous fascia, stretching across the space bounded by the ischio-pubic rami — and, becoming membranous, is cov- 28 DISEASES OF THE UKETHRA. ered (besides the muscular fibres of organic life) by voluntary muscular tissue which entirely surrounds it. This muscle has had special names given to different portions of it by Guthrie, Miiller, and Wilson. In this muscular group, described as one muscle by Cruveilhier ' (trans- verso-urethral), is often the seat of spasmodic stricture ; and it is here that muscular contraction may oppose the passage of an instrument into the bladder for several minutes, even when there is no evidence of ure- thral disease. These are the muscles which constitute the voluntary " cut-off," over which every healthy individual has full control. To allow the urine to pass, these are voluntarily relaxed, with the vesical sphincter, and then the detrusor expels the urine by its tonic tendency to contraction, over which the individual has no control. If a catheter be introduced, so as to do away with any effect of the "cut-off" mus- cles, no voluntary effort of the individual can arrest the stream of lu-ine, nor indeed cause it to flow with greater force unless the abdominal muscles or diaphragm be called into action. This "cut-off" then controls urination in health : relaxed, the urine flows ; voluntarily contracted during any part of the act, the stream is cut off as sharply as if by a knife. Some erectile tissue and a good deal of unstriped muscle are found around this as well as around all other portions of the urethra, but the function of the cut-off muscle must be kept clearly in view, on account of its bearing upon catheterism and spasmodic stricture. The membranous urethra is, of all parts, the most positively fixed. There is no marking on the mucous lining of the canal to indicate any division between it and the spongy portion. The separation into parts is arbitrary. The prostatic urethra bores the prostate, sometimes barely covered by that organ above, sometimes surrounded by a considerable thickness of the same. Unstriped muscle, of which the prostate is mainly composed, sur- rounds the urethra from one end to the other, and enters largely into the erectile structures of the penis as well. Stilling ° has clearly de- scribed and given prominence to the latter fact. The diameter of the urethra varies even more than its length. It has been estimated at from two to six lines. A fair, average, well-formed adult urethra measures about three-eighths of an inch in diameter. Much more important, however, from a practical point of view, is the relative size of the urethra, and this does not vary. Every urethra has normally two points of sensible narrowing, and two of decided dilata- tion, the former at the meatus urinarius and triangular ligament of which the meatus is always the smaller. Like every pipe designed by Nature or art to throw a smooth stream, the orifice is smaller than any other portion of the tube, a fact to be constantly held in view. The two • Op. cit. " " Die rationelle Behandlung der Harnrohreu Strieturen," etc., Cassel, 18'70-'Y2. THE URETHRA. 29 Fig. 1.— {Thompson.) a, 6, and c, represent the Prostatic, Membranous, and Spongy Portions. points of enlargement are the fossa navicularis (so called from its sup- posed resemblance to a boat), which, is situated just inside the meatus, and the bulbous urethra, occupying a position im- mediately in front of the triangular ligament. Of the two, the latter is the larger. The urethra enlarges again in the prostate (prostatic si- nus). Fig. 7, from Thompson, shows these points in diagram. In the fossa navicularis lies the valvule or lacuna magna (Fig. 8), a little mucous flap on the roof of the urethra about half an inch from the meatus, shutting in a fossa about two lines deep. In this valvule the points of small instruments are very apt to be- come engaged. There are other blind pouches or lacunse of variable size scattered along the urethra, chiefly on its roof, and known as the sinuses of Morgagni. They run parallel with the urethra for perhaps half an inch, and terminate in a cul-de-sac. Cruveilhier found one an inch long. The openings of these sinuses all look toward the meatus, and are often large enough to receive the points of fili- form instruments, a fact to be remembered in ma- nipulating with fine bougies {see Fig. 29). Another lacuna in the urethra, which may catch the point of a fine instrument, is the sinus pocularis (Guth- rie) or utriculus of the prostate, a deep little de- pression running down in front of and underneath the veru montanum. The mucous glands of the urethra are small clusters of minute fol- licles, very abundant, opening either on the free surface of the mem- brane or into the sinuses of Morgagni. Cowper's glands are small, round, lobular bodies about the size of cheiTy-stones, lying just behind the bulb of the urethra in the trans- verso-urethral muscle. Their ducts are sometimes very long, but aver- age a full inch, and open into the floor of the urethra. Their fluid is supposed to aid in diluting the sperm. The urethra has about the same amount of sensitiveness in health as the conjunctiva. In the prostatic sinus, however, sensibility is exaggerated. The color of the membrane is a pale pink. In a state of rest its walls lie in contact, obliterating the cavity of the canal, so that a cross-section presents a slit instead of an opening (Figs. 9, 10, and 11). CuEVE OF THE Ukethea. — In connection with the anatomy of Fig. 8. — (Cnweilhier.) 30 DISEASES OF THE URETHRA. the urethra, it is advisable to give some details of explorations, and of catheterism and the use of instruments in the normal canal. Fig. 9. — iCruveilhier.) Vertical Section tliroagli Glaus and Fossa Navicularis. Fig. 10. — (CrureUTiier.') Transverse Section of Penis. Fig. 11. — (Cnweilkier.) Transverse Section of Centre of Prostate Ejaculatory Dncts. Sp, Sinus Pocularis. The lowest point of the urethra is just in front of the triangular ligament, where it lies about one inch beneath the symphysis pubis. From this to the meatus the canal takes any position according to the direction given the penis ; toward the neck of the bladder, however, the urethra is said to have a fixed curve. This is not strictly true, for straight instruments may enter the blad- der — a proceeding rather diflBcult, often pain- ful, never absolutely indispensable, if indeed necessary. At rest, however, the urethra has a curve which, in the membranous portion, is fixed, and runs, on an average, at a distance of from two-6fths to three-quarters of an inch from the symphysis pubis. It varies slightly with individuals and in the same individual at diflFerent periods of life ; being shorter and sharper in the child, longer in the old man. A distended bladder or enlarged prostate lengthens the curve. The proper average curve, as recognized since Sir Charles Bell,' and insisted on by Sir Henry Thompson," the one which will mathematically accord with the greatest number of urethrse, is that of a circle three and one-quarter inches in diameter ; and the proper length of arc of such a circle, to represent the sub-pubic curve, is that subtended by a chord two and three-quarter inches long.^ An instrument made with a short curve of this description will readily find its way through the nor- mal urethra into the bladder without the employment of any force. It is very desirable that instruments intended for habitual use should be so constructed, inasmuch as many of the difficulties of catheterism are due to a defective curve in the instrument employed. The defect most fre- ■ " Morbid Anatomy of the Urethra." ' "Stricture of the Urethra." ' "In the winter of 1852-'53, assisted by the late Dr. Isaacs, I made a scries of careful experiments upon sections of frozen subjects, as well as by injecting the urethra with numerous substances, afterward carefully cutting out the casts. I found the average curve to be identical with the one given above." — Van Buben. CURVE OF THE URETHRA. 31 quently encountered is a too great straightness of the last half-incb — a deviation of the curve at its most important point. In an instrument properly made (Fig. 13) it ■will be found that a tangent to the axis of Fie. 12. Instrnmeiits as ordinarilv made, \rith Faulty Curve, Oa, Od (Beniqu6). Correctly-curved Conical Instru- ment, Ob. Length of Natural Curve of Lrrethra,/Oft. Length of Cord of Curve of Sound, hO, 2^ in. the curve at its extremity will intersect the projected axis of the shaft at a little less than a right angle {n h A). If the curve comprised only a quarter of the circle, the tangent would meet the projected shaft at a Fio. 18 ^.—Faulty Curve. Fig. 13 5.— Faulty Curve. right angle {m g h) ; but instruments made of this length and a little longer, as they are usually found, invariably have the last part of the ' An instrument destined for habitual use by the patient is sometimes made half an inch short in the curve, on account of the greater ease of introduction of such an instrument through the pendulous urethra. 32 DISEASES OP THE UKETHEA. curve tilted off into a faulty direction, as shown in the plate (Fig. 13), making the angle, between a tangent to the axis of the curve at this point and the projected axis of the shaft, obtuse {IjK), and falling with- in the right angle. Figs. 13 A and B represent faulty curves— stiU occasionally encoun- tered on instruments. Fig. 14 shows the correct curve. It is better to prolong the curve around the circle, and even slightly decrease that of the terminal quarter of an inch, as instruments so made are much less apt to be defective, and the point is, for all prac- tical purposes, still at right angles to the shaft, and one and three-quar- ter inch from it. A knowledge of this relative position and direction of the point is of great importance in difiScult catheterism. A moderately short curve is as good as a long one, provided it is accurate ; indeed better, for, should the instrument be made with the full length of curve, three-tenths of the circle, that portion subtended by a chord of two and three-quarter inches, Fig. 14.— Proper Curve. J- its point is so far from the shaft that it is sure to " wabble " when the point encounters an oiistruction. This objection is all the more applicable to the Beniqu6 instrument (Fig. 13, dho), on account of its having a posterior as well as an anterior curve. This " wabbling " is not of serious importance in the healthy canal, but it is very distracting to the surgeon when a tight stricture is to be entered. Here the short conical point, at right angles to the shaft and one and three-quarter inch from it, is vastly the superior in point of steadiness, and is equally certain to follow the urethral curve accurately. ExPLOEATioiT OF THE Ueethba — Cathetekissi. — The introduc- tion of a sound, staff, or catheter into the bladder, is generally spoken of as " catheterism." The use of the staff or sound is sometimes denomi- nated " sounding." The manceuvre in either case is the same. There being given a canal of certain dimensions and curvature, and an instru- ment to fit it, the problem is to introduce the latter into the former. Notliing is easier, although to perform the operation perfectly is less simple than would at first appear. No amount of instruction, no volumes of directions, can teach the student how to pass the sound. He must learn by doing it, first upon the dead, then upon the living body. Some suggestions may, however, be given. Always make the patient lie down on his back, with his head on a pillow, his legs slightly separated, his body relaxed, his fears quieted, and himself as comfortable as possible. Both hands should be practised in introducing the sound, and the surgeon should keep his elbow sup- ported during most of the operation, in order that bis hand may be more steady. If the right hand is used, the surgeon places himself at CATHETERIZATION. 33 Fie. 15. the patient's left, and vice versa. To explore the canal, a simple, blunt, steel instrument, of medium size, is selected and properly -warmed. The penis is gently encircled by the fingers and thumb of one hand, the instrument held lightly with the points of three fingers and the thumb of the other. The shaft of the instrument is held over the fold of the groin, its handle nearly in contact with the skin, from which latter (the integument, first of the groin and then of the abdomen) it is not to be moved away until the point of the instrument is about to enter the fixed portion of the urethra (membranous). The instrument, at first held along the groin, with its point high and handle low (Fig. 15), is entered at the meatus, and the penis is mould- ed up over it. It is not pushed into the urethra, but the urethra is made to swallow the instru- ment, as it were. When the curve, and perhaps an inch of the shaft, has disappeared with- in the meatus, the handle of the instrument is swept around over the surface of the belly, so as to lie exactly over the linea alba, parallel with it, and still close to the integument (Fig. 16). The whole shaft of the instrument is now to be gently pressed toward the feet, being still kept close to and parallel with the surface of the belly (the penis, meanwhile, being lightly grasped behind the corona glandis, and held steady). The point of the instrument should be followed with the little finger of the hand which manages the penis, and, when it gets fairly past the penoscrotal angle, the whole scrotum, -vyith the testicles and penis, should be largely seized with the hand and pressed up against the pubis, with slight up- ward traction. The point may now be felt to settle down and adapt itself to the sub-pubic curve, whence on, the weight of the instrument, properly directed, should carry it into the bladder. As soon as the curve lies well against the symphysis, scrotum, testicles, 3 Fig. 16. 34 DISEASES OF THE URETHRA. rie. 17. and penis should be dropped; the hand which held them takes the instru- ment simply steadies it in the median Une, and gradually carries the shaft away' from the abdomen (Fig. 17), making the handle describe the arc of a circle, and depressing the shaft between the thighs, un- til it lies nearly in the same plane with them. No pushing movement should be imparted to the instrument during this time. The handle is simply made to describe the arc of a circle, and the point, in a healthy urethra, cannot go astray. While the instrument is being depressed between the thighs, the free hand is employed in pressing down upon the mons veneris and root of the penis (Fig. 18), to stretch the suspensory ligament — a point of importance to the easy introduction of an instrument, and one which supplies to the short curve all the advantages claimed for the longer B6niqu6 curve. When the instrument is in the blad- der, its point may be moved freely from side to side by partly rotating the handle. The instrument should be withdrawn with the same slowness and care with which it was intro- duced. No traction is need- ed. The motions used in introduction are simply reversed. The handle of the instrument is lightly caught, and, without traction, made to describe the arc of a circle, until it touches the abdomen over the linea alba. It is then carried around to the groin, and, by a tilting motion, unhooked from the urethra, end- ing exactly where it commenced along the groin, the handle low, the point high. The first principle of instrumentation in the urethra is to avoid the use of force. Even in a healthy subject, sometimes, the beak of the instrument will become arrested by contraction of the unstriped muscle surrounding the canal. A little patient waiting will overcome this, and the instrument glides on. The arrest of a sound from muscular con- FiG. 18. CATHETERIZATION. 35 traction, however, usually takes place in the membranous urethra, from Bpasm of the "cut-off" muscle (spasmodic stricture). The practised touch rarely fails to detect at the handle of the instrument the slight contractions of the muscular fibres around its point, and in this way diagnosis with organic stricture is easy. Gently holding the instrument ia place for a few minutes, with slight forward pressure, will tire out the muscles, and, if the obstruction is muscular, the sound will shortly pass. There is another point at which a large instrument is liable to arrest in a healthy urethra, namely — the triangular ligament. Here, it will be remembered, the urethra is narrower than anywhere else within the orifice, and just in front of this point exists, naturally, the greatest width of urethra. Now, if the canal be flabby, or the instrument not large enough to distend it (a small sound is much more apt to catch here than a large one) the point may become arrested along the floor by the triangular ligament, or along the roof (more rarely) in the little fossa lying above the edge of the sub-pubic ligament. The instrument is known to be arrested by the bulging out of the curve in the perinasum, as the shaft is being depressed between the thighs and the rebound of the handle when liberated. The obstacle is overcome by gently manoeu- vring the point of the instrument, by partial withdrawal and reintro- duction, or by slight depression of the beak, then lifting it over the obstacle with a finger in the perinasum, at the same time pulling up the point of the instrument to make it sweep the roof of the canal. This will generally render the introduction of a finger into the rectum un- necessary. The dangerous " tour de maitre " ' might be gently tried, but no force should ever be used in any manipulations at this point, as a false passage is easily made here, and under these very circumstances. The depression of the handle of the instrument alone is capable of exert- ing enormous power. The sound represents a lever of the first order, and the surgeon has the long arm. With a little patience a suitable instrument will always pass into the bladder, unless there is stricture. When the point has traversed the membranous urethra, it must continue on freely, if the prostate is normal. The so-called spasm of the neck of the bladder does not exist as an obstruction to the passage of instruments. Instruments, small enough to engage in the sinuses of Morgagni, are not used in the healthy canal. Instrumentation in morbid conditions will be detailed in connection with the different diseases requiring it. A silver catheter is introduced in the same manner as the sound. In using soft instruments without a stylet, the penis is slightly pulled upon, so as to efface any circular folds, and the instrument is pushed ' The lour de mditre consists in introducing a sound with the shaft between the legs antil the point is arrested at the bulb. Then the handle is rapidly made to describe a semicircle until it reaches a vertical position, when it is at once depressed between the thighs. It is brilliant, effective, but dangerous. 36 DISEASES OF THE UKETHKA. straight onward into tlie bladder. If it gets arrested, it doubles up, and the hand becomes conscious of a stoppage in the forward gliding move- ment. Partial withdrawal and rotation during the next forward move- ment will cause it to pass. No instrument should enter the urethra unless it is smooth, polished, and well oiled. Warmed oil, thrown into the canal with a syringe, greatly facilitates the passage of instruments. The sensation experienced by the healthy urethra is that of hot points pricking the canal along the part being traversed by the foreign body. As the instrument enters the membranous urethra, a desire to urinate begins to be felt, which increases as the prostate and neck of the bladder become distended by the instnmient, so that the patient sometimes believes that urine is flowing away, in spite of the surgeon's assertions and his own observation to the contrary. Nausea, and even syncope, may occur as the instrument distends the prostate, especially on the first introduction in sensitive young people. Occasionally, dis- tention of the prostatic sinus produces a partial venereal orgasm. If the patient faints, the instrument should be withdrawn at once and the legs elevated, while the head is hung over the edge of the lounge upon which he has been lying. The faoility with which this may be done, if necessary, is one of the reasons for placing the patient on his back. The introduction of special instrtiments (lithotrite) will be given, with their description. DiEFOBMITrES OF THE URETHEA. The urethra is subject to arrest and error of development, but is not often seriously deformed. Among curiosities of deformity may be mentioned the abnormal position of the meatus on the side of the glans penis ; the termination of the ejaculatory ducts in a separate canal, run- ning along the dorsum of the penis and opening behind the glans ' (gonorrhoea of this canal has been noted) ; termination of the urethra in the groin." Only isolated instances of these rare deformities are known. The urethra is absent where there is no penis. The bladder is usually also lacking in these cases, and the ureters discharge into thp rectum. No case of double urethra is known, except with double penis. Val- vules, pointing backward (Guyon), occasionally exist congenitally in the urethra, and partially prevent the outward flow of urine, but offer no obstacle to the introduction of instruments. They are found about the veru montanum, or near the bladder. Congenital stricture has been observed several times by NSlaton ' and by James Syme.* In these cases dilatation alone was not effective. Internal urethrotomy was required. Congenital urethral dilatations of great size have been observed in a I Cruveilhier, op. cit., p. 420. » HaUer, quoted by Pitta, op. cU. Phillipg, " Traits des Maladies dea Voies urinaires," p. 271. * British Medical Journal, p. 1, 1862. / ATRESIA UKETHE^— HYPOSPADIAS. 37 few oases, attended by atrophy of the corpus spongiosum at the dilated point. Their relief is effected by cutting away the redundant tissue, accurately coapting the edges of the wound, and treating as for longi- tudinal incision of the urethra. All the foregoing anomalies are exceedingly rare, and would not probably be met with at all in general practice. There are other de- formities, however, which are more common, namely — imperforation, atresia, hypospadias, and epispadias. Impeefoeahon and Ateesia. — The meatus alone may be imper- forate (or nearly so), or any portion of the canal may be obstructed by a membranous partition, or replaced by a fibrous cord : in these cases the urachus sometimes continues open for the escape of urine. They all call for surgical interference, and that too, at once, if the ura- chus be closed. If the meatus alone is occluded, an opening is made at the point where it ought to be, and the healing of the wound prevented by daily use of bougies. If a diaphragm exists farther down, it may be punctured with a fine trocar. The same instrument may be used where there is atresia, the point being pushed along the course which the urethra natu- rally follows. If thf atresia involves a portion of the pendulous ure- thra only, success may be confidently hoped for, leaving the patient in a condition of serious organic stricture, requiring the persistent use of means to keep the canal open. The bleeding is not great, and may be arrested by cold and pressure. When, however, the whole urethra is replaced by a fibrous cord, the prognosis is very bad ; yet, even here, it is the surgeon's duty to attempt to open a passage into the little suf- ferer's distended bladder. A direct opening from the perinseum into the bladder would be the most judicious surgical proceeding in these cases, the urethra being attended to afterward. Without a previous opening in the perinseum, a fine trocar, a blunt tenotomy-knife, or a silver probe, may be used, to cut and break down the connective tissue, occupying the position where the urethra ought to be, and this may be continued on from the meatus into the region of the neck of the blad- der. Sometimes immediate success crowns this desperate course, while again the attempt has been abandoned, and after a number of hours urine has found its way out through the artificial opening. Several very interesting cases have been collated by Guyon.' Such openings necessarily tend to recontract, and throughout life occasional use of the sound would be required. Hypospadias aitd Epispadias are the most common congenital deformities of the urethra. According to Baron, ' epispadias occurs once for one hundred and fifty cases of hypospadias. ' " Des Vicea de Conformation de TUr^thre chez I'Hoinme et des Moyena d'y remfe. dier." Thfese, Paris, 1863. * Quoted by Dolbeaii, "De I'Epispadias," etc., Paris, 1861, p. 11- 38 DISEASES OF THE URETHRA. Hypospadias {vtto, beneath; and^uj, I divide). — This deformitj consists in an arrest of development of a portion of the lower wall of the urethra, its lateral halves failing to unite in the median line. The em- bryo at two months has hypospadias normally. The scrotum has not yet united, and, if natural evolution ceases here, the last degree of hypospadias results with bifid scrotum. Hypospadias may occur at any point in front of the membranous urethra, but does not involve the lat- ter or the prostatic portion of the canal ; consequently, no matter how- extensive hypospadias may be, the patient has control over the escape of urine. When hypospadias is scrotal, the penis is usually very imper- fectly developed, imperforate, and looks like a large clitoris. The bifid scrotum, kept reddened and moist by the urine where its two surfaces come into contact, passes very well for a vulva, and, in this way, some of the so-called hermaphrodites are formed, the true sex perhaps only being discovered after adult age has been reached — when the beard be- gins to grow, and the testicles to develop. The monstrosity known as hermaphrodite does exist, but is excessively rare. To constitute a true hermaphrodite, there must be penis and testicle, uterus and ovary.' Hypospadias, anterior to the peno-scrotal angle, is more common than the scrotal variety, and most frequent of aU is hypospadias confined to the glans penis or its immediate vicinity. That part of the urethra lying between a hypospadial opening and the meatus is usually absent or impervious, but may be patulous for a short distance in front of the opening in the floor of the urethra, or even up to the meatus. Hypo- spadias, as commonly encountered in practice, consists of an absence of the fraenum preputii, and a flaring open of the meatus inferiorly, or an inferior opening in the canal within a few lines of the natural meatus, the position of which is usually marked more or less perfectly in its usual site. The glans penis may be bifid. The urethral orifice in hypospadias is small, as a rule. The only disturbances caused by hypospadias are functional. The patient may not be able to pass water without wetting himself, as in scrotal hypospadias, and if the opening is too low in the canal he may be impotent, from inability to throw the semen against the uterine orifice. Simple hypospadias rarely calls for surgical interference, and opera- tions which have been performed for its relief are not over-encouraging in their results — that is, in regard to restoring large portions of the canal — but rapid advances are now being made in this direction (Duplay). Hypospadias of the glans penis is unimportant ; many patients possess it without being aware of the fact. It may be necessary to enlarge the opening in case of stricture of the urethra, in order to intro- duce instruments of sufficient size to accomplish thorough dilatation, 1 Concerning hermaphrodism, may be consulted, with advantage, the extensive werk of Isidore Geoffroy Saint-Hilaire, " Des Hermaphrodismes : Hist. g6n. et prat, des Anoma- lies de rOrganisation," etc., 1836, vol. ii. ; and Art. "Hermaphrodism," Nouveau Diet. d« M4d. et de Chir. pratiques, 18'73, vol. xvii., p. 488. X HYPOSPADIAS— EPISPADIAS. 39 If a hole exists in the floor of the urethra, and the canal is found to be pervious in front of it up to, or nearly up to, the meatus, the case may be operated upon as if it were simple imperforation, and, after continuity of the canal has been established, the hole in the floor might be closed by a plastic operation (see Fistitla). Complications. — One complication of serious importance may occur with hypospadias, which always demands operation. It is where the corpus spongiosum and urethra are too short, so that, although the mea- tus urethrse may be found at or near the apex of the glans, still the short urethra acts like the string of a bow, and keeps the penis curved at all times, particularly during erection. The patient is usually retromingent. These cases are rare, but they have been operated on successfully.' Each operation must be modified according to the amount of de- formity. The indications are, to loosen the urethra and transplant its orifice sufficiently far back to keep it from exercising any traction when the penis is erect, and to incise the fibrous sheaths of the corpora caver- nosa beneath transversely, and freely enough to allow the organ to be straightened ; or even to divide the fibrous septum of the corpora caver- nosa with a tenotome, if it also is contracted (as performed successfully by M. Bouisson'' for curvature of the penis). This point of " straight- ening the penis " is important. If it be neglected, although the urethra may be liberated, still the penis will remain curved during erection, because the sheaths of the corpora cavernosa are contracted and indis- tensible. The bleeding is very apt to be troublesome in this operation. Acupressure was of service in arresting it in Weir's case. Flaps may be taken from the sides of the scrotum to cover the under surface of the penis, from which the urethra has been taken away ; and if, as in Weir's case, the patient desires to marry, an imperfect intromittent organ may be furnished him, which will put an end to his inability to cohabit, but not to his impotence. Epispadias {km, above ; and^iS, T separate) is a fissure of the supe- rior wall of the urethra with ectopia of the canal (Guyon). It is very rare. The urethral opening may be upon the glans, or anywhere along the top of the penis, as far back as its root. When the membranous and prostatic urethra are involved, there is also extrophy of the bladder. The orifice of the urethra in epispadias is large. Sometimes a finger may be passed through it into the bladder, that part of the urethra lying in front of the opening being an open gutter. Incontinence of urine is frequently observed when the opening is far back, especially if the pubic bones are separated. There may be complete epispadias without exstrophy of the bladder, Dolbeau' has published an autopsy of this condition, with plate. The 'One case by Dr. Weir, New York Medical Journal, March, 1874. ' Quoted by Guyon, op. cit, ' " De r^^pispadiaa, ou Fissure ur^tbrale sup6rieure, et de son Traitement," p. 46, Plate m. Paris, 1861. ^Q DISEASES OF THE UKETHRA. penis is short and thick in epispadias, or small and more or less devi- ated. The pubic bones are usually, but not necessarily, separated in complete epispadias. In such cases there may be hernia of the bladder, without positive exstrophy.' Epispadias is an arrest of development in the upper wall of the urethra, but it is still a matter of hypothesis how the lu-ethra gets above the vmited corpora cavernosa ; for, even when the genital buds, which are to form the corpora cavernosa, are stiU separate at the fortieth day of foetal life, the urethra is beneath them. The fact, however, remains, as proved by Dolbeau's dissection, that the lu-ethra gets above the cor- pora cavernosa, and fails to unite in its upper wall, the corpora cavernosa effecting their faulty union none the less. With exstrophy of the blad- der, where the lower part of the abdominal wall is absent, and the pubic bones do not come together, it is easier to understand how the roof of the urethra may be wanting throughout. Treatment. — Mature surgical judgment can promise little from op- erative procedure in epispadias. The adaptation of a proper urinal is the best treatment, either the model advised for exstrophy (Fig. 75), or the rubber urinal (Fig. 73). Operations which have been undertaken nearly always fail, erections and contact of urine, with smallness of the flaps, being the chief causes. The operations which have been most successful in covering over the canal are those of Nelaton and the modification by Dolbeau. They consist in freshening the edges of the flattened urethral furrow, and bringing down over it a quadrilateral flap of integument, which is adjusted, epithelium inward. The raw siu'face of this flap is in its tium covered by sliding flaps (epithelium outward), from the sides of the penis ; or by dissecting up a flap from the scro- tum, leaving it attached on both sides and running the penis under it, so as to bring the raw siufaces of both flaps into contact, separating the scrotal flap after firm union has been efi^eoted. Both of these op- erations have been successful in roofing in the canal, but the inconti- nence of urine has not been overcome.' XJRETHBAIi AND SEXTTAL HYaiENE. Before passing to the morbid conditions of the urethra, its hygiene in health and disease demands consideration. That the urethra may be in a healthful state, able to get well if dis- eased, and then to remain weU, two points must be observed. Thesf Bomprise fully the hygiene of the canal. They are : (1.) That the urine be non-irritating in character. (2.) That sexual excitability be quieted. ' Joum. de Med., Chir. et Pharm., p. 14, 1841. ' For minute details of the operation, see Nelaton, " Traits de Patbologie exteme " and Dolbeau. Th^se cit. UEETHRAL AND SEXUAL HYGIENE. 4] (1.) Urine, to be non-irritating, must be normal, faintly acid or neu- tral, free from sharp crystals, and not too concentrated. Hence meas- ures tending to bring the iluid to this state are hygienic. These meas- ures include general hygiene of the skin, stomach, muscles, lungs, etc., but also in many cases (especially where the subject is of gouty habit) certain dietetic precautions. The latter consist in the avoidance of all alcoholic fluids, especially sweet fermented wines and malt liquors. New ale is particularly harmful. All of these substances tend to create sharp crystals of uric acid in the urine, as well as to concentrate and acidify it. From this cause alone inflammation of the urethra may spring. Lemon-juice is also somewhat irritating to the urethra, as are, to a mild degree, all the condiments, salt, pepper, mustard, and, it is said, asparagus. In inflamed states of the canal, general hygiene prescribes rest. (3.) The quieting of sexual excitability is an object not less impor- tant, but far more difficult to accomplish. No part of the body can be in perfect health unless its function is being regularly and satisfactorily performed. This is seen in stomach, brain, muscle, excretory duct. For example, when all the urine escapes from the urethra, through a large fistula in the perinseum, the fore part of the canal contracts and becomes hyperaesthetic. The urethra, however, only performs the function of a sexual canal at longer or .shorter intervals. If there were no erotic fancies, the ure- thra would never be called upon to participate in the sexual function, and the latter would have no influence over its health or disease. In the eunuch the hygiene of the urethra undoubtedly does not include the sexual problem. If, then, the individual be absolutely pure in thought, word, and deed ; if he never have nor have had an erotic fancy, direct or remote, then his urethra would be a urinary canal, and its hygiene would be simple. But absolute purity is not a common attribute of man, as any one who has the honesty to accept facts must allow, and the rule that every male adult has more or less strong sexual longings and necessities must be admitted. Hence is established the rule, borne out daily and hourly by an intelligent study of the parts concerned, both in health and dis- ease, that the urethra is not in the best conditions for health unless the sexual needs are attended to. There is no possible means of accom- plishing this result except marriage. Fornication is always irregular, unnatural, often excessive, and therefore is harmful and worse than nothing, looked at from a merely worldly point qf view. Masturbation is degrading, and bears upon the whole well-being of the individual by ruining his morale. Nature's safety-valve, involuntary ejaculation during sleep, is inefficient. Marriage alone allows healthy, natural, un- stimulated sexual relations, and alone accomplishes the first necessity of urethral hygiene — namely, sexual quietude. Hence the value of mar- 42 DISEASES OF THE URETHRA. riage as a curative agent in morbid conditions of the urethra, especially if there be any nervous element in the case — an element which is almost invariably present in some degree. In all conditions of acute inflammation, sexual intercourse must be, of course, absolutely interdicted. Excessive indulgence is bad at any time, but worst of all is stimulation without relief. This state is, un- happily, a common one among the unmarried men of large cities. Such individuals, looking at suggestive pictures, reading exciting books, tak- ing part in impure conversation, become ripe subjects for nervous dis- ease of an obscure sort, not only of the urethra but of the whole body. In fact, this undue stimulation, without appropriate relief, is far more often the cause of hypochondria, melancholy, and functional perversion, than is the masturbation to which the public generally ascribe it. Nor can such an individual, by any plan of fornication, escape the evil con sequence to which stimulated but ungratified desire exposes him. Mar riage with a pure woman may right him — rarely any thing short of this. Hence when such a case presents itself where marriage is impossible, or if the patient be already unhappily married, there is but one course left to advise, and that is absolute continence and an effort at purity of thought, with strict avoidance of all possible temptations to erotic thought or act, whether entering through the mind, the eye, or the ear — whether actual or implied, direct or remote. Could such a patient imitate the heroic example of St. Augustine — a record of which that honest father of the Church has left behind — he could control the hy- giene of his urethra, and doubtless save himself much distress in life. INJITErES OF THE TJEETHRA. Injuries of the urethra, of seemingly an unimportant nature, often entail serious consequences. From the position of the canal, and par- ticularly from the fact that it runs along the middle line of the peri- nasum, it is more exposed to injury than any other portion of the genito- urinary apparatus. CoNTTTSioiT of the pendulous urethra is rare. If severe, it is fol- lowed by effusion of blood, hsemorrhage, inflammation, abscess, slough, and finally traumatic stricture — often by fistula, with loss of substance. Contusion of the deep urethra, on the other hand, is quite common. The sub-pubic ligament lies directly beneath the symphysis pubis, fill- ing up the angle made by the junction of the two bones. This liga- ment is nearly as hard as bone, while its lower edge is thin and sharp. In all falls upon the perinseum, the urethra lies between this sharp edge and the body upon which the individual falls. The injury to the urethra is in proportion to the force of the blow upon the perinseum. The canal may be entirely cut across, or more or less crushed trans- versely. Injury by violence to the perinseum involves to a greater oi CONTUSIONS OF TTRETHEA. 43 ess extent the membranous urethra and the bulb which partly overlies it. The immediate results are swelling, more or less escape of blood from the injured bulb into the surrounding tissues, often haemorrhage from the urethral orifice ; diflSculty in emptying the bladder, perhaps amounting to absolute retention; possible infiltration of urine; peri- neal abscess and fistula; and finally traumatic stricture of the most obstinate character. Injury to the perinseum is not uncommon at any age from falling astride a fence, while walking on it, a wheel, while mounting a coach, etc. In boys a kick in the perinseum is often suiE- cient to damage the canal permanently, without apparently occasioning any immediate injury. Treatment. — If the patient can pass water and there is no infiltra- tion of urine, no attempt should be made to introduce an instrument into the bladder immediately after contusion of the urethra, for fear of making a false passage at the injured point of the canal. All means, local and general, must be used to keep down inflammation. If, how- ever, there is retention, either immediate or secondary, from inilamma- tion, and warm baths, local fomentations, and opiates do not relieve it, an attempt should be made to pass a soft, French olivary catheter very gently into the bladder. Failing in this, a long filiform whalebone bougie may be tried ; and, if this pass, a soft catheter, open at both ends (Fig. 26), may be made to enter the bladder pushed along upon it as a guide. Should this manoeuvre be ineffective, a Thompson's probe-pointed silver catheter (Fig. 33), gently manipulated, is pretty sure to find its way in. If the bladder cannot be readily reached, peri- neal section should be at once resorted to, as this remedies the reten- tion, and is the best treatment for the traumatic stricture which will inevitably follow. If a soft instrument can be introduced easily, it should be with- drawn after the bladder has been relieved, and reintroduced when necessary. If much difiiculty is experienced in passing the catheter the first time, it should be tied in and left for a day or two, unless it causes the patient too much irritation, and then be withdrawn, cleaned, and reintroduced at intervals. As soon as the inflammation following the injury subsides, the passage of conical steel sounds must be com- menced, increasing in size until the largest instrument is reached which the meatus will admit, and this must then be introduced by the patient himself weekly for a time, and then at appropriate intervals for an in- definite period, to prevent recontraction of the traumatic stricture. If infiltration of urine has taken place, large, free, dependent in- cisions must be made in the scrotum and perinseum ; to let out the urine and prevent sloughing, the scrotum must be elevated, and quinine and iron promptly commenced and followed up, to combat further complica- tions. In this or any other condition of serious complication or diflSculty, the soundest surgery demands the performance of perineal section at 4^ DISEASES or THE UEETHEA. once, inasmuch as this course not only provides for a free issue of urine (infiltrated or not), but puts the urethra under immediate control, and includes the proper means of avoiding traumatic stricture. Wounds inflicted on the Ueethea feom without. — In children severe wounds in the perineal urethra may result from the breaking of the earthen vessel upon which they sit to empty the bowels and bladder. These may be followed by infiltration of urine with slouo-hing. Any part of the urethra is liable at any time of life to ordinary cutting injuries, inflicted by accident or design. Fracture of the pelvis, gunshot-wounds, etc., may damage the urethra very seriously. In a general way it may be stated that wounds of the urethra heal more readily in the perinseum than elsewhere (as illustrated by the median operation for stone), and are not apt, in this region, to be followed by fistula, unless there is some obstacle to the free escape of urine in front of the injury (stricture). Transverse wounds of any portion of the canal are followed by stricture (Reybard).' Longitudinal wounds, cor- rectly coapted, are not. "Wounds of the scrotum, extending into the urethra, are more liable than others to be followed by infiltration of urine, on account of the looseness of the connective tissue of the part. Treatment of External Wounds. — Wounds involving the perineal urethra, if the canal be healthy (cuts made for stone), and the incision nearly longitudinal, may be left to granulate without interference. If, however, the wound is transverse, it should be dilated systematically while healing, as after perineal section for stricture. Where the pendu- lous urethra is wounded, the following course should be pursued : Unite the edges of the wound, at once and very accurately, with the finest silk suture. Draw off the urine from four to six times in the twenty- four hours. The catheter should be small, so as to disturb the pro- cess of repair as little as possible, and it should be employed often enough to keep the bladder from becoming distended. Should the bladder fill, a little urine is apt to be forced along the urethra out- side the catheter, when the latter is introduced, and the object of using the instrument — ^to keep the wound from the contact of urine — to be frustrated. When the surgeon cannot see his patient often enough to empty the bladder regularly, a catheter of pure caoutchouc, of medium size, should be first introduced into the bladder, the wound united over it, and the instrument left in, corked, to be opened every few hours. It should be retained until healing is complete. A Holt's self-retaining catheter may be used, or an ordinary vulcanized rubber instrument (retained as described in Chapter X., Fig. 67). Neither a metallic nor a hard woven instrument should ever be allowed to remain tied in the urethra, except in fracture of the penis. They are too irritating for the delicate mem- brane, liable to provoke ulceration at certain points, if long retained; ■ " Traits pratique sur les EtoSoisaeraeuts de TUrSthre," Paris, 1858. UKETHRAL FEVER. 45 and should not be used if more suitable instruments are at hand. If the wound in the urethra fails to unite by first intention, the catheter should be withdrawn, and the fistula treated {see Fistula). Wounds nnrajCTED upon the Ueethea eeom within are main- ly such as are made by the surgeon in careless or rough manipula- tion (false passage), by divulsion of stricture, by internal urethrotomy, by lithotomy carelessly performed — especially in children where the urethra is cut or torn transversely — by the passage or rough extraction of stone fragments, the introduction of foreign bodies by the patient, etc. When such wounds occur, the urine comes in contact with the raw surface, and " urethral fever " is the common but not inevitable conse- quence. The more altered and decomposed the urine, the more liable is the patient to suffer. XXEETHEAL OR TJEINAEY FEVER. The uncertainty which surrounds that condition known as urethral fever has not yet been entirely cleared up. The recent and able mono- graph of Girard," the thesis of Malherbe," and the paper of Banks,' pre- senting new cases, collating old and advancing new opinions, may be consulted with advantage. The affection may assume either of four distinct types : 1. There may be a sharp chill, of longer or shorter duration, coming on anywhere within the first twenty-four hours (occasionally later), after manipulations upon the urethra or bladder, attended by an elevation of the temperature, and followed by fever (with perhaps delirium) and by sweat. After this there is no further trouble, or there may follow a number of days of general febrile excitement, malaise, inappetence, loss of strength, etc., and a slow recovery, or other paroxysms of chill and fever, with more or less complete intermissions, may ensue. This is the most common form. 2. There may be only a few slight rigors without much marked fever ' or any sweating — these passing off and leaving the patient as well as before. 3. There may be a distinct violent chill coming on rapidly, but of variable duration, attended by intense prostration, alarm, anxiety, and excitement at first, accompanied by violent vomiting, profuse diarrhoea, coldness, and lividity of the surface, almost total suppression of urine, all the evidences of uraemia, and a rapidly-fatal issue. 4. There may be slight chill and fever, followed by the (usually rapid) development of septicaemic symptoms and death, or, more slowly, by true pyaemia and death, the autopsy revealing abscesses in the prostate, ' " Resorption urineuse et Uremie dans les Maladies des Voies urinaires," Paris, 1873 ' " De la Fi6vre dans les Maladies des Voies urinaires." Th^se, Paris, 18'Z2. '"Certain Rapidly-fatal Cases of Urethral Fever after Catheterism." — Edinburgh 4Q DISEASES OF THE UKETHEA. kidney, liver, lungs, suppuration in the joints (knee, shoulder), fluid in the pleuras, pericardium, etc. All cases can be arranged under these heads. The first two are by far the most common, and fortunately so, since they are the least dis- astrous. That all these disorders should depend upon the simple absorption of urine through an abraded surface is in the highest degree improb- able. Other forces are at work, and these are probably shock and reflex action, suspending the function of the kidneys, often already diseased. The condition of the urine also has much to do with the origin of urethral fever. It produces no effect in contact -with a wound- ed surface, when it is normal, being sometimes used (in France) as a dressing to fresh wounds.' When in ammoniacal fermentation, it is undoubtedly capable, if absorbed, of occasioning septicaemic and pysemic phenomena, and, unfortunately, in bladder and urethral disease, the urine is very often more or less decomposed. The mystery about urethral fever is, why it does not occur more constantly, when the conditions are the same. The majority of patients escape, whether the urine is ammoniacal or not, whether the wound or the violence is great or small. The same patient may have a chUl one day and escape it after an exactly similar operation on the next, or vice versa. The simple gentle passage of a small soft bougie may give rise to it, while violent divulsion or urethrotomy, performed a day or two after- ward, may produce no such result, and again after divulsion, which has been negative, the passage of a steel sound may produce a chill. Nor is it instrumentation alone which is the exciting cause, since patients, upon whom no instrument has ever been used, have well-marked exacer- bations of chill and fever in connection with urethral and bladder dis- ease, and these patients cease to have chills (which they usually call '' dumb ague ") after the use of instruments in their urethra has dilated the stricture. Other patients have no chill until dilatation has reached a certain limit, after which every effort to pass an instrument of a larger size is liable to be followed by urethral fever. The extent of the injury done is no index of the amount of fever that will follow. The gentle passage of a smooth sound may cause speedy death, while extensive wounds and lacerations of the canal are often absolutely innocuous, and that, too, where the urine is strongly alkaline. The position of the injury inflicted by the instrument is of impor- tance. At and near the meatus no amount of wounding seems capable of giving rise to chill, though decomposed urine pass freely over the raw surface. The danger increases in proportion to the depth at which ' Dr. Partridge, at my suftgestion, injected sixty-minim doses of lealthy urine into tlie subcutaneous tissue of the arm of many patients at the Charity Hospital, in 1873 never exciting suppuration.— Z"eyCT. (See, also, note under Extravasation of Ueine). TREATMENT OP URETHEAL FEVER. 47 the injury is seated. Nor does a wound seem to be necessary at all, since cases are on record where death, following rapidly upon the intro- duction of a smooth instrument, has failed to reveal by autopsy any lesion of the canal. Here shock and reflex action arresting kidney secretion would seem to be the immediate cause of death. The chill may come on before the instrument used has been withdrawn from the urethra (Case XVI.), but usually it does not follow for some hours, and generally not until after urine has flowed through the canal. In the rapidly-fatal cases, old and often advanced kidney-disease, or at least intense kidney hyperaemia, is found on autopsy ; but in some cases these organs have been pronounced normal. Even in these latter there has usually been suppression of urine ; but simple suppression of urine does not often kill in one or two days, and, to solve the problem in these cases, we are forced to fall back upon the efiects of shock. Treatment. — The treatment of urethral fever is mainly prophylactic. The object is to avert chill ; for, after the latter has occurred, but little can be done to modify the paroxysm. After chill, morphine subcutane- ously produces quiet, and seems to bring on the sweating stage more promptly ; while, in ursemic conditions, every efibrt must be made by cups, baths, hot air, and cathartics, to stimulate the skin and intestine into action, and relieve the laboring kidneys. The prophylactic treatment of urethral fever is simple. Operations performed under the influence of an ansesthetic are perhaps less liable to be followed by chill. Operations should be avoided if possible upon patients who are found to have structural kidney-disease ; and, when surgical interference is unavoidable, particular attention must be paid to buUding up such patients, and exceeding gentleness employed in manipulating them. Where the urine is highly alkaline and decom- posed, more trouble is to be anticipated than where the opposite condi- tion obtains. Among medicines, quinine probably holds the first place for its power of averting chill. The free and prolonged use of this remedy, before and during the treatment of urethral and bladder disease, seems positively to lessen mortality, and averts complications after opera- tions, as proved by the testimony of almost all surgeons having the largest opportunities of observing this class of disorders. Yet quinine is not infallible, and will not always keep off (see Cases X., XI., and Xn.) chill ; but that it is useful in the great majority of cases there can be little doubt. In preparing for an operation, the patient may take five or ten grains night and morning for several days previously — and it is customary to administer ten grains with a quarter of a grain of morphine at the time of operation. Patients subject to mild re- peated chills should be kept upon quinine constantly during the whole course of active treatment. Quiet and rest in bed, immediately before and for some hours after an operation upon the urethra, should also be 48 DISEASES OF THE UEETHRA. insisted upon in cases where trouble is anticipated ; and, added to this, the relaxing influence of a warm bath is useful. The urine should also be rendered bland and dilute by the previous administration of demul- cents with a mild alkali, such as the citrate of potash. It is exceedingly doubtful whether any thing more than this can be done. Tying in a catheter will not avert chill, and is harmful in other respects. Drawing off the urine frequently through a catheter is usu- ally impracticable, and of doubtful efficacy. Gouley ' believes that he derives benefit (as a prophylactic) from ten-drop doses of the tincture of the sesquichloride of iron three times daily, and mentions favorably two-minim doses of Fleming's tincture of aconite, suggested by Long " as a preventive of chill. A few cases to illustrate urethral fever will at once make evident the difficulties which surround its study. The profession is familiar with Thompson's case,' where a man with old, tight stricture died on the third day after the passage of an instrument, which had been used upon him very many times before. Vomiting with severe chill came on in an hour — immediate suppression and death followed. Autopsy failed to reveal any lesion of the urethra caused by the instrument. The kidneys were intensely congested and soft. Among Velpeau's ' cases — ^which have become classical — no kidney- lesions were found in several patients who died in this sudden manner ; and hardly a year goes by that the medical journals do not furnish re- ports of further victims to urethral fever, some without, but the majority with kidney-disease. Finally, the following three personal cases are selected out of a num- ber as illustrating some of the uncertainties which surround the aifec- tion under consideration : Case X.^ — A gentleman of twenty-two, unmarried, strong, finely built, with' powerful frame and vigorous constitution, came from the country, in IS"?!, for treatment for trau- matic stricture, dating from a slight injury during boyhood — although the patient was not aware of this fact. Eight months previously, immediately after gonorrhoea (his first at- tack), he had retention. A surgeon to whom he applied broke one silver catheter in trying to force a passage through his tight stricture, but succeeded in reaching his blad- der with a small instrument on another trial, after employing much force, drawing, the patient said, a pint of blood. The next day, according to the patient, severe " intermit- tent fever " came on, which lasted three months. Attempts were made at catheteriam several times subsequently during the eight months, followed invariably by chill, fever, and sickness for two days. Sometimes chills came on when no instrument was used; Examination detected a stricture in the deep urethra, which would only admit a fili- form whalebone guide. A good many slight chills followed its introduction into the blad- der. There was a great quantity of blood and pus in the urine, so that examination ' " Diseases of the "Urinary Organs," 1873. ^Liverpool Med.-Chir. Jour., January, 1858. " " Stricture of the TJrethra," third edition, London, p. 94. * " Lemons orales d. Clin. Chir.," etc., Paris, 1841, p. 326. = This case is detailed at length in the report of the Proceedings of the New York Pathological Society (Medical Record\ 1873. URETHKAL FEVER. 49 failed to establish the presence of any kidney-disease — of which there did not exist the remotest symptom. No preparatory treatment was employed, no quinive taken ; but, on the fourth day, over a whalebone guide, Thompson's divulsor was passed through the stricture and screwed up to No. 20. (The meatus took No. 15 easily.) No chill nor the least unpleasant symptom of any sort followed. In a week the patient introduced No. 15 himself and left the city. He continued perfectly well, passing his instrument occasionally for eighteen months, when he again acquired gonorrhoea, and had to give up the use of his sound for two months. On resuming its use he only succeeded in passing No. 12 with force, causing much pain. Cystitis ensued. He returned to New York, demanding another operation, which should be more radical than the first. Only No. 6 would pass. Cystitis was pretty well marked. Blood and pus abounded in the urine. There was no evidence of kidney- disease. Fifteen grains a day, of quinine, were given to the patient for two days. He was put to bed and kept quiet. Urethrotomy (internal) was performed, a cut not a line deep being made. But little blood flowed. No ether was given. Five grains of quinine were taken after the operation. In half an hour severe chill, vomiting, and purging, came on ; total suppression, and death in thirty hours, in spite of vigorous diaphoresis and catharsis, and a slight rees- tabhshment of the urinary flow. Autopsy showed the right kidney somewhat atrophied, about two-thirds of the organ being the seat of parenchymatous nephritis. It was intensely congested. The left kid- ney was still further degenerated and more atrophied. There were several small abscesses in its walls ; its pelvis was dilated. The left ureter was absolutely occluded, one inch from the bladder, so that no fluid could be squeezed through it. The occlusion was mem- branous and did not seem very recent, but there was no hydronephrosis, and the urine in the kidney was not decomposed. The walls of the bladder were immensely hypertro- phied. Remarks. — The bladder-walls were one inch thick, evidently due to long-standing stricture, which had existed from boyhood. The atrophy and degeneration of the kidney were so far advanced that it seemed probable that they had at least commenced when the first operation (divulsion) was performed ; yet this violent operation, which tore the floor of the urethra, and brought a quantity of Mood, was the first time that an instrument had been used in the paiienfs urethra for a year without being followed by chill. A iiliform bougie, four days before, had produced numerous chills. On the other hand, the patient passes for himself, with violence, a No. 12 — produces cystitis, but no serious sjonptoms. Finally, a small out is made through the stricture, a small instrument only passed, and death follows in thirty hours, after severe chill and suppression. Case XI. — Mr. , married, sixty-one years old — a weak, thin, white-headed, old man — came for cure of a stricture of over twenty years' duration, which had been dilated some years before, but allowed to recontract. His condition was one of retention, over-distention, overflow, atony ; he constantly dribbled, night and day. A study of the case gave the impression that external urethrotomy would be unavoidable. Only the flnest whalebone guide could be passed into the bladder, and that with the utmost care and patience. By careful and persistent effort the stricture was dilated up to No. 3 (soft bougie) in three weeks. The first passage of No. 3 — in spite of three weeks of quinine — gave the old man a tremendous chill, coming on five hours afterward with vomiting, high fever, and prostra- tion, which confined him to bed for ten days. There was partial suppression during the 4 50 PISEASES OF THE UKETHRA. Srst twenty-four hours. The next instrument used was Thompsou's divulsor, over a whalebone guide. This was introduced at the office, without ether, rapidly screwed to No. 1, and withdrawn ; nrnch Hood followed. There was no chill, nor the least unpleasant symptom. Gradual dUatation (with steel instruments) was now resumed. On the Jirsi iniroduHion of No. 9, withimt any force, the patient being in fine condition— taking cod- liver oil and qumine daily— anomia about the condition. When this complaint has once complicated a gonorrhoea, the chances are that every succeeding urethral inflammation will be attended by its rheumatism, in spite of all efforts to keep it off. Fortunately all patients with gonorrhoea are not liable to this complication- — a small minority only is affected. An ordinary patient with gonorrhoea, even having a pronounced rheumatic diathesis, may expose himself to cold, moisture, and fatigue, without getting any rheumatism ; or, if he does get an attack, its course is not varied nor its symptoms modified by the coexist- ence of urethral discharge. It is, then, an individual idiosyncrasy which causes a patient with gonorrhoea to develop rheumatism, and not any tendency to suffer from the latter complaint. Women possess a strange immunity from gonorrhoeal rheumatism. They do suffer from it, but only exceptionally. It is supposed that the explanation for this may be found in the fact that the vagina and not the urethra is the usual seat of gonorrhoea in the female. Gonorrhoeal rheumatism resembles rheumatic gout more than rheu- matism. The local inflammatory character of the symptoms is usually inconsiderable, and the constitutional sj'mpathy is not of a severity proportionate to the trouble in the joints. The date of appearance of the rheumatic complication from the be- ginning of the urethral discharge is variable. It has been noticed as early as the fifth day, but usually does not come on tiU a later period. Fournier places the usual date of the outbreak between " the sixth and fifteenth day," rarely during the second or third month, or at any later period. The old idea, that the rheumatic complication is the result of a ' For bibliograpliy, see Art Medical, November and December, 1857, vol. vi. " Ob- servations et Materiaux pour servir 4 I'Histoire de I'Arthropathie blennorrhagiqne," Oh. Ravel, and fournier, he. cit. g2 COMPLICATIONS OF GONOKRH(EA. metastasis of the gonorrlicBa, is untenable. There is no diminution of the discharge previous to or coincident with the invasion of the rheu- matism, and there exists no indication to increase the urethral flovr and thus " save the synovial membranes." The discharge is not usually at all modified, although it is sometimes notably diminished a few days after the rheumatic symptoms have set in— which may be explained by the fact that the rheumatism keeps the patient more at rest, or, by the revulsive action which any intervening inflammatory aff'ection is liable to exercise over a purulent discharge. Where the complication co'mes on late in a clap, it has been observed that its advent is preceded by an exacerbation of the discharge for a few days. The seat of the disease is variable — joints taking the first rank ; the synovial sheaths of tendons and muscles the second ; then coming syno- vial bursas and nerves. The eye not infrequently suffers. The peri- cardium (Brandes) and meninges of the brain and cord (Ricord) seem to be involved occasionally. Concerning the joints, Fournier tabulates one hundred and twenty cases, of which thirty-nine are his own. The whole number of joints affected in these cases was two hundred and twelve ; the knee eighty-three times — over two-thirds of all the cases ; ankle, thirty-two times — about one fourth ; fingers and toes, twenty-five times — about one fifth, etc. The large joints, particularly the knee, are by far the most often involved, and, when the smaller joints suffer, they do so consecutively. The disease is rarely absolutely confined to a sin- gle joint ; but still it shows a marked tendency to be mono-articular. Fournier's division of the disease into three prominent varieties is con- venient and practical. The first form — a common one — is a hydrarthrosis, attacking usually the knee, sometimes the ankle or elbow. This form is generally mono- articular. It comes on insidiously ; but the effusion into the joint, which is usually considerable, may take place rapidly. The pain is slight, but is increased by walking, running, or moving the joint. There may not be enough pain to call the patient's attention to his joint, although this is unusual. The integument over the affected region preserves its color, and there may be no constitutional disturbance. The affection tends to remain indolent, and to undergo resolution slowly, lasting sometimes many months. The second form is more like ordinary rheumatism. More or less local and general febrile reaction is the rule, and this form is usually poly-articular and liable to be attended by trouble in the tendons, eyes, etc. The symptoms are like those of ordinary rheumatism, only more moderate. The pain, at first severe, is usually notably modified by rest — far more so than is the case with ordinary rheumatism. Constitu- tional symptoms occur ; but the fever is moderate, and subsides after a few days, while the local disturbance continues. This relative lack of proportion between the constitutional and the local symptoms is a strong GONOERHCEAL RHEUMATISM. g3 diagnostic feature of the malady in question. When only one joint is affected, there is sometimes a total absence of general symptoms. When several joints are involved, they become so, as a rule, consecu- tively. The malady, however, does not become so general as it does in ordinary rheumatism. It is more stationary, less mobile, does not jump from one joint to another. When a new joint is involved, those previously affected continue to suffer — with, of course, occasional excep- tions. Resolution is even more tardy than in ordinary rheumatism. A secondary hydrarthrosis, rare in simple rheumatism, is not uncommon in the gonorrhoeal, variety. The sweating, so constant in simple rheuma- tism, does not occur, even where there is a good deal of fever, or, if it does come on, it is of short duration. The acid concentrated state of the urine, found in simple rheumatism, is not noticed, nor does the blood show the same excess of fibrine. Finally, the pericardium, endocar- dium, pleurae, etc., are very rarely involved. Slow resolution is the usual termination of the disease, but articular pains, or very persistent stiffness, may be left behind ; or, more rarely, chronic hydrarthrosis, chiefly of the smaller articulations (Brandes), anchylosis, or even white swelling — the latter only in lymphatic or scrofulous patients (Sordet). Acute suppuration does not occur (Four- nier). The third form which the affection may assume is that of vague, ambulatory — sometimes very persistent — pains in joints, which do not appear to have suffered any structural alteration, and of which the function is undisturbed — the knee, wrist, shoulder, foot, and jaw. This pain, which may be the only symptom, is rebellious to treatment, and, after it has gradually subsided, is apt to return, if from any cause the amount of urethral discharge becomes increased. The synovial sheaths of the tendons of the extremities may be affected, either alone, or, more commonly, in connection with whatever joints are involved. There are tumefaction along the course of the ten- don, redness of the integument, occasionally very intense, if the tendon be superficial, severe pain on pressure, and partial or entire abolition of the movement of the muscle belonging to the tendon involved. This affection, like the others, undergoes gradual resolution. Hot local ano- dyne fomentations are indicated. The burs£E may also suffer. In this case we have an acute or sub- acute hygroma, which is peculiarly painful and sensitive to pressure for a long time. Two bursse seem most liable to the attack, the one lying between the tendo-Achillis and the os calcis, and the other situated beneath the inferior tuberosity of the same bone. This explains the pain in the heel, so often complained of by these patients — alluded to by Swediaur. Other bursse suffer, but more rarely. The actite S3-mptoms accompanying inflammation of bursse usually 8i COMPLICATIONS OF GONOREHCEA. nier ' mentions a case of gonorrhoea! hygroma of a bursa over the ischium, which he saw with Verneuil. The symptoms attending it were so severe as to lead these gentlemen to a diagnosis of deep sup- puration. They made preparations to incise the swelling, when a sharp pain suddenly appeared in the knee. The operation was postponed, in a few days the hygroma disappeared " with surprising rapidity," while the knee-joint became acutely inflamed. Evidences of muscular rheumatism may attend the symptoms of rheumatic trouble elsewhere. The nerves do not always escape. Fournier observed sciatica five times among his thirty-nine cases. Diplopia (Fournier), deafness (Swediaur, Fournier), and little superficial collections of serum near the affected joints (Fournier, Ricord, F6r6ol), have been mentioned as rare occasional complications. The following excellent table, arranged by Fournier, gives at a glance the characters distinguishing gonorrhceal from ordinary rheumatism : Oonorrhmal Eheumatiam. 1. Cause. — Urethral inflammation. No influence of cold in the production of the rheumatism. 2. Very rarely observed in women. 3. Non-febrile, or much less so than sim- ple rheumatism. Even in acute cases, reac- tion never attains the habitual intensity of rheumatic fever. 4. Symptoms habitually limited to a small number of joints. The affection never becomes general to the same ex- tent as simple rheumatism. 8. Less movable than simple rheuma- tism, going from one joint to another less quickly. No deUtesoence, no real jumping from one joint to another. 6. Local pains generally moderate, al- ways less than in simple rheumatism. Sometimes remarkable indolence. 7. Frequently a tendency to hydrarthro- sis, following the acute fluxion. 8. No sweating. 9. TTrine not modified. 10. Blood not furnishing a marked buffy- ooat. 11. Cardiac complications very excep- tional. 12. Frequent coincidence with a special ophthalmia, inflammation of the synovial sheaths of tendons, inflammation of bur- Simple Rheumatism, 1. No etiological relation with the state of the urethra. Habitual causes — ^cold, ia. heritance, rheumatic diathesis, etc. 2. Common in the female, although less frequent than in the male. 3. Eeactional phenomena much more in- tense and prolonged than in gonorrhceal rheumatism. 4. Symptoms usually involve a number, sometimes nearly all, the articulations. 5. Symptoms, movable — ambulatory fluxions ; rapid delitescence, jumpmg from one joint to another. 6. Pains always rather intense, some- times excessive, disappearing less rapidly than those of gonorrhceal rheumatism. 7. Little or no tendency to consecutive hydrarthrosis. 8. Abundant sweats, constituting a symp- tom almost essential to the malady. 9. Urine specially modified. 10. Blood forming » firm concave clot with bufify-coat. 11. Cardiac complications frequent. 12. Acute rheumatism does not aftecl the eye ; the bursae escape, as do usually the sheaths of tendons. GONOERHCEAL RHEUMATISM— TREATMENT. 85 Gonorrhmal Rheumatism. — {Continued.) Simple Rheumatism. — {Continued.) BiE, etc. The latter localities may be ex- clusively implicated. 13. Relapse in the course of Bucoessive 13. Relapse frequent, but always inde- gonorrhoeas very frequent. pendently of the state of the urethra. Treatment. — The ordinary treatment for rheumatism or rheumatic gout is not applicable. Local measures are of the first importance. In- ternal treatment is hygienic and rational, cod-liver oil, iron, quinine, tonics if required, and alkali, if the urine is over-acid, etc. The specific remedies for gonorrhoea are without effect over the rheumatism, but never- theless the urethral inflammation must be treated without interruption, As a rule, the sooner the urethra returns to a normal condition, the more effective will be the means iised against the rheumatism. Often, however, the latter will outlast the former ; but, at least, a relapse may be averted. On no account should the urethral inflammation be rekindled, if it shows a tendency to subside ; this practice has become obsolete by general consent. In all forms of the complaint, rest is of the first im- portance. During the more acute manifestations, the affected joint should be immovably fixed in a wire or other splint, and kept at perfect rest. Fifteen or twenty leeches locally applied, followed by hot nar- cotic fomentations, will usually speedily reduce pain, and bring the mal- ady to a subacute stage. A cathartic at the beginning will leave the patient more comfortable. The diet should be low while the patient is confined. After the more acute symptoms have subsided, and especially where there is effusion, the joint should be covered by a large blis- ter, followed by another as soon as the skin is dry, and perhaps a third. The blisters may be dressed with cerate, containing four or five grains of morphia to the ounce. As soon as pressure can be borne, the surface should be thoroughly painted with iodine, and firm pressure applied by means of adhesive straps encircling the joint, the whole limb, of course, being snugly bandaged. Obstinate cases, which resist treatment, are greatly benefited by a snugly-applied starch or plaster bandage. Sus- pension of the functions of a joint is of the first importance in bringing about resolution. Colchicum and iodide of potassium are rarely of any service. In chronic cases, and for the articular and muscular pains, Rus- sian and Turkish baths, with local douche, friction, and massage, render valuable service. GONORRHCEAIi OPHTHALMIA. There are two forms of ocular trouble caused by gonorrhoea. The first is rheumatic in character, nearly always (Ricord, Fournier), but not invariably accompanied by other signs of gonorrhceal rheumatism, hav- ing no connection with contagion as a cause, and affecting the mem- brane of Descemet, the iris, or the conjunctiva. Thp spnnnrl fnrm is coniimp.tivitis. dpnpTidi'ncr n.lwnvs; nnon nnntao*inn. gg COMPLICATIONS OF GONOEEH(EA. The distinction between these two affections should be kept constantly in view. Rheumatic Goxoeehceal Ophthalmia. — To Abernethj, Mackenzie, and particailarly Ricord, is due the credit of having first accurately de- scribed this affection. It is generally associated with the poly-articular variety of gonorrhoeal rheumatism. It may precede, or follow, the de- velopment of rheumatism elsewhere. Contagion will not produce it. Its essential cause is the existence of a urethral discharge. According to Fournier, it is more frequent than gonorrhoeal conjunctivitis, as 14 to 1 ; cold, fatigue of the eye, etc., have no power to produce it. An indi- vidual idiosyncrasy seems to preside over its appearance. Should it occur with one urethral inflammation, the chances are that it will reap- pear with the next. It is far more common in the male than in the female. Sometimes it appears to exercise a revulsive action upon the joint trouble, and vice versa, the one disappearing to be replaced by the other, but this exceptional. The rule is contained in Brandes's asser- tion, " There exists no other relation between gonorrhoeal ophthalmia and gonorrhoeal rheumatism than one of coexistence." * In brief, gon- orrhoeal ophthalmia is a localization of gonorrhoeal rheumatism upon the eye, all the rest of the body (perhaps) escaping. Symptoms. — Inflammation of the m,em,hrane of Descemet (aquo-cap- sulitis) is the most common form of attack. Here the conjunctiva is only moderately injected, the cornea is transparent, but more than usu- ally prominent. A cloudy, smoky appearance of the fluid of the ante- rior chamber is the most characteristic objective symptom. Sight is slightly troubled, objects looking misty. There is no pain, but some- times a sensation of uneasiness about the eye. Photophobia is absent or very mild. Sometimes there is a slight flocculent deposit on the pos- terior face of the cornea, with the escape of a little blood into the aqueous humor (OuUerier). The iris is unaffected, perhaps a little slow in its movements. There is no deformity of the pupil, no change in color of the iris, no other sign of iritis — ^points strongly insisted on by Cullerier.' When the iris is attacked, the symptoms do not differ from those of simple iritis ; redness of the cornea, radiate peri-comeal injection, con- tracted deformed pupil, sluggishness or abolition of the movements of the iris, change of color, effusion of lymph into the pupil, plastic depos- its in the anterior chamber, more abundant in gonorrhoea than in ordi- nary iritis (Mackenzie), obscurity of vision, photophobia, lachrymation, peri-orbital and occular pains. Fournier has described a rare conjunctival form of gonorrhoeal oph- thalmia. There are simple conjunctivitis, injection of the conjunctiva, ■ " Du Rheumatisme blennorrhagique " (trans.), " Arch. Gen. de M(5d.," 1854. ^ " Des Affections blennorrhagiques." Lecons cliniques publi^es par Eug6ne Eoyet Paris, 1861. r r o . GONORRH(EAL OPHTHALMIA. 87 oniform, or marked at certain points — the secretion is scanty, muco- purulent. There are slight, perhaps no lackrymation, a little itching about the eyes — sometimes absolutely no pain, photophobia, or altera- tion of vision, no symptom of iritis or of aquo-capsulitis. These varieties of ophthalmia, unlike the contagious conjunctivitis, are rarely mono-ocular ; when so, the form is usually iritis. Both eyes are rarely attacked simultaneously. After one has recovered, inflamma- tion may attack the other, run its course, and then return to the eye first involved. To get the disease the patient himself must have gonor- rhoea, unlike the conjunctivitis of contagion, which may be produced in any healthy individual by the mere contact of gonorrhoeal pus. Gonorrhoeal ophthalmia runs a rapid course, declining with unusual speed. It may last several weeks, or only a few days. Relapse is not infrequent. Of the three forms, conjunctivitis is the least harmful, aquo- capsulitis is not grave ; the iritis alone is liable to leave trouble behind in the shape of adhesions. Treatment is mainly expectant. The eye must be kept at rest in all cases. The best local applications are emollient lotions and collyria frequently used, warm water or steam — with atropine, in case of iritis. Astringent collyria are useless, even harmful. Irritating pediluvia, the judicious use of revulsive cathartics, and a low diet, constitute the gen- eral treatment. If the symptoms prove obstinate, the frequent applica- tion of small mild blisters to the temples and forehead is of service. In mild cases, patients do better if not confined. They may even attend to business, if the eye be kept covered. In severe cases, housing is neces- sary, local emissions of blood may be practised, and repeated purgation should be resorted to. When the peri-orbital and frontal pains are se- vere in iritis, large doses of quinine seem to be of service, with the local inunction of belladonna-ointment, or of a liniment composed of ol. menth. pip. four parts, chloroform and liq. ammonias, of each one part : or — 5 '■ Chloroform : tr. opii : ol. oliv., aa q. s. M. If the pains persist, in spite of these measures, codeine or morphine may be used at night, by the stomach, or subcutaneously. GoNOEEHCEAL CoNJUNCTITlTlS. — This terrible malady is fortunately rare. Its sole and only cause is contact of gonorrhoeal pus with the conjunctiva. It has no other relation with gxjnorrhoea than this, and may affect the surgeon or the nurse as well as the patient, provided only a little of the contagious pus touch the conjunctiva. Hence the necessity of forewarning patients of the danger they run in neglecting the most scrupulous cleanliness of the hands after dressing the penis, using injections, or passing water. For the surgeon, this precaution is equally necessary, together with the other one of burning all pieces of sponge, linen, lint, etc., which are brought into contact with gonorrhoeal pus, derived either from the urethra or the eye. If this be neglected, S8 COMPLICATIONS OF GONOKRHCEA. the subsequent use of the sponge on a healthy eye may carry the conta- gion to it, and give rise ta a dangerous malady. This disease is truly a gonorrhoeal conjunctivitis, and is easily sepa- rable from gonorrhceal ophthalmia, a disease impossible upon a given subject unless he is at the same time himself suffering from urethral in- flammation. The so-called sympathetic (metastatic), gonorrhceal oph- thalmia is of the latter variety, and should never be confounded -with true contagious conjunctivitis. Gonorrhceal conjunctivitis is rare ; of 37,034 cases of disease of the eyes treated at the New York Eye Infirmary, it occurred 59 times, once in 628 cases (Bumstead). It is much more frequent in the male than in the female, on account of the greater opportunities for contagion. The right eye suffers more often than the left, since most patients handle the penis, and rub the right eye, with the right hand. P6nanguer ' states the proportionate occurrence of the disease in the eyes to be four times in the right to once in the left. Tlie symptoms are those of purulent conjunctivitis intensified. The rapidity with which the symptoms aggravate is often appalling. The slight dry sandy feeling attending the first congestion of the eye is of the shortest duration, as is the secretion of tears and muco-pus. Within a few hours after contagion, the dischage is frankly purulent, and the inflammatory symptoms go on increasing rapidly in severity, until, in three or four days, often sooner, destruction of sight is inevitable. Some- times the safety of the eye is compromised in a few hours (ten to twelve). The vessels of the conjunctiva rapidly fill with blood, and its tissues become distended with serum (chemosis). The border of the infiltrated conjunctiva overlaps and partly conceals the cornea, the lat- ter lying, as it were, at the bottom of a cup filled with pus. The eye- lids have an erysipelatous redness, are very oedematous, and swollen. The upper overrides the lower. There is spasm of the orbicular muscle. Pus is retained in large quantities. Pain, ocular and peri-orbital, is often intense. The cornea soon falls into ulceration, if the chemosis continue. There is, first, a purulent infiltration between its lamellae, then softening and ulceration, superficial at first, and usually situated near the circumference of the cornea, perhaps obscured from casual inspection by the overhanging, chemosed conjunctiva. Tliis ulceration progresses rapidly to perforation, the aqueous humor escapes, perhaps hernia of the iris occurs. The cornea may be pressed out into an anterior staphy- loma, or be destroyed by the ulcerative process, or fall out, as a whole, like a watch-glass, allowing the contents of the eye to escape. The general symptoms are moderate. Fever is usually mild, except in rare cases of suppuration of the globe, and soon gives place to a nervous, depressed, irritable condition, attended by insomnia, agitation, inquietude, more rarely stupor. ' "De I'Ophthalmie blennorrhagique." Th^se, Paris, 1851. GONOERHCEAL CONJUNCTIVITIS. 89 Diagnosis. — The following table, prepared by Fouinier,' set? forth the distinguishing characteristics of the two ocular aiFections, liable to be found upon a patient with a urethral discharge. The distinctions can- not be too strongly insisted upon, on account of the liability to confu- sion of tfro conditions, one of which is so harmless and so little bene- fited by remedies, the other so destructive and so positively under the control of treatment. Gonorrhceal Conjunctivitis. 1. Essential cause — inoculation of the conjunctiva with gonorrhceal pus. 2. A rare affection. 3. May affect subjects not suffering from gonorrhoea. 4. Usually only one eye involved. 5. The symptoms are those of the grav- est kind of purulent ophthalmia. They af- fect the conjunctiva primarily. 6. Symptoms fixed, not going from one eye to the other. 1. No tendency to relapse in subsequent gonorrhoeas. 8. No coincidence with rheumatic mani- festations. 9. Prognosis excessively grave. Often loss of the eye. 10. The eye is only saved by a most energetic treatment. Gonorrhceal Ophthalmia. 1. Contagion plays no part in the pro- duction of the malady, which is developed under the influence of an internal cause, the nature of which is unknown. 2. An infrequent complication of gonor- rhoea, but still much more common than the contagious ophthalmia : : 14 : 1. 3. Only attacks patients already suffer- ing from gonorrhcea. 4. Commonly both eyes. 6. The symptoms are those of an inflam- mation of the membrane of Descemet, of an iritis, or of an oculo-palpebral conjunctivitis. 6. Sometimes the inflammatory phenom- ena are mobile, passing from one eye to the other. Y. Frequent relapses in the course of subsequent gonorrhoeas. 8. Coincidence with gonorrhceal rheu- matism very habitual, almost constant. 9. Prognosis without gravity. 10. Expectation, or the simplest treat- ment, sufficient for a cure. Prognosis. — When a severe purulent conjunctivitis develops in an individual with a urethral discharge, or even in a friend, especially if any history of contagion can be elicited, the prognosis is most grave. Unless an energetic treatment be instituted, the eye is lost, and, if aid come a little late, some lesion of greater or less severity and affect- ing vision is pretty sure to remain behind. Fortunately, both eyes are rarely involved. Treatment. — There is not a moment to be lost. Delay may sacrifice the eye. The essentials. »f treatment are four : 1. Relief of tension. 3. Relief of chemosis. 3. The early free repeated use of a strong cauterant. 4. Cleanliness. Each of these four is about equally important. ' " NouT. Diet, de Mdu, et de Chir. prat.," p. 261, 90 COMPLICATIONS OF GONOERHCEA. The greatest care is necessary in handling the tender, swollen eye. No pressure is allowable. The dressings should be the lightest pos- sible — even the pressure of the swollen lids upon the eye is prejudicial, and must be met by early, free canthoplasty at the external angle, an operation to be repeated if necessary. All the dressings should be per- formed by a skilled hand, else they will be inefficient. The utmost care should be used in protecting the sound eye from contagion. It may be hermetically sealed with lint and collodion where the nurse is not trust- worthy. Old soft rags are most suitable for wiping off the discharges, and these should be destroyed at once by fire. The pus retains its con- tagious properties for hours after it has dried, and fresh pus has been found to be still contagious when diluted with one hundred parts of water. The rapid and virulent nature of the inflammation occasioned by the contagion of gonorrhoeal pus has been amply demonstrated by certain oculists, who have treated pannus by inoculating the eye with this material for the purpose of exciting an acute inflammation. If the patient is seen early, before his symptoms have run high, and before the secretion is frankly purulent — within the first twenty-four, at most forty-eight hours — if he is robust, it is advisable to take three oi four ounces of blood from the temple, or mastoid process of the affected side, by leeches or cups. If the effect seem favorable, this local blood- letting may be repeated in ten or twelve hours, and even a third time if necessary. Irritant purgatives, and a low diet at first, are of advan- tage. Perfect rest of body, and, if possible, of mind, should be secured. The sick-room should be obscurely lighted. If the patient is not robust, not an ounce of blood can be spared, a laxative rather than a cathartic should be given, while the diet must be nourishing and supportive, even stimulating if there be much depression. Under no possible circumstances is a mercurial course advisable, or a continued depressing treatment harmless. The local treatment is the same for all cases. If the patient is seen very early, iced-water is to be applied locally upon a thin fold of cloth, which must be constantly changed. As soon as pus begins to form, a solution of gr. x to xx of nitrate of silver should be painted over the conjunctiva, and the iced-water continued. Every few hours the eye must be reinspected, and the nitrate-of-silver solution reapplied. As pus begins to form more abundantly, or if the patient is not seen until suppuration is profuse, the strength of the solution must be increased up to 3 j to the ; j, or the solid stick may be employed, being care- fully drawn over the entire ocular and palpebral conjunctiva. The cornea is of course spared in applying any caustic. After using strong solutions of the nitrate of silver, the excess should be washed away with a solution of common salt. The object of these powerful applications is, to restrain the forma- tion of pus and change the discharge into a sero-sanguinolent one. GONORRHEAL CONJUNCTIVITIS— TREATMENT. 91 They should be made sufficiently often, and sufficiently strong to pro- duce this eifect. The iced-water compress should be kept up for a num- ber of hours after each application, then the lids should be anointed with cold cream, and left uncovered, simply shaded from the light. Cauterization should be repeated whenever the discharge gets abun- dant and thickly purulent. The water or cerate will keep the outside of the eye reasonably clear, but the swelling of the lids and spasm of the orbicular muscle tend to confine much of whatever discharge there may be. Hence the value of canthoplasty. It allows dressings to be made easily, prevents the ball from suffering pressure (thus contributing to preserve the cornea), and makes cleanliness easy. The outer canthus should be con- tinued by an incision down to the bone. A skilled nurse from time to time should gently separate the lids, and squeeze a few drops of warm water into the eye from a soft rag, removing all external pus with the same cloth. A syringe should not be used to wash the eye, for fear of spattering. A mild solution of nitrate of silver, gr. v to x, is sometimes of advantage, dropped into the ej'e between the cauterizations. The treatment must be continued unremittingly, the eye, being washed, dressed, and inspected, every two or three hours, until the symptoms abate. An anodyne may be required, to produce sleep. Chemosis is treated by extensive and deep scarifications performed with the curved bistoury or scissors. These scarifications must be thor- ough. They should never be made before, always after a cauterization, otherwise the surgeon will have to wait some time for haemorrhage to cease, or he will not apply his cauterization thoroughly, and, furthermore, an unnaturally hardened condition of the conjunctiva is liable to be left behind by the healing of the scarifications, the surfaces of which have been cauterized down to the bottom. Some of the chemosed conjunctiva may be snipped away, but deep scarification with a bistoury, often repeated, is better. When the cornea becomes opaque, use atropine at once, and, with- out waiting for ulceration, puncture the anterior chamber, repeating this operation as often as the cornea becomes tense. It is better to do this, especially if there be ulceration, than to run the risk of hernia of the iris, or possible escape of the contents of the globe. Peri-orbital pains are combated as are those of gonorrhoeal oph- thalmia (p. 87). When the acuteness of the symptoms begins to subside, milder astringent collyria may take the place of the nitrate of silver ; such as — 5. Alum exsic, gr. yj-xij to the gj. or — 5. Zinci sulph., or — B . Sodae biborat., gr. v-x 22 STKICTUKE OP THE UKETHRA. These may be applied to the eye by means of any of the ingenious " droppers " which the shops afford, or, if the patient can slightly open and close the Uds, he may diffuse the solution over his eye by throwing back the head until the plane of the face becomes horizontal, then closing both eyes, and dropping a little of the solution (not too cold) over the inner canthus of the one to be medicated. Now, by several times rapidly opening both eyes to their widest extent and then shut- ting them, the fluid enters the eye and circulates over the globe. This method does not succeed with strong solutions, causing pain, and should not be used with solutions which stain the skin. Nitrate of silver should always be applied by an experienced hand, and be brought into contact with every portion of the conjunctiva. The inflammation once reduced to a subacute state, tends to get well slowly. The discharge drags along on an average for from two to four weeks — often longer. In these cases blisters behind the ears, on the temples, seton at the nucha, etc., have been recommended, together with plenty of good food, fresh air, tonics, stimulants, etc. Granular conjunctivitis and anterior staphyloma may be mentioned as not very rare complications of gonorrhceal conjunctivitis. They have no essential connection with gonorrhoea, and the student is referred for their treatment to works on diseases of the eye. CHAPTEE V. STRICTURE OF TEE URETHRA. Definition. — ^Varieties ; Muscnlar, Organic. — Organic Strictnre. — ^Form. — ^Number. — Seat. — The Lesion in Stricture. — Causes. — Time of Occurrence of Stricture. — Irritable and Resilient Strictnre. Ax unnatural narrowness of an}' portion of the canal of the urethra constitutes stricture ; or, since the urethra is naturally a shut canal. Sir Charles Bell's definition may be more accurate, and any loss of dilata- bility may be termed stricture. This contraction of the canal, following the first definition, to constitute stricture, must be unnatural, for the urethra has certain points of normal contraction — namely, the meatus and the beginning of the membranous urethra, and these are not strict- ures. They become so, however, if they are unduly small. Thus, an individual with an average-sized penis and urethra, whose meatus mil only take No. 8 or 9, has stricture (congenital) of the meatus, although he may never suffer any inconvenience therefrom. Again, any inflam- matory condition of the walls of the canal, or spasmodic contraction of the same, constitutes stricture, as does also any growth upon or beneath MUSCULAR OR SPASMODIC STRICTURE. 93 the mucous membrane — cancerous, tubercular, syphilitic, membranous, oolypoid.' A collection of fluid outside the canal may constitute stricture, abscess, serous or hydatid cyst, etc. — any thing, in short, which lessens the size of the canal when distended by the stream of urine — foreign bodies of course excepted. In all the last-named conditions, however, stricture is only an epiphenomenon, and not the disease itself. In this section, pure stricture only will be discussed. Stricture is of two kinds : 1. Muscular, or spasmodic ; 2. Permanent, or organic — the latter congenital, or acquired. Inflammatory stricture does not exist as a disease of the urethra. The smallest amount of in- flammation will lessen the calibre of the canal, just in proportion to the amount of turgescence of the mucous membrane ; but this is unimpor- tant. No amount of simple inflammation of the urethral mucous mem- brane gives rise to enough diminution of the size of the canal to occa- sion serious inconvenience (retention), unless occurring in connection with organic stricture, assisted by muscular spasm or complicated by prostatic congestion. A croupous membrane may exist within the urethra and obstruct more or less the flow of urine ; but this is exceed- ingly uncommon. Rokitansky " speaks of " very rare cases " where " we find primary croup occurring, on the urethral raucous membrane "—this chiefly in children. Membranous deposits may occur upon the surface of organic stricture, or behind it ; but these are not to be confounded with true croup. 1. MusouLAE OK Spasmodic Steictuee. — Spasmodic stricture is of the commonest occurrence ; but, as in the case of inflammation, un- less complicating preexisting organic stricture, it is usually an afiec- tion of no special importance. The predisposing cause of spasmodic stricture is a sensitive, high-strung, nervous organization, often in con- nection with an irritable, gouty, or rheumatic constitution, and par- ticularly in those whose sexual functions are not regularly exercised. The exciting causes are any local irritation, inflammation, foreign body, irritation of the rectum (reflex action), ingestion of certain substances, cantharides, turpentine, etc., mental emotions, malaria. The seat of con- traction is in the unstriped muscular fibres which surround the urethra at the irritated point (stricture, foreign body), or at the membranous urethra in the voluntary " cut-ofl^" muscle. The action of many of these causes may be readily illustrated. Take a nervous, excitable young man with a healthy urethra — a fortiori, with an irritable bladder or inflamed urethra — and attempt to pass a ' (Polypi very rarely grow in the spongy urethra. They are chiefly found — discovered after death — in the prostatic sinus ; sometimes in the fossa navicularig, where they can be felt and seen during life. Their symptoms are those of stricture. When within reach, they may be excised or torn away, and the base from which they grow cauterized. They seem always to spring from the floor of the urethra. — Beyran, " Polypes de I'Uretre chez I'Homme."— Caz. M'ed., 41, 1863.) ' Sydenham translation, vol. ii., p. 235. 94: STRICTURE OP THE URETHRA. bougie for the first time, and the chances are that it will be arrested. It may be grasped and firmly held at any part of the canal, but this is more liable to occur just as the instrument is entering the membranous urethra, where its point may be detained for many minutes by an in- voluntary contraction of the cut-off muscles. If the end of the sound is held quietly for a few moments against the contracting muscle, the spasm will j-ield and the instrument pass on into the bladder. Any for- eign body in the urethra is liable to excite this amount of spasm around it. If any portion of the canal is in a state of irritation, especially if shght organic stricture exist (this is a potent cause of spasm), some contraction is almost certain to take place at this point on the approach of an instrument, and to recur after the sound has passed along, giving the sensation of " grasping " or " biting " upon the instrument, which is so well marked in most strictures. The spasm caused by cantharides is attended by a good deal of con- gestion as well It is styled strangury — a term too well known to re- quire further comment. What surgeon has not witnessed spasmodic stricture, caused by modesty or shame, perhaps anxiety, fear, irritated mind (Cooper), as shown by the total inability of some patients to pass water before a class of students or even in the presence of a physician alone in his office.' In such cases there is not a failure of the detrusor urinse to con- tract, but there is failure of the compressor urethrse to relax. The pa- tient contracts his abdominal muscles and his diaphragm, and uses all his will, but to no purpose. Let the surgeon now gentlj' introduce a well-warmed and oiled catheter of medium size into the bladder, and the spirt that will follow, as soon as its eye touches urine, will easily convince him that there is no fault to find with the contraction of the detrusor. Whether malaria alone can cause spasmodic stricture is doubtful, but certainly there are two cases on record ' where spasmodic stricture occurred paroxysmally every twenty-four or forty-eight hours, and was cured by quinine after other means had failed. As instances of spasmodic stricture from neighboring irritation and reflex action, may be cited retention coming on suddenly in connection with inflamed hemorrhoids after operations near the anus, especially where the sphincter ani has not been paralyzed by section or stretching ; retention occurring ^vith irritable ulcer, or even from worms. Thomp- son, quoting Tuffnell,' gives a case where all the symptoms of stricture existed, and where a diagnosis of stricture of the membranous urethra ■ In one (persocal) ease, from this cause, a patient waited one hour and a half before he could pass water, and that too in a closet adjoining the office with the door partly closed. His bladder was moderately full, he had no organic stricture, and was doing his best. '^ Thompson, op. eit.; and B. Brodie, Medical Gaietle, vol. i., p. 107. ° Dublin Medical Press. ORGANIC STRICTURE. 95 was made, when it was discovered that the patient had tape-worm. The latter was treated, and after the worm had been discharged the stricture and its symptoms disappeared. Strongly concentrated acid urine may occasion spasmodic stricture in a gouty individual, attended by more or less congestion — perhaps posi- tive inflammation — and this all the more readily if there be a small amount of organic stricture. Certain forms of lumbar neuralgia attended by painful spasmodic contraction of the urethra have been described by Neucourt.' Diagnosis. — Spasmodic stricture always occurs suddenly, the stream of urine between the paroxysms being of normal size. This difference is sufficient to distinguish it from organic stricture where the stream is permanently small. Treatment consists in the discovery and removal of the cause, pay- i ig special attention to sexual irregularities, the gouty diathesis, con- centrated urine, and points of congestion, or commencing organic stricture in the urethra. Retention produced by simple spasm can al- ways be relieved by the hot bath, rest, and an opiate, or at once by an anesthetic and the catheter. Belladonna seems powerless. Peemanent ok Organic Steictuee. — Congenital stricture has been described (see Ateesia). Here we have to do with organic stricture, the result of a previous pathological process. FoEii OF Steictuee. — All strictures may be ranged under three heads : (a) linear, (V) annular, (c) tortuous. (a.) Linear Stricture. — Here the stricture is like what would be caused if a thread were tied around the canal (Fig. 24) ; or it may consist of a thin membranous diaphragm, with its orifice at the centre or on one side ; or be a crescentic fold or free band, encircling the urethra entirely or partially in a transverse or oblique direction. It is single or multiple. (5.) Annular Stricture. — This form is broader, as if a flat tape had been tied around the canal (Fig. 25). The term is applied to strictures not over a quarter of an inch long-. (c.) Tortuous or Irregular Stricture. — Here all other varieties come in. Such a stricture may be an inch or more long — even the whole pen- dulous urethra may be in a hardened, stiffened, narrowed condition. The amount of contraction in stricture varies from an almost im- perceptible narrowing of the canal to nearly absolute occlusion, so that, after death, it may be impossible to introduce even a bristle through it. Absolute occlusion does not occur except after the canal has been sev- ' ArcMv. Gen., July, 1858. Fig. 1i.—{Yoillemier.') 96 STKICTDKE OP THE UKETHKA. ered by an injury, and tlie urine has found an escape through the wound ; or where numerous large fistulas have long existed, giving exit to all the urine. The urethra in front of a stricture always continues pervi- ous, whether urine pass through it or not ; although, from lack of ha- FiG. 25.-(,Diitel.) bitual distention, its walls are liable to become somewhat rigid, sensibly diminishing the normal proportions of the canal. NuMBEE OF Steicttjees. — Stricture is usually single. Out of two hundred and seventy preparations, showing stricture, found in the mu- seums of London, Edinburgh and Paris, Thompson ' found, in two hundred and twenty-six cases, solitary stricture. Hunter saw, in a single urethra, six ; Lallemand, seven ; Colot, eight ; Leroy d'EtioUes, eleven — the latter on a living subject. Thompson has seen three — at most four — and believes that if more are found they must be considered as irregular contractions of the same stricture. Seat of Steicttjee. — Upon this subject the laborious investigations of Thompson, upon the two hundred and seventy specimens above re- ferred to, must be considered final, especially as daily experience with patients bears out the truth of his conclusions. He divides the urethra into three regions : 1. The bulbo-membranous, including one inch in front of and three- ' "Stricture of the Urethra," third edition, 1869. PROSTATIC STRICTURE. 97 quarters of an inch behind the junction of the spongy with the mem- branous urethra. 3. From the anterior limit of region one, to within two and one-half inches of the meatus, embracing from two and one-half to three inches of the spongy urethra. 3. The first two and one-half inches of the canal from the meatus. The two hundred and seventy preparations showed three hundred and twenty strictures. Eegion 1 contained 215 strictures — 67 per cent. " 2 " 51 " 16 " " 3 " 54 " 17 " There were 185 cases of one stricture only, situated in region 1. " « -^ly a u II a (( K 2 t( « 24: " " " " " « Q Thompson did not find in any preparation, or upon any living patient, or in any autopsy, a prostatic stricture. Walsh ' describes a stricture in the museum of the Royal College of Surgeons, Dublin, as commencing in the posterior part of the membranous and extending into the prostatic urethra. Leroy d'Etiolles^ says that he has in his collection one specimen showing prostatic stricture. Ricord ' narrates that he has encountered it, and Civiale * makes the same assertion. In brief, the situation of organic stricture is as follows : Most frequently in the bulbo-membranous urethra, sometimes as far back as the posterior part of the membranous portion — that is, at a distance varying from four and one-half to six and one-half inches from the meatus. Next in the first two and one-half inches of the canal, usually just at the meatus, or at the posterior limit of the fossa navicularis, and finally at some in- termediate point in the spongy urethra. Prostatic stricture, formerly considered so common, may be said practically never to occur. The frequency of stricture at the bulb and fossa navicularis is explained by the greater vascularity of these portions of the canal, and the greater amount of erectile tissue found there. It is weU known that gonor- rhceal inflammation tends to settle upon these localities, after the rest of the mucous membrane has returned to its normal condition. Injury inflicted by the rough use of the nozzle of a syringe, in injecting the canal, probably has something to do with the subsequent formation of stricture near the meatus. Traumatic stricture most often invests the membranous Tirethra, just beneath the sub-pubic ligament. The Lesiok in Steictuee. — The morbid change in organic stricture may be a mere thickening of the mucous membrane, the surface having lost its polish, being congested, and perhaps covered with granulations, ' Dub. Med. Press, January, 1856. " " Des R^tr^cissements de I'Urdthre," Paris, 1845, p. 83. 'Notes to Hunter on Venereal, second edition, Philadelphia, 1859, p. 168. * " Maladies des Organes genito-urinaires," sec. ed., Paris, 1850, toI. i., p. 168. 1 98 STRICTURE OF THE URETHRA. These changes are the result of chronic inflammation, and resemble those which occur in any teguraentary structure of the body which is kept in a condition of mild chronic inflammation ; namely, there is a proliferation of cellular connective-tissue elements and a consequent proportionate increase in the thickness, density, and inelasticity of the membrane. This process takes place just within and beneath the mu- cous membrane, and not on its free surface, as shown by A. Guerin,' who states that, in one hundred autopsies of patients with gonorrhoea, more than one-half of whom had stricture, he found the morbid process in these latter always to have acted immediately beneath the mucous membrane and in the spongy tissue. If the stricture is a little more ex- tensive, a few whitish transverse fibres will be found encircling the canal, beneath the mucous membrane. If more advanced stUl, the meshes of the spongy tissue will be found glued together, obliterated, and a mass of dense, fibrous, callous material encircling the canal and holding it permanently contracted. This tissue may be slight in extent, cicatri- cial in character, tightly contracted, or it may be exuberant, knobbed, and excessive in amount, so that it may be readily felt from the outside of the canal, having a cartilaginous or even woody hardness. In this callous, fibrous mass, the microscope detects no yellow, elastic fibres (Thompson). Flaps, valves, and free bands, adhesions, etc., are formed by atrophy of foEicles, or of portions of submucous tissue ; or the bands may be caused by the use of instruments in the canal — perforating a flap, for example. Cattse of SrEiCTTjEE. — Omitting congenital and other varieties of stricture already alluded to (cancerous, etc.), organic stricture is always caused by inflammation or a traumatism. Inflammation of the urethra is the most common cause, whether this be simple urethritis or gonor- rhoea ; but the latter is far oftener followed by stricture, and that simply because the inflammation is more severe and more continued. Of two hundred and twenty oases of stricture studied critically by Thompson, one hundred and sixty-four (seventy-five per cent.) owed their origin to gonorrhoea. The longer the duration of a given gonorrhoea the more certain is it to be followed by stricture. This is almost surely the case where gonorrhoea prolongs itself indefinitely iu the gleety stage, the latter condition being nearly conclusive proof of forming stricture. Gonorrhoea attended by chordee is more apt to be followed by stricture than are those cases where this complication does not exist. Should the chordee be " broken," stricture becomes inevitable, and that too of the traumatic sort. Any thing connected with urethral inflammation which indicates that the morbid process has extended outside of the mucous membrane, and has invaded the delicate meshes of the erectile tissue aiounJ the canal, warns us of coming stricture. The plastic exudation, • Zoc. di., p. 125. CAUSE OP STRICTUEE. 99 as it is called, once effused, glues the meshes of erectile tissue perma- nently together, and the cell-proliferation, starting with the urethral inflammation, goes on after the latter has ceased, making new fibroid material, of which the tendency is steadily and more and more to con- tract. Cicatricial tissue manifests this tendency to contract and obliter- ate the canal, even more strongly than the tissue formed by cell-pro- liferation after inflammation. Linear longitudinal incisions do not occasion stricture. Whatever contraction occurs in them, when they unite without loss of substance, being in a longitudinal direction, would tend rather to increase than diminish the calibre of the tube ; hence no stricture follows operations for stone (properly performed). Transverse incisions, on the other hand, are always followed by more or less strict- ure (Reybard).' If the incision only just open the canal, the amount of stricture wiU be inappreciable. If the urethra be partially severed, its upper wall being left intact, the contraction and subsequent strict- ure will be only partial, proportionately to the degree of section, and retention from such a stricture might never occur. When, however, the whole canal is divided across, then stricture, going on steadily to retention, is inevitable. Thus we may have a traumatic stricture giving scarcely anj' or indeed no symptom, and detected only by accident during a careful examination, although this is so rare as to be nearly hj'pothetical. For, even if only a portion of the floor of the urethra be cut across, yet the upper wall rarely escapes bruising, or injury of some 30rt, which may involve it in a chronic inflammation and overgrowth, causing it to assist in the formation of the stricture starting below. If the edges of a urethral wound slough from any cause, the subsequent stricture is by so much the more considerable. Any injuries of the canal, involving loss of substance, produce strict- ure. To this class belong urethral chancres and ulcerations, gangrene from crushing or following phlegmonous erysipelas or infiltration, ulcers produced by prolonged pressure, stone, retained catheter, etc. But classical traumatic stricture, such as it is the rule to encounter in practice, is formed most often low down in the canal (farther frorn the meatus than strictures produced by clap), involving the membranous urethra, and generally caused by a crushing injury to the perineeum. The urethra in this region is particularly exposed to contusions. It is fixed and cannot get out of the way, and the sharp edge of the sub-pubic ligament has a great deal to do in the causation of the injury.^ ' "Traits pratique de Retrecissements du Canal de I'Uretre." Argenteuil Prize, 1852. " In January, 1866, assisted by Dr. Gouley, I endeavored to demonstrate, upon the 'irethra of the cadaver, the effect of blows inflicted upon the perinjeum with a bluntish instrument. The subjects were placed upon the back, the legs moderately separated, and the blow administered by Dr. Gouley, standing over the cadaver, and using the broad base of a common axe. The effect of the blow was always found, upon subsequent dissection, to have expended itself upon the urethra, directly beneath the edge of the Bub.pubic ligament. The injury inflicted varied with the force of the blow. The bulb was always contused, but, unless the force of the blow was considerable, the mucous IfjQ STRICTUEE or THE URETHRA. The injuries wliicli have been reported as causing traumatic stricture in the perinaeum, with or without a penetrating wound, are innumerable. Among the most classical may be mentioned falls from a height, the patient lighting astraddle a beam, a chair, a stump, a manger, the limb of a tree, the corner of any blunt object, a tnmk, a box, etc. ; falls astraddle a fence while walking upon it, of a wheel while mounting an omnibus, of the tongue of a wagon ; falls upon a sharp object, as a chisel, the breakage of a chamber-pot upon which the patient has been sitting ; falling with one leg through a hole in the ice, or down a coal-hole in the sidewalk; being thrown forward upon the pommel of a saddle, while riding ; fracture of the pelvis, kicks in the perinsEum from man, woman, child, or beast, etc., ad infinitum. This, perhaps, unnecessarily minute detail of injuries capable of causing stricture is given, because they are all occurring constantly. The authors have seen cases from each cause, and very many from some of them. They are very liable to be overlooked by the patient when, at the time, they do not give rise to haemorrhage or retention. The injury is often slight, not causing much immediate disturbance, and the patient forgets it ; he never has a gonorrhoea, perhaps, and yet in after-years symptoms of stricture come on, and the canal is found highly contracted at its membranous portion ; or, in trying to relieve retention in fever, the physician finds his cathe- ter unexpectedly arrested. In these cases, a strict inquiry into all ante- cedent injuries of the perinseum should be made, in order to get all the information possible upon the nature of the stricture. Traumatic strictures are particularly liable to be sensitive, irritable, and resilient, and usually require harsher means of treatment than ordi- nary dilatation, and the employment of more persistent and intelligent measures to prevent recontraction afterward, than most strictures from other causes. Hence the imperative importance, in these cases, of in- sisting upon an intelligent use of the full-sized steel sound by the pa- tient himself, for an indefinite period of time after cure — generally for the remainder of life ; a task certainly irksome and disagreeable, but no more so, and no less necessary, than a truss to the ruptured, spectacles to the weak-sighted, an artificial leg to replace an amputated one, and certainly more necessary and less irksome than the daily use of the razor. The only treatment of gonorrhoea which may cause stricture is the use of injections. The nozzle of a syringe, if long or roughly used against an inflamed mucous membrane, may irritate it sufficiently to keep up local inflammation, until it becoilnes chronic, and passes on to that cell-proliferation and thickening which constitute stricture. lin- ear strictures of the first half-inch from the meatus are doubtless often _ caused in this way. Secondly, too strong injections may cause stricture, membrane of the membranoua urethra escaped injury. Sometimes the membranous urethra beneath the sub-pubic ligament was partially lacerated, and sometimes totally severed ; but this required a very forcible blow.— Vak Bpeen. STEICTUKE— DATE OP APPEAEANCE. IQl usually situated from two to four inches down tlie canal, rarely lower. The rdle of injections in producing stricture has been doubtless over- rated ; probably none of the fluids ordinarily used are able to occasion it, unless employed of very unusual strength. But, granting thait gon- orrhoea alone is amply sufficient to cause stricture, yet it is a singular coincidence, to use no stronger term, that most patients possessing par- ticularly tight resihent stricture, not due to injury, but yet behaving as if they were traumatic, with a very sensitive, hypersesthetic urethra in front of them — that most of these patients have used strong injections of the nitrate of silver, in attempted abortive treatment, or with the idea of " burning out " the disease — injections strong enough to bring blood freely, often to be followed by several hours of severe urethral pain. As a general rule, it may be stated that any injection strong enough to produce either of these two results (blood or subsequent prolonged pain) is capable also of originating organic stricture. The opinions of the profession, regarding the instrumentality of injections in causing stricture, have varied. Formerly it was believed that injec- tions of all sorts produced stricture ; but soon it was noticed that, although no injections were employed, still stricture continued to fol- low gonorrhoea. Then all rdle of causality was denied to injections, of whatever nature, and however used. But a pretty extensive experi- ence seems to justify the placing of the truth between the two extremes, attributing the bad effects of the remedy only to its excessive strength, nitrate of silver being most often to blame. Time of Occtjeeencb of Steictuke aitee Gonoeehcea ai^^d Injuet. — Of the 164 cases of stricture following gonorrhoea, tabiilated by Thomp- son, in 10, symptoms appeared immediately after or during the attack ; 71, within one year ; 41, between three and four years ; 23, between seven and eight years ; 20, between eight and twentj^-five years. J. D. Hill,' from 140 cases of stricture from all causes, makes the length of the period, between the cause and the first symptoms of stricture noticed, to be : after gonorrhoea, shortest period two years ; longest, thirteen years — after urethral chancre, shortest period ten months ; longest, three years — after injury, shortest period four months ; longest, eighteen months. The statement in the latter table of statistics, doubtless lit- erally correct, tends to mislead. Ater . a traumatism, of the crushing kind, to the perinasum, for instance, the classical course of events is as follows : From oedema and efiusion of blood, at first, there is more or less ob- struction to the flow of urine ; perhaps, if the canal is severed, there is retention. If the latter has not occurred, inflammation comes on, and the' size of the stream is still further diminished. Now inflammation subsides and repair begins, and, with this repair, contraction goes hand- in-hand. Consequently, after a transverse or crushing wound of the ' "An Analysis of 140 Cases of Stricture of the Uretlira," London, 18T1. 102 STRICTURE OF THE URETHRA. urethra, where repair begins stricture commences. It may not manifest itself by retention, or, indeed, by any symptom which the patient ob- serves for four months or for several years, but it is there none the less. If the injury has been slight, or the canal only partly involved, no appreciable symptom may occur for years (ten or twelve), as when boys have been kicked at school, have fallen on a fence, or been thrown upon the pommel of a saddle. The point of importance is this : traumatic stricture comes early because the violence causing it is greater (usually) than the violence of simple inflammation of the urethra. Let the vio- lence be trifling, and the interval may be exceedingly long. With this understanding, then, the deductions to be drawn from the above statistics are confirmed by daily observation : namely, that the symptoms of stricture appear earlier after a traumatism than after gonorrhoea, the date of their appearance measurably proportionate to the extent of the injury, and that the greatest divergence is noticeable after gonorrhoea. It is totally exceptional, however, for symptoms of organic stricture to come on " immediately after or during the attack " of gon- orrhoea — as Thompson states occurred in ten of his cases — unless stricture existed previous to the attack, unnoticed by the patient, as sometimes undoubtedly occurs {see Case X.). Ieeitable aot) Resilient Steictdbe. — A stricture is said -to be irritable when it is sensitive, easily excited to inflammation from slight causes, rebellious to the use of instruments, fretting as it were under their employment. A resilient stricture (so named by Syme) is one which, without being necessarily irritable, is elastic. India-rubber-like, contracting quickly after being dilated, sometimes to an extent greater than existed before the use of the dilating instrument (see Case XV.). Traumatic strictures are sometimes of this type, as are strictures toUow- ing strong injections of nitrate of silver. CHAPTER VI. STRICTURE OF TEE URETHRA. Instruments and their trso.— Filiform Bougies witli Manoeuwes alone, and as Guides.— Bougies.— Bulbous Bougies.— Oathetere.— Sounds.— Scale.— Advantages of Steel Instruments,- Instruments for Divnlsioa ■with Manceuvres.— Instramenta for Internal Urethrotomy -with ManocUTres.— Perineal Urethrotomy ■with and ■without a Guide.— Eectal Puncture.— Supra-pubio Puncture.- Dieulafoy's Aspirator. Befoee passing to the diagnosis, symptoms, and treatment of strict- ure, it is better at once to describe the instruments to be used, the methods of manipulating them, and the operations in which they are employed, in order to avoid endless repetition. Great mechanical ingenuity has been displayed in the construction INSTRUMENTS— BOUGIES. 103 of instruments for the detection and treatment of stricture. Such of them will be mentioned as are considered best suited for these objects. Space will not allow a description of more than the tjpe instruments of each class. The instruments which it is necessary for the surgeon to possess in order to be able to meet the requirements of all cases of stricture are : different varieties of bougies, sounds, and catheters with a scale ; instru- ments for divulsion, internal and external urethrotomy ; trocars, canulae, and an aspirator. BOTJGrES. FiLrPOKM OR Haie-like Bougies are such as measure one millime- tre or less in diameter — size No. 2 (one millimetre diameter) being the smallest size that can be accurately measured on a scale-plate. There are three varieties of filiform bougie : the French, English, and whale- bone. They are all made conical, narrowing down to a fine point, and gradually increasing for an inch or two until the full size of the shaft is reached. The whalebones are olive-tipped. Fbench Filifoem Bougies are of three varieties. They are black, and made of a gummy material spread smoothly over a woven frame. Some are entirely so composed, and in choosing these it is well to select the stiffest. Others are furnished centrally with a fine copper or lead wire running down to the point. These can be bent and twisted into spiral form at their extremity, to facilitate introduction, and avoid lacu- nsB and false passages ; while in the third variety (Benas bougies) the central wire is replaced by a fine whalebone shaft to give it greater firmness. Of these bougies, the first named, those without any central shaft, are often provided with a little metallic cap upon one end, furnished with a female screw, so arranged that it may be screwed upon the end of another instrument. By means of this ingenious device, when one of these bougies has been made to penetrate a stricture, and has reached the bladder, some other instrument which it is desirable to use for rup- turing or incising the stricture, or drawing the urine, may be screwed into it and then pushed forward, following its guide through the stricture into the bladder. The filiform bougie coils up in the bladder, doing no harm there, and is withdrawn with the larger instrument. The device is due to Maisonneuve ; it has been largely applied by others. Yellow JSnglish filiform bougies are used in the same manner. Two cautions are necessary in regard to the employment of this species of urethral guide : 1. The little metallic cap upon the bougie should always be examined before it is used, to make sure that it is firmly attached to the bougie. They become loosened by time, and, if a defective instrument be used, there is danger of leaving the bougie behind in the bladder. 104 STRICTURE OF THE URETHRA. 3. If the stricture be very tight, it will sometimes happen that, after the instrument, which has been screwed into the bougie, has followed its guide up to the strictured point, the metallic cap of the latter will refuse to enter there; the bougie will double up just in front of the cap, and, if force be used, a false passage will be made alongside of the stricture. The English bougies are stiffer and less liable to this accident than the French. The deduction is, use the utmost gentleness in following the guide into the bladder, and, if the screwed instrument does not run smoothly along, desist, and choose some other plan for overcoming the obstacle. Soft filiform bougies are also constructed two feet long, to serve as guides, by being introduced into the bladder, and then threaded through a soft French gum-elastic catheter open at both ends (Fig. 26). Over such a [j guide a catheter may sometimes be safely conducted into the bladder. The same device is employed by the French in the shape of a small flexible catheter, pro- vided with a filiform point eight inches long. The point is introduced as a fili- form bougie, and the catheter pushed after it into the bladder. This is equiv- alent to the other device of a conical catheter, so arranged as to screw into an armed (screw-tipped) filiform bougie (Fig. 27). The Exglish Fuxfokm Ixsteuitents are a little stifFer than the French. They Fig. 26. are of a yellow color, made of a woven fab- ric, and covered with varnish. A modifi- cation has recently been introduced into such of these in- struments as are designed to serve as conductors, in order to prevent the tendency to double up in front of the stricture in the manner above narrated. This \ modification consists in the insertion of a piece of whalebone into the axis of the instru- ■ — ^s^ ment for an inch or more in front of the cap, so as to give it additional firmness at this point. , Whaxebone Fiufoem Bougies are thin, haii^ i'"ie- 28. like strips of whalebone, very smooth, conical, with slightly bulbous points. By dipping them into hot water, the end may be variously shaped (an expedient employed in difficult catheterism in the last century) — twisted into spiral, bent into zigzag (Fig. 28), a modification which is of vast assistance in threading tortuous strictures and escaping false routes and lacunae. Fig. 27. filiform: whalebone bougies. 105 The instrument may be rotated during its passage, and its point be thus presented at different portions of the circumference of the canal, BO as finally to engage it in the orifice of the stricture. These bou- gies, about two feet long, are also used as guides for larger instru- ments, not by being screwed upon them, but threaded through a metal- lic loop made for the purpose, upon the under side of the instrument which they are to guide — an adaptation of Desault's principle — the lat- ter being known as "tunneled" instruments." Whalebone instruments are easy of introduction, and capable of rendering most important ser- vice as guides, but three cautions are necessary in their employment for this purpose : 1. The guide should be two feet long. No cracked, bent, fissured, or frayed-out instrument should ever be used. 2. In employing a whalebone as a guide, it should be first introduced into the bladder, then threaded into the instrument to be guided, and the latter pushed gently down to the strictured point, while the whale- bone is held stationary at the meatus. If force be used here, the slender gtiide may double up and a false passage be made ; but this may always be avoided by gently and continuously retracting the guide, as the con- ducted instrument is passing the dangerous point, and until it reaches the bladder. The length of the guide (two feet) easily allows this to be done. 3. The loop of the instrument to be conducted should always be amply large, and be smoothed off in front so as to have a rounded and not a cutting edge ; and, if the movement of extracting the guide, as the tunneled instrument is being introduced, cannot be performed as above described, both instruments should be withdrawn ; for, if the one be pushed forward forcibly, or the other pulled back, there is danger of cutting off a portion of the whalebone and leaving it in the canal— an accident which has occurred in very competent hands. Whalebone bougies may be made of any size. The larger ones are useful in treating strictures situated in the pendulous portion of the canal. Gutta-percha bougies should never be used in the urethra. They become brittle by age, and are liable to break. Mancbuvees. — Regarding the method of introducing filiform bougies, a few words will suffice. Their fine points are liable to catch, chiefly in the lacuna magna (Fig. 8), but also in any of the numerous sinuses of Morgagni, in any false passage, or against membranous bands and folds of the urethra, in the tortuous turnings of a stricture, or in the softened reticulated membrane behind it (Fig. 39). With the whalebonfe bou- gie—often with any filiform instrument — these obstacles may be gen- erally surmounted. There are two special manoeuvres for accomplishing this: 1. When an instrument catches, partially withdraw and slightly ' Refer to note uoder " Perineal Section with a Guide." 106 STRICTURE OF THE URETHRA. rotate it, pusHng it forward whHe making the rotatory movement. This device rarely fails in finaHy engaging the instrument m the orifice of the stricture, especially if the filiform point be bent or twisted m any direction (spiral, zigzag), so that its extremity may lie outside of the axis of the shaft of the instrument (Fig. 28). 3. An excellent method of finding the orifice of a stricture, especially where false passage exists, consists in cramming the urethra fuU of Tia. 29 (Dittd). -Sliowlng LacanfB and False Passages In which the Points of Filiform Instruments are liable to be caught. filiform bougies, engaging their points in all the lacunae and false pas- sages, and then trying them, one after another, until that one is pushed forward which is presenting at the orifice of the stricture, when it will at once engage. The use of filiform bougies in threading tight strictures is greatly facilitated by first injecting the urethra full of warm oil. Filiform bou- gies, intelligently used, make impassable strictures the greatest rarities in a surgeon's practice. Bougies. — Of other bougies (not filiform) the French and English conical only need be described — the blunt are not useful, nor are the olive-tipped of as much service as the simple conical. French conical bougies are black, woven, and covered with gum. They come of all sizes, and are necessary in the treatment of stricture up to size 8 or 10. The olive-tip is of advantage in the large, objectionable in the small THE BULBOUS BOUGIE. 107 sizes. When choosing olive-tipped bougies, preference should be given to such instruments as are rather stiff, but have a long, slender, flexible neck, supporting the bulb. When held vertically, bulb upmost, and touched upon the olivary tip, the neck should yield at once (Fig. 30, A). Such an instrument will guide itself safely and override obstructions. Fio. so— A. Fig. 80— B. The olivary points found on the English conical bougies are useless, as far as any advantage derived from the bulb is concerned, from a neglect to make the neck of the instrument flexible (Fig. 30, H). English yellow bougies are smoother and stifier than the preceding. They keep much better in the changeable climate of New York. All of the foregoing instruments are introduced without a stylet, by simple direct pressure with (perhaps) rotation. The Bulbous Botjgie {bougie-d-boule) is an instrument essentially necessary for the accurate diagnosis of stricture. They are found of French and English make. The latter are apt to be too stiff. They consist of a flexible, woven shaft, headed by an acorn-shaped extremity, of a diameter much greater than that of the shaft. They are sized according to the diameter of the head. A set of them, running from 3 to 20, is required. Any thing too tight for 3 (IJ mill, diam.) may be said, practically, only to admit a filiform instrument (size 1). In choosing bulbous bougies, they should be selected with nicely conical short head and an abrupt shoulder (Fig. 31).' Instrument-makers have them of all varieties, with very pointed, even oval heads and no shoulders — occasionally with two or three bulbs. These are not useful. For economy's sake, an instrument with fixed curve has been constructed of steel, having a small shaft, and terminating in a screw upon which may be screwed acorn-shaped heads of different sizes, also of steel. This instrument is better than no bulb- ' For the method of usins the bulbous bougie, see Diagnosis of Strioiurb. rio. 81. JOS STRICTrEE OF THE URETHRA. ous sound at all, but not much superior to an ordinary blunt sound. It is too clumsy for delicate manipulation. MetalUc bulbs on slender ■wires are better, equally durable, and excellent for the pendulous urethra ; but the woven French instrument is more delicate, and the best for all cases. It may be said at once, of all woven instruments, that the English are more durable and easier to keep than the French. The latter will not stand the heat of a New York summer, unless specially protected. They soften and stick to each other and to the case in which they are kept — thus becoming ruined. This may be prevented by dusting them with French chalk or keeping them in a cool place, in hot weather. CATHETERS. Silver catheters do not wear out, and it is well to have a case of them on hand, of short curve, from size 7 to 14. They should be made slightly conical, and have a flattened wooden or other han- dle, to facilitate manipulation, marked with its number on the side of the handle corresponding to the concavity of the curve of the instrument. The handle should be immovable on the shaft, at right angles to the plane of the curve of the instrument (Fig. 33). No one not accustomed to manage difficult cases can use a silver catheter without a guide of a less size than No. 6 without risk of false passage.' English yellow elastic catheters of small sizes, conical, without bulbous point, may be useful in the treatment of stricture where the expulsive power of the bladder is de- fective. Three varieties of French flexible catheter may be mentioned : the flexible olivary, particular attention being given, in choosing the instrument, to the flexibility of the neck (Fig. 30 A) ; the flexible catheter, open at both ends (Fig. 26) ; and a flexible instrument armed with a metallic tip, to be screwed upon a filiform guide (Fig. 27). All soft catheters should be introduced without a stylet, in ordinary cases. Thompson's 2)robe-pointed catheter is an instrument very useful m skilled hands, very dangerous if not judiciously • managed. It is made of silver, from size No. 3 to any size desired. It is conical, and should be eleven inches long. Those of EngKsh make are too short. The last two inches beyond the eye are of solid soft Ke. 32. silver, much smaller in size than the shaft of the catheter, and slightly olivary at the tip ; in fact, it is a malleable silver probe upon the end of a small silver catheter. The ■ Nothing short of fracture of the penis, where compression is needed, will justify the tying into the urethra of a metallic instrument for more than a day or two at most. If THOMPSON'S PROBE-POINTED CATHETER. 109 probe may be bent to any desired curve. For greater security, a rod of metal, exactly filling the calibre up to the solid probe-point, may be screwed into the catheter, making it practically a solid silver probe- FiG. 33. Fio. 84. Fig. 35. pointed sound (Fig. 33). There seems to be some danger of the break- ing of this instrument at the eye, unless care be used in bending it. Con- sequently it has been modified by Otis, by being made hollow through- this rule be neglected, ulceration of the urethra is a necessary consequence, the points of greatest ulceration being at the peno-scrotal angle — under the suspensory ligament — at the meatus and in the bladder, where the pouit of the catheter touches. jiQ STKICTTJRE OF THE URETHRA. out, open at its tip, and -with a wire exactly filling up the whole canal. The eye at the tip is the main advantage, since the instrument may be used over a whalebone guide two feet long (Fig. 34). As suggested by Bumstead, this instrument may be used screwed upon a filiform soft bougie (Fig. 35). All solid instruments having a fixed curve are introduced as is the sound (p. 32). SOTTNDS. The most necessary instrument for the treatment of stricture is the steel sound ; for, whatever means be used to cure the stricture, rarely can that cure be maintained without the help of the sound. Steel sounds are conical or blunt. It is well to have a set of both kinds, but the former only are necessary. They should be made of the short curve (page 31), that one which is based upon the natural curve of the fixed part of the healthy adult urethra. The hard- est steel is used in their construction. They are capable of a high degree of pol- ish, and are smoother than anj- other instru- ments used in the urethra, metallic or soft. The conical instruments to compose a set run between Nos. 9 and 20 inclusive. The conicity of No. 9 runs through four sizes (that at its point is No. 6), of No. 10 11, 12, 13, through five sizes, of No. 14 through six, and all other instruments, from No. 15 on, run through seven sizes, the largest instruments going through over eight and nine numbers, the full size of the instrument being in every case reached just at the end of the curve. Thus No. 16 would measure 10 at its tip, penetrate 11 of the scale-plate for a distance of about four lines, penetrate 12 for about half an inch, 13 for an inch, 14 for an inch and a half, 15 for two inches, and, gradually enlarging around the curve, just fit 16 as the shaft becomes straight (Fig. 36). Blunt instruynents have a spherical extremity and fit the same aperture of the scale-plate throughout Both mstruments measure-shaft and curve-about nine inches, ^ -iTll'^.: ™in the flattened handle t.vo and one-half inches. Upon this t™ Cl^JZ latter the number is stamped, and, if desired, the diameter ''""'• of the mstrument and the corresponding French size. Small conical sounds with a tunneled extremity are serviceable, with a whalebone hlitorm bougie as a conductor (Fig. 37). SCALE PLATE. jji SCAXiE. The scale for grading the sizes of instruments has never been very accurately fixed, except in France. The English scale, -which has been, until recently, the favorite wherever the language was spoken, is arbitrary and inaccurate, vary- ing so much that instruments marked with the same num- ber may be found to differ two millimetres in diameter. The tendency of late years, in this country as well as in England, has been to adopt the French scale, simply because it was fixed and immutable. The only valid objection to this scale is, that it involves too many instruments in a case for the ordinary surgeon, entailing needless expense in procuring them and care in keeping them in order, with no compensating advantage, since with cow^■ca?^■?^s Fia. 88.— American Scale, Front. o = o QS- o^ o « . o= o - 111 f 1 « -o *^ lO'~ =o -f io^ "O in^ :0= »0 -^ ^O^ * o w . ^ — -^ O >^ u E i c a. CL < o M 1 io i ^ _ _ n " c _ J : ^ B w, Q) bo a Fig. 89.— American Scale, Back. the surgeon has the advantage of using a wedge, as well as a lever, and, by carefully inserting any given conical steel instrument through a strict- STEEL VERSUS SOFT INSTRUMENTS. 113 ure, he practically does (with less violence) the same thing as if he passed 4 to 7 different blunt instruments (according as he uses a large or small sound), since the conicity of the sounds runs through four to seven or more sizes (p. 110).' Advantages of Steel Instbuments foe dilating Steictuee. Since Thompson, one of the most brilliant minds connected with the subject of genito-urinary surgery, decided at one time in favor of the use of soft instruments for dilating stricture, a vrord will be necessary to state the reasons why the authors of this treatise hold a contrary opinion. In regard to facility of manipulation, that depends on prac- tice, and he will use this, that, or the other instrument the best, who has used it the most. Less barm can be done with flexible than with solid instruments, undoubtedly, and on this account they are to be rec- ommended for the unskilled, and for all, however expert, in the low sizes — below No. 9. In trained hands, however, the steel sound is perfectly safe ; it is smoother than any soft instrument, and certainly can be passed into the urethra with less pain than can any other instrument, and is capable of effecting more dilatation, in the same length of time, with the employment of less force." Steel instruments, made with the curve and conicity already described, possess all the powers of the "wedge, and of a lever of the first order. The surgeon holds the long arm, the fulcrum is a sliding one, situated at the junction of the shaft with the curve, perhaps steadied by the surgeon's finger. The immense power which the application of this compound mechanical principle, in the construction of the instrument, gives to it, is not appreciated by sur- geons. The ease with which harm may be done, in using force with con- ical sounds, is rarel}' realized until after an accident has occurred, and then the surgeon is liable to ascribe the mischief to chance rather than to his own carelessness. Swelled testicle, congestion of the neck of the bladder, irritation of the stricture, even false passage, may be produced by a surgeon in too great a hurry, or using force. It is a rule, from which no departure should be made, either on account of solicitation by the patient, or desire to push the case to a rapid termination, never to use force with any instrument in the urethra — especially with conical steel sounds. The character of the stricture may, occasionally, in the judgment of the operator, sometimes require force, but the motive for its use must never be haste, or desire to effect a rapid cure. The weight of the instrument, aided by a little coaxing, will usually exert all the power necessary. " Festina lente" is the golden rule. Patience and gentleness will effect more than force in the long-run. ' Followint' a practical feature adapted to scale-plates by Dr. E. A. Banks, of New York, the plate is made six inches long, and marked in inches. Markmgs m miUimetres and centimetres might be added. _ , ^ • ■ » Patients tested, at the same sitting, with soft and steel mstruments, almost mvaria- bly complain less of the latter. Q4. STRICTURE OF THE UEETHKA. INSTRUMENTS FOR DIVTJLSION. DivuLSiON signifies forcible rupture. There are three instruments well suited for the treatment of stricture by this method. Thompson's instrument for " rapid dilatation," as he terms it, consists of two parallel blades, slightly curved toward the beak, at which they are joined. The blades may be separated laterally, to the desired extent, by turning the handle. When the blades lie in contact, the instrument resembles a slightly conical metallic sound, size 8, a little curved toward the beak, which terminates in a slight bulbous expansion. By turning the handle, the blades may be separated to an extent corresponding to size 17, or larger. The degree of separation is indicated by a register in the han- dle. The instrument is marked by lines one inch apart, commencing from the point of greatest dilatability. These lines are to indicate the depth of this point from the meatus, after the instrument has been intro- duced. A small metallic slide, on the outside of the shaft, is so arranged as to slip up and down when the instrument is closed. In using this instrument, the depth of the stricture to be acted upon is first accurately determined with the bulbous bougie. The metallic slide is then pushed down upon the closed instrument, until its distance from the point of greatest dilatability equals the distance from the meatus to the centre of the stricture. The instrument is now passed into the ure- thra until the meatus is touched by the slide, whereupon the latter is slipped up to the handle, and the operator is confident the point of great- est dilatability of the instrument corresponds to the centre of the strict- ure. No ansesthetic is required. The patient is lying upon his back, Thompson's idea of the proper use of this instrument (as expressed by his naming it a " rapid dilatator ") was, that it should stretch as much as possible without tearing. To obtain the greatest usefulness from the instrument, however, this idea must be abandoned ;' on the contrary, it should be used with the avowed object of rupturing (divulsing) the stricture. In this way only can its full and best effect be obtained, and, so employed, it is the best instrument we possess for performing divul- sion. It accomplishes all that Reybard claimed for deep internal sec- tion, in his celebrated monograph," which obtained the Argenteuil prize from the French Academy in 1853, and it does this without the dangers to which these deep internal sections were liable — hasmorrhage infiltration, abscess. It splits the stricture, and allows a splice to be put into it by the healing process. The dense, hard tissue constituting stricture gives way under the application of sufficient force before the soft, naturally elastic parts around it ; and the fact, that a torn wound bleeds less than an incised wound of the same part, at once establishes the advisability of preferring divulsion to incision, and that all the more ' Thompson has recently given up the use of the instrument. — Bpmstead (oral com.). "Traitlj pratique des Ketr^cissements du Canal de I'UrMre," Paris, 1843. INSTRUMENTS FOE DIVULSION. II5 strongly for strictures situated low down in the urethra, where it is diffi- cult to arrest severe bleeding, should it come on. Thompson's instrument has been very advantageously modified by American ingenuity. The modifications consist in making it smaller in its shaft and tunneling its beak (Fig. 40), so that it may be introduced through a tight stricture with safety, over a whalebone guide (p. 104). It is also made to terminate in a little screw, so as to be adaptable to a soft filiform guide passed through the stricture. In the latter case Fia. 40. the instrument is provided with a slightly bulbous tip, which may be screwed upon its beak, instead of the filiform bougie, bringing it back to its original simplicity, where it may be used without a guide, if de- sired. The American instrument, furthermore, is made to expand to a greater extent than Thompson's, fully up to size 20 (or larger, if de- sired) — a degree of distention which it is often desirable to bring to bear upon a tight stricture in a naturally large urethra. After the instrument, with or without a guide, has been introduced to a proper depth, the operative procedure is as follows : The handle is turned rapidly until the blades have been separated to an extent several sizes larger than the patient's meatus will admit. The failure of the operation, if it is unsuccessful, usually depends upon the employment of too little force. It is better to tear too much than too little. If any thing gives way it will be the stricture, and not the healthy urethra, and this is the object which the operator has in view. The patient may prefer to screw up the instrument himself, taking perhaps half an hour to perform the operation.' The pain, which may be at first quite severe, becomes as a rule sensibly modified as soon as the stricture begms to rupture and blood shows itself at the meatus. The stricture may be nearly always felt, sometimes almost heard to tear. After blood begins to flow, further separation of the blades rarely increases the pain to any extent. It is always a pleasant thing to see blood, as this indicates that the operation is' being successful. Some strictures are so elastic (resilient), that, although the instrument is screwed up to its highest dimensions, they still refuse to rupture ; no blood flows, or there is only a slight staining ; and, after the divulsor is withdrawn, instead of a ' As actually happened in one of the authors' cases. 116 STEICTURE OF THE UEETHRA. No. 20 passing with comparative ease, as the surgeon and patient had expected, both are surprised to find that, perhaps, only a 7 or 8 wUl go, and that with difficulty and pain. Case XV. — A striking case, illustrating this point, occurred January, 18'72, at the Charity Hospital. The patient bad an old stricture about four inches down the canal, which admitted 7 with difficulty. Thompson's divulsor was passed without a guide, and screwed up to 20 — its fullest extent. After withdrawal of the divulsor it was found that 18 would not pass; 12 and 9 also failed, consequently the divulsor was reintroduced, accurately adjusted, and again screwed up to its fullest extent. Again No. 9 steel was tried, then 1 ; finally. No. 3 soft French conical bougie, which entered the stricture, but was arrested and would not pass on. On attempting to withdraw this bougie, it was "grasped " powerfully by the stricture. Here was an instrument smaller than the shaft of the divulsor used, but yet grasped more tightly than was the divulsor itself when first introduced. Six hours after divulsion the patient had partial retention. On the following day every thing returned to the same condition as before the operation. No trouble followed the attempt at divulsion. Thi> condition of the stricture was absolutely unaffected. Such cases must be subjected to the use of a divulsor which separates sufficiently to rupture them, or must be cut. They are rarely amenable to ordinary dilatation afterward, if the divulsion fail. Traumatic strict- ures and those caused by nitrate of silver are sometimes, but not inva- riably, of this variety. A caution is necessary in withdrawing the divulsor. As the instru- ment is being unscrewed, so as to bring the blades together, after they have done their work, it is proper to push the whole instrument on still farther into the bladder — which should always contain about three ounces of urine, if possible. In this way the accident, during withdrawal, of catching a fold of mucous membrane in the closing blades at their point of junction, may be avoided, an accident very liable to happen if this precaution is neglected. If the instrument is properly made, this is less apt to occur; the blades, where they come together at the angle of junc- tion, should be decidedly rounded off, not coming flatly together. If a small flap of mucous membrane should be caught, it can never be de- tected until traction shows the instrument to be retained. It is now too late to attempt to dislodge the fold which has been pinched into the an- gle of the blades. It cannot be done. The little piece of membrane must be torn off. This tearing is hardly noticed by the patient, as the mucous membrane is not sensitive. The accident seems to have no effect in producing urethral fever, nor does it seem to influence in any way the success of the operation ; but it is decidedly more agreeable, tc the surgeon that it should not happen. Haemorrhage, after the operation, is trifling. The callous tissues dc not tend to bleed much when they have been torn. A full-sized conical steel sound, as large as the meatus will admit (the latter may be incised, if unnaturally small or strictured), should be introduced at once into the bladder, for the sake of testing whether or net the stricture has been thoroughly divulsed. Sometimes the stricture is so torn that an anglf DIVULSIOJSr. ^ jjY or pocket, is formed at tlie previously strictured point in the floor of the urethra, in which the point of the sound engages. A knowledge of this fact suggests the means of overcoming it— by keeping the point of the sound well up against the roof of the urethra. If the stricture has been thoroughly ruptured, though it may be still felt by the sound, yet, upon the withdrawal of the latter, there will be no " biting." It requires more force than is usually supposed, to rupture a stricture thoroughly. After the operation it is expedient to keep the patient in bed for from twenty-four to forty-eight hours, and this especially if the urine is highly alkaline or decomposed, or the bladder very sensitive and irritable. In the latter condition it is always prudeut to administer, before or immediately after the operation, ten grains of quinine with a quarter of a grain of mor- phine, to keep oif, if possible, or moderate, the chill and urethral fever which may ensue. Contact of urine with the cut surface cannot be avoided ; a little urine usually flows away as the instrument is being screwed up. Accidents may, of course, happen with this operation, but they are rare. Especially if the urine is healthy, the patient may pass water at once over the wound, and go about his business without feeling any ap- preciable discomfort.. It is prudent, however, to retain him in bed for a while, if possible, as severe urethral fever sometimes follows the opera- tion, and abscess and infiltration are not beyond the range of possibility. Epididymitis may also come on. It is not very uncommon for a certain amount of blood to escape during the operation, under the skin around the urethra ; this frightens the patient, but is of no importance : if let alone, it will be reabsorbed in a few days. No after-dressing is re- quired, if the patient remains in bed. If he goes about, a little collodion over the meatus will be suflScient to keep his clothes from getting soiled by blood. The treatment after divulsion consists in the introduction of a full-sized conical steel sound on the seventh day after the operation (un- less urethral fever should occur, and run particularly high), and, finally, in the continued use of the sound, as after cure by dilatation. The operation of divulsion, blind and rough and brutal as it appears at first sight, has proved itself exceedingly mild in its immediate, and sat- isfactory in its ultimate results. In cases where the bladder and urethra are very irritable, it seems sometimes as if less urethral fever followed divulsion than the simple use of an ordinary small dilating instrument (Case XI., p. 49) ; true, there may be a good deal of constitutional dis- turbance, as indeed after any operation in the urethra, but this is excep- tional where the urine is not too alkaline, and where the kidneys are not diseased. Death may follow divulsion in exceptional cases, as it may the use of any instrument in the urethra. Case XVI. — In January, 1872, a robust, middle-aged man, with an oldtiglit stricture at the bulbo-roembranous junction, some hypertrophy of the bladder, and mild chronic cystitis, appeared at the Charity Hospital. The patient was a vagabond, had been a hard 118 STKICTUEE OF THE URETHRA. drinker, and, some time before, in the worlihouse, had had a light attack of what was con- sidered delirium tremens. Divulsion was performed upon this patient. He had a chill during and at the close of the operation, before the instrument could be removed from the urethra. A little morphine was thrown into his arm, and gr. x quinine given. He went on rapidly into a low state of fever, with mild, rambling delirium (resembling mild delir- ium tremens somewhat), and died on the ninth day. He had no chills, except the slight one at the moment of operation. The post mortem proved that pyeemia was the cause of death. The stricture was found ruptured longitudinally along the floor of the urethra. There was a small, diffuse, half-formed abscess in the scrotum, communicating with the urethra through the incision. This had appeared on the fourth day after the operation, and grown very slowly. Several abscesses were found in the prostate, and another, of the size of a nut, in the left lung (none in the liver, spleen, or kidneys). There was slight pleuritic eSusion on both sides, and a good deal of fluid, and recent plastic lymph in the pericardial sac. On both aims, around the points of puncture made for subcutaneous injection of morphine, there was a patch of diffuse subcutaneous suppuration. This patient was evidently ripe for suppuration at any point injured. When Thompson's divulsor is used upon a guide, it is a very safe instrument in treating even the tightest strictures. It is preferable to the instruments of Holt or Voillemier, both because there is in the opera- tion no sudden shock of driving home a shaft, and because all the force is brought to bear upon the spot which it is desired to rupture, while the rest of the urethra is spared ; furthermore, the amount of separation of the blades may be regulated at will, and the surgeon may cease turn- ing the handle as soon as he feels assured that the stricture has been sufficiently ruptured. HOLT'S DIVtrLSOE. This instrument is preferred by many for the rupture of stricture. A few words will suffice to describe it. It consists essentially of two parallel blades, inclosing a hollow central shaft, through which a drop of urine escapes when the beak of the instrument enters the bladder. When .TIEMANN-Co a^ga= (£@0= 1«'THI- rie. 41. closed, the instrument resembles a slightly conical, curved sound, of small size, with a broad handle for convenience of manipulation. Coni- cal, hollow metalhc tubes of different sizes accompany the instrument. After the beak has entered the bladder, a tube of suitable size is selected, and fitted over the central conducting shaft between the two INSTRUMENTS FOR DIVULSION. 119 blades. This tube is driven forcibly home by a single stroke, the penis and handle of the instrument being held immovably by the surgeon's disengaged hand. The two parallel blades are forcibly separated by the passage of the large conical shaft between them, and the stricture, unless too resilient, is ruptured. The operation is not very painful, and no anassthetic is required. Holt performs it with the patient standing up against a wall, supported on either side by an assistant. The whole instrument is withdrawn together, being partially rotated from side to side, to disentangle any shreds of mucous membrane which might be caught. The results and necessity for sub- sequent use of the sound are the same as after all other operations. Holt's instrument may be tipped with a screw, for the adaptation of a soft filiform bougie guide, in case the stricture is tight. An adjustable metallic tip covers the screw when no guide is to be used. Bumstead has enlarged its sphere of action, by having the dilating tubes made much larger than those of the original instrument. Where many strictures are to be dealt with at once. Holt's instrument may be useful, but for general application it is much inferior to the American modification of Thomp- son's instrument. VOILLEMIEE'S DITULSOR. This instrument is essentially the same as Holt's, but is more simple, and therefore better. It consists of two thin parallel blades joined in a curved, slightly conical beak (Fig. 43). These blades fit into grooves on either side of conical, cylin- drical, solid shafts of different sizes up to 20. It may be used with a whalebone guide, or screw-tipped, with a soft bougie. The blades are introduced closed ; a shaft of suitable size is well oiled, and into its external grooves are fitted the thin parallel blades, which, filling the grooves, make the instrument cylindrical. The shaft is driven forcibly Fia. 42. 120 STKICTUKE OF THE URETHRA. home, as in the mancBuvre with Holt's instrument. The blades of Voilleinier's instrument separate laterally, those of Holt's vertically. Subsequent use of sounds is necessary for permanent cure. INSTRUMENTS FOE INTERNAL URETHROTOMY. Four instruments only need be described, suitable for the treatment of strictures in different portions of the canal. The CoiJ'CBAiiED Bistouet. — Civiale's " bistouri-cach6 " (Fig. 43) serves to enlarge the meatus, or to cut strictures within about the first inch of the canal from the meatus. It consists of a small concealed blade, which may be disclosed by pressing upon the handle, after the instrument is introduced. A screw arrangement in the handle regulates the extent to which the blade may be made to cut. This instrument is introduced closed, the blade is protruded to the desired extent, and the instrument is suddenly withdrawn, cutting its way out. If other strictures are to be forcibly dealt with at the same sitting as that in which the orifice is to be enlarged or a stricture near by cut, the deeper strictures should, if possible, be attended to first, to avoid the confusion which the bleeding from the cut orifice might occasion. A full-sized steel conical sound is introduced at once to control haemorrhage, which is usually trifling in amount, but sometimes consider- able. ' On withdrawing the sound after a few moments, if there is only Fig. 43. a slight oozing of blood, the cut is best dressed by the insertion into the meatus of a shred of lint or cotton-wool to prevent union. If the bleeding be considerable, a shred of lint is introduced into the cut, and the meatus is plentifully painted over with collodion. The mea- tus must be pressed laterally, while the collodion is being applied ; otherwise a little blood wUl ooze up, and the collodion will not ad- here. With this dressing, hasmorrhage and oozing become impossible. With no other dressing is the patient's linen safe from the possibility of being soiled. At the next urination the dressing is removed, and it is rarely that any considerable haemorrhage follows. A full-sized conical steel sound is to be introduced into the meatus daily for a few days, and then at longer intervals, to prevent too much contraction during cicatrization ; or, more simply, the patient may keep the cut open with a hair-pin, visiting his surgeon twice during the week. INSTRUMENTS FOR INTERNAL URETHROTOMY. 121 CIVIALE'S TJBETHEOTOHCE. This instrument consists of a straight, small shaft, terminated by a flattened bulb, which conceals a small semicircular blade (Fig. 44). By means of a mechanism at the handle this blade may be protruded to a greater or less extent, as desired, a register in the handle indicating the degree of protrusion. The bulb is to be passed through the stricture, and then pulled forward until it meets resistance. The blade is now protruded and the whole instrument drawn out, until the stricture has been divided, when the blade is sheathed and the instrument withdrawn. This is the safest urethrotome which can be employed. It is applicable to strictures within four inches from the meatus, but, before it can be used, the stricture must be large enough to admit the bulb. If it is Fig. 44. desired to use it upon a very tight stricture, the contraction must be first stretched somewhat by Thompson's divulsor upon a guide. No urethrotome cutting from before backward is safe without a guide. Haemorrhage after internal urethrotomy is, as a rule, greater than after divulsion. If it becomes alarming, it may be arrested, after collodion over the orifice has failed, by injections of persulphate of iron ; or, as a last resource, by perineal section, with plugging of both ends of the ure- thra. Otis and Banks, of New York, have each recently produced modifica- tions of Civiale's urethrotome, the main difference in each case being that there are bulbs of many sizes which may be screwed upon the same shaft ; the instruments may be used with conductors. The principle of action and method of cutting are the same. The after-treatment of internal urethrotomy is the use of the steel sound, as after all other methods of cure. MAISONNETTVE'S UBETHROTOMB. This instrument is serviceable where it becomes necessary to incise stricture situated deeper in the urethra than four inches. It consists of a hollow wire with a linear opening on that side which corresponds to the roof of the urethra. The knife, of different sizes, cutting from before backward, and from behind forward, with its exposed obtuse angle always blunted, is attached to the end of a long stylet which fits into the groove of the instrument. The blade is prevented from slip- ping out by a projecting shoulder on either side, which runs inside the hollow wire. Bumstead has advantageously modified the original in- strument by making the knife run only to the beginning of the curve, instead of up to the point, and by making the tube a little more solid. 122 STEICTUEE OF THE UEETHEA. The instruments, as now made, have the blade on the lower side (Fig. 45). This urethrotome is to be used with a screw-tipped filiform bougie. It is introduced, following its guide, and depressed until the straight portion of the tube has passed the stricture. Then the blade is entered, pushed rapidly down, as far as it will go, and immediately retracted, the instrument being twisted a little, if desired, so as to nick the stricture again during withdrawal. The objection to this instrument is, that if a large blade is used the healthy urethra is incised longitudinally, often for its whole length anteriorly to the stricture ; an accident perhaps of no very great moment, but entirely unnecessary, while, if a small blade is used, the whole thickness of the stricture is not cut through. Voillemier has attempted to over- come this objection by adapting a shield to the blade from which the latter may be pro- truded when the strict- tu-e has been reached, but the modification is complicated and un- satisfactory (Fig. 46). Another objection ap- plicable to all instru- ments for incising the deep lu-ethra is, the lia- bihty to hasmorrhage, if the incision is suiB- ciently deep to be ef- fective. Such hasmor- rhage at the bulbous portion of the canal may be very difiScult to control. The after- treatment is the same as after all other opera- FiQ. 46. tions. j^^ INSTRUMENTS FOR DILATING AND CUTTING STRICTURE. 123 Several Fio. 47. DILATING URETHROTOMES. instruments have been recently devised to cut strictures of ^ large calibre, such, for instance, as have been dilated but are somewhat resilient, and cannot be further effaced by dilating instruments, or, indeed, to cut any stricture after first having put it upon the stretch, an idea first successfully carried out by Reybard. Per- haps the most useful of these is Otis's urethrotome for strictures of large calibre (Fig. 47). The instrument is of large size (No. 10), consists of a straight round staff, from near the end of which a parallel bar may be separated by a screw in the handle. Along the top of the instrument runs a groove concealing a fine blade, which, at a certain part of the groove, runs over a concealed ridge (after the manner of Ricord's coarcto- tome), and then again sinks into the groove, by being drawn forward, and, cutting for about one and a half inch, disappears. The distance of this little ridge in the groove from the handle is marked in inches upon the shaft of the instrument. A register in the handle indicates the extent of separation of the two parallel blades. A soft large guide screws on the end of the instrument, so that it may be used, if de- sired, in the deep urethra. The instrument is also tunneled. In using this instrument, the exact position of the stricture is first ascertained with the bulbous sound. The instrument is now introduced so that the ridge in the groove shall lie exactly at the strictured point. The two blades are separated until the stricture is put well upon the stretch ; and, finally, the concealed knife is pulled forward over the little ridge, cutting its way through the stricture in its course, and then again sink- ing down out of sight. INSTRTTMENTS FOR EXTERNAL PERINEAL URETHROTOMY. Besides some of the special instruments already described, only two others are requisite in order to meet the requirements of any case (and there are few of them) calling for external section. 1. A simple staff, broadly grooved on its convexity, the groove running off at the end, and the instrument not conical (Fig. 48). This instrument is introduced as far as the stricture, when the latter is impervious, and is cut upon in the operation of perineal urethrotomy without a guide. 12i STEICTURE OF THE URETHRA. It may be used with a guide, the latter being a whalebone bougie, intro- duced through the stricture (Fig. 49). In this case it is practically the same instrument as the staff of Syme ' {see note, page 137), the eminent Fig. 43. Fig. 49. Fig. 50. surgeon who gave this operation its reputation. Syme's staff is unsafe compared with the means now at our command, and is rarely used. 3. The catheter-staff of Gouley (Fig. 50). This most excellent instru- ment is a metallic catheter (they are made of various sizes), grooved on its convexity, the groove being bridged over at its end, forming a loop to receive its guide — a filiform whalebone bougie. Scalpels, probes, and a long, slender, probe-pointed director, are re- quired for the operation. EXTEBNAI, PERINEAL TTEETHROTOMY, WITHOUT A GtHDE. Few operations in surgery are more formidable than this one of ex- ternal perineal urethrotomy, wilhout a guide. The surgeon who ap- proaches it should be thoroughly at home in the anatomy of the perinse- um, and even then should be prepared for possible failiu-e. The patient ' " Stricture of the Urethra," Edinburgh, 1849. EXTERNAL UKETHROTOilY WITHOUT A GUIDE. 125 IS tied or beld in the lithotomy position, after he has been anassthetized. The scrotum is held up out of the way by the assistant who manages the grooved staff. Ether relaxes spasm, and a last attempt to pass a fili- form bougie, after the patient has become unconscious, may be success- ful, where previous efforts have failed. Should the attempt succeed, the operation at once becomes simple and easy. Failing, the operation without a guide must be undertaken. The perinseum having been shaved, an external incision should be made directly in the median line from two and a half to three inches long. It should be carried down layer after layer, until the urethra has been opened into upon the end of the blunt staff previously introduced up to the front face of the strict- ure. The perinaeum should be turned toward a window, and a couple of hours of daylight always allowed, in order to have an abundance of time, if the operation proves complicated. Haste, in this operation, is bad surgery. After the urethra has been laid open, the subsequent steps of the operation are greatly simplified bj' adopting Avery's suggestion for getting room and light. It consists in transfixing each ilap of the wound with a stout ligature about three feet long. The ends of each ligature are now knotted, thus forming a long loop on either side, which may be held by assistants. By means of these loops the wound is kept open to the bottom without the necessity of thrusting fingers or spatulee into the small space, where the fingers of the operator alone are neces- sary. With the urethra opened in front of the stricture, the surgeon care- fully searches for the anterior opening of the latter with a fine probe, or, better, a fine probe-pointed director. If the opening can be found, and the director passed through it, the rest of the operation is simplified at once : but this fortunate result is rare. Having failed to find the orifice of the stricture, after a patient search, the surgeon feels for the hole in the triangular ligament, below the depression lying above the sub-pubic ligament, and cuts into it through the fibrous mass by successive strokes of the scalpel, always in the median line. At short intervals during the operation, the surgeon gently endeavors to coax his fine director, prop- erly curved, through any opening he may think he sees, into the dilated urethra beyond. After each failure he resumes the cutting in the median line, guiding his knife by frequently taking the bearings of the tubera ischii, and with his finger in the rectum. In this way he con- tinues, feeling his way as he goes, until finally his director finds some orifice through which it passes onward into the bladder. When this has been effected, a probe is passed in the groove of the director, also into the bladder ; and now, by separating the two, a gush of urine is seen to mingle with the blood, announcing that the bladder has been reached. The director, once in the bladder, should not be removed until after the opening has been increased, and a large instrument (nothing is better than the little finger), can pass into the bladder. A mistake often made 12Q STRICTURE OP THE URETHRA. in searching for the opening into the urethra with a probe is in trying too high up, too near the sub-pubic ligament. Having now opened a way into the bladder, all fibrous bands in the roof of the urethra ' must be cut with the knife, and any fibrous material detected in the floor of the canal, at either extremity of the incision, should be freely divided. Finally, a blunt steel sound, as large as the urethra wiU admit, should be passed through the meatus into the blad- der, the meatus being cut if necessary. This sound should be intro- duced several times, to make certain that it glides easily and without obstruction. If the stricture is an old one, it is always well to search the bladder for stone after the operation, and to remove any that may be found. Venous haemorrhage may be abundant, but it is easily re- strained by plugging the wound with lint or tow, and tying the legs together after the operation. The scrotum should be bandaged up out of the way, to prevent the possible infiltration of its loose tissue by blood or urine. The thighs should be elevated, and a cradle used to keep off the weight of the bed-clothes. This operation may be greatly simplified by puncturing the dUated urethra in the median line, if it should be found to be distended with urine behind the stricture, as is sometimes the case. Through such an opening, an instrument may be passed to the posterior face of the ob- struction, and thus serve to guide the incisions from the gTOOved staff at the front face of the stricture through the callous mass. A perineal fistula may be utilized for the same purpose. After external perineal urethrotomy no instrument should be tied into the bladder. Hitherto it has been common to tie in a catheter and leave it during the greater part of the cure, but experience has proved that this practice is dangerous, as being liable to give rise to ulceration at the various points where it makes pressure, both in the urethra and bladder, while it undoubtedly retards the healing of the perineal open- ing [see note, p. 127). Moreover, it is generally a serious additional cause of uneasiness to the patient, and is liable to leave the urethra indurated throughout its whole length, from the inflammation resulting due to its prolonged pressure. Furthermore, the urine, after a time, invariably passes through the urethra alongside of the catheter, thus defeating the object of its introduction, and finally, cystitis at the neck of the blad- der is kept up and often permanently established by the pressure of the foreign body. It is very desirable that the first tendency of the perineal wound to heal should not be interrupted ; the constant pres- ence of a foreign body at the bottom of the wound inevitably modifies and delays the process of repair. The surgeon must satisfy himself, be- fore the patient recovers from his anassthesia, that he can introduce a full-sized sound easily into the bladder. ' A neglect of this precaution sometimes renders the subseauent introduction ot m- PEEINEAL URETHEOTOMT, WITH A GUIDE. 22" The urine will pass at first through the perineal opening-. The after-treatment consists in the passage of a full-sized steel coni- cal instrument into the bladder, commencing on the fourth day and re- peating every three or four days until the wound has healed, thus forcing it, as it were, to heal with a large splice. After the wound has united, to prevent recontraction, the patient must pass dilating instruments at proper intervals, as after any other treatment designed to effect a radical cure of organic stricture. InBltration and abscess may occur after the operation, and it is not very uncommon for fever to run high ; but the results are usually excellent, unless the patient have organic kidney or other disease. Diluent, mucilaginous, alkaline cooling drinks, with qui- nine, tonics, supporting diet, and rest, complete the treatment. EXTERNAL PERIM-BAL UBETHEOTOMY, WITH A GUIDE.' This is an operation much simpler than the one just described. When external section of a stricture is contemplated, no effort should be spared and no amount of time grudged which is given to attempts at introducing a whalebone bougie. Even after the patient has been ' Between the years 1847 and 1862, at first at the Bellevue Hospital, and afterward also at the New York Hospital, I devoted much time and labor to the study of old and neglected cases of stricture ; numbers of which, some complicated with abscesses and fistute, others traumatic in character, were found among the patients in the almshouse then connected with the BellcTue Hospital, and the sailors to whom the New York Hos- pital at that time afforded aid. At this period surgical operations for the rehef of these aggravated and complicated cases of stricture were rarely resorted to except where life was threatened by retention, and catheterism impossible, when the operation known as " the perineal section " was undertaken — generally with the double object of relieving the retention and, at the same time, dividing the stricture longitudinally with the knife from the periuasum so as to afford this chance of permanent cure. But this operation was always undertaken with reluctance, being justly regarded as uncertain in its success, as to the possibility of reaching the bladder, as well as in its ultimate result. Being reserved for desperate cases of retention — often complicated with extravasation, in broken-down sub- jects, it was not unfrequently followed by death ; and when this immediate result was happily escaped, the remoter results of the operation in a curative way were far from satisfactory. It was the uniform practice, after the operation was completed, to introduce a catheter of medium size (No. 9 or 10) through the urethra into the bladder, and to tie it in, replacing it every four or five days, or when it should become intrusted by calca- reous salts, by a fresh instrument. The object of this practice avowedly was to afford a channel through which the urine might escape, other than the perineal wound, and to allow the perineal wound as it granulated to heal around the catheter, and thus form a new urethra. I soon found that neither of these results was in fact usually attained; the urine always escaped more or less freely beside the catheter and through the perineal wound; and the perineal wound rarely healed entirely while the catheter was worn — a fistula almost always persisting. I also satisfied myself, by observation, that the pro- longed contact of the catheter was usually followed by inilammatory thickening of the urethral walls throughout the whole length of the canal ; that in some instances it gave rise to excessive irritation, and in most cases to chronic inflammation of the bladder ; and, in exceptional cases, that ulceration was liable to occur, both of the urethra and ' bladder at certain points, from prolonged pressure of the instrument — from which I have known more than one fatal result. I subsequently searched out and tabulated all the recorded cases of perineal section in the books of the New York Hospital from its foun- dation, and found that a majority of the patients left the institution with unclosed peri- neal fistulse after wearing a catheter from one to six months, instances of their returning to the hospital within the year, to seek relief from relapsing urinary obstruction, being not unfrequent. Influenced by this experience, I took the responsibility of deviating from 128 STRICTURE OF THE URETHRA. anaesthetized, tlie attempts should be renewed, for ether always relaxes urethral spasm, and, if, finally, a whalebone guide enters the bladder, the sm-geon may congratulate himself and the patient's friends — for what would have been one of the most diiEcult operations of surgery (section without a guide) becomes at once one of the easiest. A whalebone once in the bladder, the catheter-stafF, or a tunneled steel stair, is passed over it up to the stricture. An incision through the perinseum in the median line readily exposes the end of the staff, and beyond it the black guide is seen disappearing among the tissues. Avery's threads make it easy to keep the guide in view, and a little the usual practice, and left no catheter in the bladder after operating by the perineal sec tion. The success which followed was highly satisfactory. The contact of the urine which now escaped entirely through the perineal wound, was not found to retard the process of repair by its contact with the granulating surfaces. The introduction of a full-sized steel sound through the urethra into the bladder every day, or every other day, ■was found sufficient to antagonize any tendency to contraction on the part of the recently- divided stricture or strictures, and usually at the end of the sixth week I found the perineal wound closed. After teaching the patient to introduce a steel sound for himself, at proper intervals, I was then able to discharge him with little if any chronic cystitis, and, if true to his own interests, cured of his strictures as far as the disease in its ad- vanced stages is susceptible of cure. Sir Benjamin Brodie's dictum, that a perineal fistula wiU usually close spontaneouslv if the normal calibre of the urethra be preserved, was fully vindicated by the results thus obtained. I had already given much attention to perfecting the shape and finish of steel sounds, and their adaptation to the normal curve of the urethra {see note 3 p. 30), and, by constant and laborious efforts with the instrument-makers, had finally succeeded in getting them to make the short-curved instruments now in use in this city. While thus engaged, the Jaeksonian Prize Essay, on stricture of the urethra, of Mr. Henry Thompson, first reached New York, and his more formal and complete exposition of this subject confirming my efforts, I gladly accepted it as authority. The short-curved steel instruments, at first made blunt, I had subsequently finished with slightly-conical extremities. The old instru- ments which they replaced were made of heavy wire, bent into long, ridiculous, and con- stantly-varying curves, so awkward that they were rarely employed — bougies being gen- erally preferred. These improved steel sounds I found of great service for introduction after perineal sections. Their adaptation to the natural cui-ve of the urethra, and their conicity, made it easy to get sounds of the largest size into the bladder. To facilitate this, it was my habit to search out and remove, at the time of the operation, all strictured points in the urethra anterior to its perineal portions, dividing those at and near the mea- tus freely with the bistouri or meatotome, and those lying deeper by Civiale's urethrotome, so as to be able to pass the largest possible steel sound through the urethra into the bladder with entire ease, while the patient was still under the influence of the anaesthetic. With this precaution I rarely experienced difficulty in the subsequent introduction of the largest steel sound, without recourse to anaesthesia ; and the patient, at the earliest possi ble moment, was made to introduce the instrument for himself, and taught that his future safety depended upon his honesty to himself in continuing this practice, Syme, of Edinburgh, who, twenty years ago, was regarded as a very high authority, had declared himself emphatically in favor of dividing old and resilient strictures by the knife, from the perina;um, as a mode of cure preferable to dilatation, even where bougies could be readUy introduced. He disputed with Reybard, of Paris, the claim of originat- ing this mode of practice, the only apparent difference between them being that Reybard proposed to operate upon the stricture from within the urethra, whereas Syme advocated incision from without. The operation for the cure of stricture, which bears his name, is simply a modification of the old "perineal section," the stricture being divided from with- out upon a fine grooved director of steel, which had been previously insinuated through it to serve as a guide to the knife- I found Syme's delicate grooved director, with its defective flaring curve, a dangerous instrument in hands less skilled than his, and, when filiform bougies were first obtained from Paris, I succeeded, by their aid, in getting through a good many old strictures which had hitherto been to me impassable, and such patients I induced to submit to perin.'eal PERINEAL URETHROTOMY, WITH A GUIDE. J29 careful following up of this conductor soon lets the surgeon into the dilated urethra behind the stricture ; the catheter-staff passes on into the bladder, urine flows through it, and the operation is satisfactorily accomplished. The only precaution worth mentioning is the necessary exercise of care not to cut off the whalebone guide in front of the staff by a careless stroke of the knife, as this might at once reduce the sur- geon to the necessity of operating without a guide. After-treatment id the same as after the operation without a guide. The result of external perineal urethrotomy is usually excellent • but death may occur due to shock, pyemia, septicsemia, erysipelas, hospital- gangrene, infiltration, urethral fever with or without suppuration, etc. section, upon (he filiform hougie as a guide. I found the operation sufficiently easy and certain in its accomplishment, and the result, with the aid of the improved steel sounds, prompt and satisfactory. Rejecting Syme's instrument, but retaining the leading idea of his operation for stricture, I employed a full-sized blunt staff, with a groove on its con- vexity, running oflf at the middle of its blunt extremity, and large enough to lodge a fili- form bougie (Fig. 48, p. 124). This I used instead of Syme's instrument, of which, indeed, it was a modification — ^his delicate grooved director, of steel, being replaced by a filiform bougie (Fig. 49, p. 124), the " shoulder" of his instrument being represented by the blunt end of my stafl^ which was placed as nearly as possible in contact with the stricture to be divided. I was in the habit of teaching students the advantages, in the way of prompt and permanent cure, of this method of operating in bad cases of stricture, especially in hospital cases where patients could not always be induced to await the more slowly- obtained results of treatment by dilatation. To distinguish cases in which a bougie could be introduced as a guide from those of more serious character, which were impas- sable, I was in the habit of designating the operation in the former case as " perineal urethrotomy with a guide ; " and I did all in my power to popularize the operation, believing it to offer better chances of cure than dilatation to a large class of cases. Finding it not always easy to pass my grooved staff down to the perineal stricture, and, at the same time, to keep the filiform bougie (which had been already introduced through the stricture) from slipping out of its groove, I bridged over the groove of the staff for its last two inches, and, threading the tubular portion over the filiform bougie, passed it in this manner down to the stricture. The extreme flexibility and adhesive surface of the filiform bougie of that day interfering with the full success of this device, I diminished the extent of the bridged or tunneled portion of the staff, at first to an inch, and after- ward to less than the third of an inch, for the purpose of diminishing friction. In dealing with cases requiring perineal section, I found a certain proportion of them were rendered so by the presence of false passages, which prevented the introduclion of instruments for dilatation. On one occasion, after getting a filiform bougie into the bladder in one of these eases, the ease with which the "tunneled" staff' could be glided over it sug- gested to me the advantage of this mode of dilating strictures where false passages inter- fered with the use of ordinary bougies, as well as of getting into the bladder, in cases of difficult catheterism.' I discussed this point with Dr. Gouley, who at that time was my assistant, and, at a later date (1865), having brought with me from Europe some improved filiform bougies finished with whalebone, I suggested to Dr. Gouley (who had frequently had instruments made for me by the cutlers) to have the beak of Thompson's dilator drilled or perforated, so that it could be threaded over one of these smoother and more rigid filiform bougies ; so as, by this device, to get command of a stricture comph- cated with false passages. This he did (for me), and subsequently, following out the idea on his own account, he had, by the assistance of a mechanic, the principle broughtto the perfection in which it is now found in the shops, adapted to all styles of urethral instru- ments—these so-called " tunneled " instruments being employed over filiform bougies, I have introduced these facts of personal history because my agency m these matters has been ignored. — ^Yan Bueen. 1 The idea of using a guide in difficult catheterism was already old in S'i''e'=„f •„^,5'™'° £^°n4 velles ConsldfatloDS sSr les Eaentions d'Urine," 1828, p 41) speaks of it °8 ^ va uaUe resonr^^^^^^ says that he found it in a work by Nauche ("Nouvelles Eeoherches sur les Efteuhonsd Urine tbu-a edition, 1S06). The sliding tabes of Wakley acted on this principle ; and t^c catheter °g!n at both ^^^^^ passed Into the bladder on a conductor over half a yard lonff, and having ^ ?^halebone in * «™«. <>« Kribed by PhilUps (•■ TraitiS des Maladies des Voies urinaires," Pans, 1800), affords another example. 9 ^30 STRICTURE OF THE URETHRA. Qertain other operations on stricture must be mentioned to be con- demned. Cutting out strictures is absurd, for the circular wound leaves traumatic stricture behind. Dupuytren's vital dilatation, which consists in tying in a large instrument pressed against the front of the stricture in the hope that it may pass after many hours, is unsurgical and has been superseded by better methods. Wakley's sliding tubes are clumsy, and Arnold's fluid pressure less good than any other pressure. Time has judged the internal use of caustics and condemned them, while the same fate awaits electrolysis, lately revived. It has been weighed in the balance, and found wanting.' PTJNCTtrKE OF THE BLADDEK THEOTTGH THE RECTUM. Only one instrument is necessary for this operation, a small, long (seven or eight inch), curved trocar with silver canula. After the action of a full enema, the patient is placed in the lithot- omy position (an anaesthetic is unnecessary), and the fore-finger of the left hand is introduced into the rectum. If the tip of the finger cannot distinctly make out the distended bladder beyond the prostate, and feel the impulse of pressure made over the hypogastrium, the operation should be abandoned. If the distended bladder is felt, an assistant presses down the hypogastrium, the trocar and canula are oiled, and gently carried into the rectum, guided by the finger of the left hand to the point of puncture. The puncture is made by a quick stroke, and should be exactly in the median line. The trocar is now withdrawn, ind a portion or all of the urine drawn oif, after which a cork is fitted md the tube tied in place with a T-bandage. The contraindications of the operation are a large prostate, a small Dladder, no fluctuation — and cases where there is no prospect of a speedy reestablishment of the natural passage. The peritonseum is pulled out of the way by the distended bladder, and is in no danger of being wounded in ordinary cases. If the puncture is not in the median line, and a seminal vesicle be wounded, epididymitis may follow. A good deal of care is necessary to prevent the canula from slipping out. The operation is not a dangerous one. Out of forty cases reported by Cock," there were seven deaths, but in none of these could the fatal issue be attributed to the operation. If an aspirator is at hand, its use should be preferred to rectal puncture. PUNCTURE OF THE BLADDER ABOVE THE PUBIS. This operation may be resorted to where the prospect of reestablish- ment of the natural passage within twenty-four or forty-eight hours is ' " Practical Electrotherapeutics, Ten Cases of Organic Stricture treated by ElectroW- 3is," Keyes, New York Medical Journal, December, 18tl, p. 569, * " Medico-Ohir. Trans.," toI. xxxv., 1852, p. 153. SUPKA-PUBIC PUNCTURE. ^g-^^ not promising. No special instrument is required ; a simple gum-elastic catheter will do, but a long (six inch), slightly-curved double silver tube (Fig. 51), modeled exactly like a modern tracheotomy-tube, into which a suitable trocar can be fitted, is most convenient. The inner tube should project beyond the outer, and be furnished with eyes near its point. Fio. 51. which latter should be rounded, the size of the whole not being more than No. 10. The inner tube should be withdrawn and cleaned every forty-eight hours, the bladder washed out, and the external tube kept constantly in place. The operation is not a diificult one. The mons veneris is shaved, and an incision made down to and through the linea alba. Then, with the handle of a scalpel, the fat and connective tissue are separated until the fluctuating bladder can be felt. An assistant now makes gentle pressure upon the abdominal walls, while the surgeon, with his finger on the bladder close above the symphysis pubis, forces the tube above de- scribed, armed with a well-fitting trocar, quickly into its cavity. The tube is snugly tied in with tape, and the wound stitched around it. A piece of yellow English elastic catheter may be used instead of the tube, but it is kept in place with more difficulty. On account of the possibility of infiltration, the outer tube should not be removed until the walls of the new route have become consolidated throughout, which is accom- plished in three or four days. Case XVII. — A patient was brought to the New York Hospital upon whom this opera- tion had been performed some weeks before, but who had carelessly allowed his instru- ment to become displaced. Retention recurred, and the urine, finding an outlet through a breach in the walls of the new route, followed the extra-peritoneal layer of connective tissue through the external abdominal ring, and into the walls of an old hernial pro- trusion. This caused the latter to present such an equivocal appearance as to call for an exploratory operation in view of the possibility of strangulated or inflamed hernia. Through the incision, made for this purpose, the extravasated urine escaped so freely as to efface the swelling, and render the opening of the hernial sac unnecessary. In case of any necessity to change the instrument before consolida- tion of the tissues has taken place around it, it is necessary first to pass a probe-pointed stylet through the tube, to the floor of the bladder ; over this the tube is withdrawn, and the one destined to replace it is passed carefully upon the stylet to its place. With care there is very little danger of wounding the peritoneeum in supra-pubic puncture, as its J 32 STKICTUEE OF THE URETHRA. reflexion is drawn well up out of the way by the distended bladder. Puncture through the symphysis pubis, and below the pubes alongside of the root of the penis, has not yielded satisfactory results. THE ASPIEATOE. The aspirator is an instrument which has been recently brought prominently into notice by Dieulafoy,' of Paris. Several modifications are in the shops already, and a vast amount of experience, obtained since the instrument has been introduced into general use, has established its reputation as a safe and most useful assistant to the surgeon interested in surgical diseases of the genito-urinary system. The instrument is used for the exploratory and therapeutic tapping of cavities for fluids or gases. Ample experience has demonstrated that a fine exploring trocar and canula may be plunged with safety through both layers of peri- tonaeum into the cavity of the intestine, into the bladder, into the cavities of joints, into the pleural sac, even through the pericardium, without lighting up any appreciable inflammatory trouble. Hence the value of this instrument in cases of retention becomes at once evident. It has been used day after day in such cases, the urine being drawn off safely, the canula withdrawn, and a new puncture made at each tapping. Within the space of eight days, twenty-three punctures were made in one case,° while, in another case," eleven punctures were made within a circuit that could be covered by a ten-cent silver piece, without the least evil result. Consequently, where the surgeon possesses this in- strument, it is to be preferred to all others for tapping the bladder. Where he does not possess it, rectal or the ordinary supra-pubic punc- ture may be resorted to. The impunity with which the bladder may be tapped, even with a large instrument, may perhaps be best illustrated by a case reported by Dr. Clarke,* of Geneva, New York. The case was one of retention, from enlarged prostate, where catheterism proved impossible. Dr. Dox punc- tured the bladder above the pubes, without any previous incision of the skin, with an ordinary trocar, one line in diameter, and evacuated two quarts of urine, after which the canula was immediately withdrawn. This operation was repeated six times in eight days, without any pre- cautions, and was followed by no ill efiects. After the eighth day the patient reacquired (and at the date of the article still retained) the power of urinating by the urethra, as well as he had before his retention. Such an excellent result could not be counted on in most cases.' Dieulafoy's smaller instrument is very portable, and is convenient ' "Traits de I'Aspiration des Liquides morbides," Paris, 1873. ' Guyon, Obs. II., Dieulafoy. ^ Uouzel, Obs. VIII., Dieulafoy. * Medical Record, June 1, 1872. * Maisonneuve was in the liabit of puncturing bladders in tliis manner, with an ordi- nary fine trocar, at the Hutel-Dieu, Paris, in 1866. — Keyes. THE ASPIRATOR. 183 for tapping- the bladder; the box containing it measures eight and a half, by four and a half, by one and three-eighths inches It con- sists, essentially, of a glass cylinder, with tight-fitting piston, and two stop-cocks, a flexible tube, and pointed hollow needle. Of the latter there are several sizes, the finest two-thirds ' of a millimetre in diameter, twelve centime- tres long, and fine enough to be used safely in all cases (Fig. 53). The method of using the instrument is the following: First, be satisfied that the fine needle is pervious — not occluded by rust or otherwise. Attach it beyond stop-cock B, or to the flexible tube, as shown in the figure. Shut both stop-cocks, B and B' ; withdraw the piston forcibly, thus forming a vacuum. By a half-turn from left to right, hook the angle A above the point B, thus keeping the piston withdrawn. The instrument is now ready for use. The point of election in puncture of a distended bladder is through the linea alba, about half an inch above the symphysis pubis. Into this spot the needle is plunged for half an inch. Now stop-cock B is turned on, and a vacuum is thus created within the flexible tube and needle. Next the needle is slowly and cautiously pushed forward until urine is seen to flow into the glass cylinder. It flows slowly on account of the size of the needle, but no pressure is required to help it. The needle is next pushed, perhaps, an inch farther into the bladder, and then there is nothing more to do until the glass cylinder is full, after which B is turned off, B' is turned on, A is unhooked, the piston is driven gently home, expelling the urine at B'. B' is now turned off, the cylinder again exhausted, B turned on, and so on, until the bladder is relieved, after which, the vacuum of the cylinder being maintained, the needle is rapidly withdrawn. The operation may be repeated as soon as the bladder refills. 2 \ l\ L I H Fia. 134- STRICTUBE OF THE UEETHEA. CHAPTEE YII. STRICTURE OF THE URETHRA. Diagnosis.— Use of Bulbous Bougie.— Symptoms of Stricture and its EesuJts as affecting the TJretlua, Bladder, Kidneys, Testicles, Kectum, Nerves, etc., including a Consideration of Inf Itration, and the Hannlessness of Healthy Urine in contact with the Tissues. — Causes of Death from Stricture.— Eeeapitulation of Symptoms and Effects of Stricture. Diagnosis. — Few morbid conditions of the body are more easy of diagnosis than organic stricture of the urethra. To examine for strict- ure, a bulbous bougie is selected of the largest size that the meatus will admit. It is oiled, introduced, and passed gently down the canal. If it goes on unobstructed into the bladder, there is no stricture ; other- wise there is, for the meatus is the smallest part of the normal canal. When the instrument is arrested by an obstruction, it should be seized with the thumb-nail and fore-finger at the meatus and withdrawn. The distance between the bulbous point and that part of the shaft seized by the thumb-nail (measured on the side of the scale-plate) indicates the distance of the stricture from the meatus. Smaller bulbous bougies are now tried, until one is found which wiU just pass through the stricture. This indicates the calibre of the contraction. After the bougie has passed into the free canal beyond, it should be retracted until its shoulder is arrested by the stricture. Now the thumb-nail is again placed at the meatus upon the shaft of the instrument, and the whole withdrawn and measured. The difference between the two measurements will give the length of the stricture. Having localized and studied out one stricture, a bulbous bougie which will pass through it is employed, in the same manner, to search the canal beyond, it being a rule, with few exceptions, that where several strictures exist the calibre of any one is smaller than that of all the others between it and the meatus, and larger than that of all deeper-seated contractions.' These bulbous bougies will detect tender places in the urethra, where no thickening exists, and will easily appreciate slight diffuse thickening of the urethral walls, not yet sufficiently defined to be pronounced strict- ure of any given length. Occasionally, in a sensitive, irritable urethra, the head of the bulbous bougie will be stopped by a musciiiar spasm of the canal, but this rarely except at congested, sensitive spots, or by contraction of the muscles surrounding the membranous urethra. Gen- tleness and a little delay will usually overcome this kind of obstruction, ■ If the bulb is arrested lower than six inches, it is suggestire of enlarged prostate, especially in patients beyond fifty-five. SYMPTOMS AND RESULTS. 105 and, after the instrament has passed the constricted part, and an attempt is made to withdraw it, the spasmodic, muscular nature of the constric- tion can be easily appreciated. The muscles will be felt to " bite " the instrument, quiver a little, then suddenly let go and recontract. In cases of doubt, a blunt, full-sized, well-warmed and oiled steel sound should be passed down to the obstructed point and gently pressed against the obstacle to tire out the muscles, which, after a few minutes, will sud- denly relax and the instrument will glide rapidly into the bladder, unless other obstacles exist. Stricture of the meatus may be predicated whenever the orifice is seen to be involved in a cicatrix, or when- ever a probe introduced within it can demonstrate a distinct pocket behind the superior or (more commonly) inferior com- missure of the orifice (Fig. 53). Care must be exercised not to con- found lacunae, which catch the points of j.,q ^ small instruments, with stricture. The endoscope and model bougies will not give any information which may not be obtained more easily by the means above detailed. Symptoms and Results of Steictuee. — Stricture may exist for years without giving rise to a single symptom of sufficient importance to attract the patient's attention. In fact, it may be said that stricture has necessarily no symptoms until it has become so tight as to sensibly obstruct the outflow of urine and semen, or has been attended by so much callous overgrowth as to interfere with the flow of blood through the meshes of the corpus spongiosum. A man may have stricture of small calibre of any part of the canal, but especially of the meatus, and yet never suffer from it in any waj' until adult life — perhaps never at all ; but this is exceptional. Case XVIII. — A young married man, of twenty-four, a Jew, applied for relief of a very considerable degree of irritability of the bladder, which had been coming on for some time, the desire to urinate recurring as often as every hour. On examination, it was found that his meatus was involved in a smooth circular cicatrix. Being questioned as to the origin of this scar, the patient declared tliat he had always had it, and had con- sidered that it was natural. He had never had any wound or ulcer upon his glans penis. It was subsequently ascertained that the wound had been made by the knife of the priest when the patient was circumcised upon the eighth day after birth, according to the Jewish rite. The stricture of the meatus caused by the healing of the wound had never given rise to any symptom until adult life, and then the only symptom was a frequent and urgent desire to urinate. The stricture was treated by incision, and the bladder-symptoms quickly subsided and remained cured. Case SIX, — A healthy married gentleman, of forty-two, apphed for treatment of frequent urination. He passed water from fifteen to twenty times daily, but was rot troubled at night. When watched, he could not urinate at all. The meatus admits No. 8, and has a pocliet behind the lower commissure. This was slit, and No. 15 passed at 136 STRICTURE OF THE URETHRA. once. After the operation the calls to urinate recurred but five times daily. The meatus healed in a few days, admitting Xo. 17 without stretching. In this case the meatus w.as occluded by a thiu duplicature of mucous membrane, which, when cut, scarcely bled. The patient has never suffered from this narrowing until now — his forty-second year. A lawsuit, full living, and excessive smoking, were the. im- mediate exciting cause of the appearance of symptoms. Instant relief followed the re- establishment of the full size of the canal. This case demonstrates the value of looking for the " pocket " at the lower commissure in obscure cases of bladder-disease, where there has been no antecedent local disorder. The symptoms usually described as those of stricture are mainly the sym20toms of the results of stricture, and consequently a description of these latter finds its place here. A certain small amount of gleety discharge from the congested (or it may be granular) surface usually accompanies the forming stage of stricture, but tliis may be so slight as not to attract attention, or may be entirely aljsent. Exceptionally urethral or other neuralgia depends upon stricture in the forming stage (Case XIV.). Tlie results of stricture are mainly mechanical in the first place. The strictured portion is less dilatable than the rest of the canal, and acts somewhat like a dam. The urine coming down with great force, and striking against this unyielding bar, tends to dilate the urethra behind it (Fig. 54), and this directlj' in proportion as the stricture is slow in form- ing, and dense in structure. If more than one stricture ex- ist, the urethra may be dilated between them. This stretch- ing process tends to dilate the mouths of all the ducts open- ing into the urethra behind a stricture. In this way the sinuses and mouths of all the follicles become enlarged, and capable of entrapping the point of a fine instrument. This is also true of the ducts in the prostatic sinus, which may become so pouched out that the floor of the prostatic urethra becomes reticulated, and composed entirely of de- pressions, separated by thin fibrous partitions — these latter representing Fig. 54. — Taken from a p.ithologicaI specimen, showing stricture of membranous urethra, with dilatation be- hind it, hypertrophy of bladder, dilatation of ureters, pelves of kidneys, etc. DIAGNOSIS. , -j^g^ what is left of the tissue which existed originally between the ducts of prostatic follicles. The ejaculatory ducts may be distended in the same way ; as may also, though rarely, the seminal vesicles— the urine being forced back into them. The force exerted laterally by the urine propelled through the urethra by the contracting bladder is much greater than is generally supposed. To understand this, it is only necessary to call to mind the hydrostatic paradox, which demonstrates the equal pressure of fluids on every square line of surface with which they come into contact. This forcible stretching of the mucous membrane behind the stricture at every act of micturition, although only slight in extent at first, weakens the tone of the stretched portion of the canal, congests it, and leads to the formation locally of an excess of mucus. If the urine be acid and irritating, these effects take place all the more rapidly. Soon a drop of urine is retained behind the stricture in the dilated portion of the canal, the mucus acting upon it as a ferment alkalinizes and decomposes it, liberating carbonate of ammonia. This acts upon the stretched urethra, and produces inflammation. This mild inflammation behind stricture is very constant. It furnishes the gleety discharge, or the morning drop of muco-pus, which glues the lips of the meatus together. The gleet of stricture gets better or worse according to the general condition of the patient, the degree of acidity of the urine, and the amount of sexual indulgence or venereal excitement. Exacerbations of gleet from slight causes, or repeated attacks of gonorrhoea, as the patient usually considers them to be, often constitute the most marked feature of the case, in a patient with stricture. In fact, it is the rule in mild cases that the patient is wholly unconscious that his urethra is at all nar- rowed. He applies for treatment, on account of his gleet, for an attack of gonorrhoea, as he calls it (bastard gonorrhoea, p. 56), and often refuses to believe that he has stricture, or that, if stricture does exist, it is of enough importance to occasion his symptoms ; and he repeatedly asserts that he makes as large a stream of urine as ever. Nothing so well as the bulbous bougie will convince such a patient of his condition. The evidence of this instrument he must admit. The gleety discharge, once commenced behind the stricture, rarely ceases entirely until the constriction has been relieved. The same discharge wiU be seen in the urine in the shape of small, stringy shreds, formed of pus-corpuscles which have been washed ofl" from the congested surface behind the stricture, and rolled into threads on their way out of the canal. These shreds may be all caught in the first gush of urine, what follows being perfectly free from them. When these white filaments are seen settling down in a glass of urine freshly passed, they constitute strong pre- Eumptive evidence of the existence of stricture ; they may be due to other lesions. As the stricture tightens, fresh symptoms are added. A cartilaginous £38 STEICTTTKE OF THE UKETHEA. hardness may often be felt from the outside of the urethra at the con stricted point. The meatus urinarius looks blue and congested, as does sometimes the whole glans penis, from obstructed circulation. The gleet continues, the stream of urine is small, often forked or curving up in a curious manner just after leaving the meatus, or there may be several streams running in different directions, or oftener one stream is projected for a certain distance, while the other drops down perpen- dicularly from the end of the penis. The last few drops of urine are retained in the canal, both mechanically by the obstruction of the stricture, and because the wave of blood, impelled by the contraction of the accelerator urinse upon the bulb in the final effort at clearing the canal, cannot pass along the corpus spongiosum, on account of the obliteration of its meshes at the point of stricture, and thus fails in its function of expelling the last few drops of urine from the canal. By this same obliteration of spongy tissue, erection is sometimes rendered imperfect and painful. The surface congestion of the stretched urethra behind the stricture in time extends backward to the bladder, and brings on irritability (so called) of that organ. The intervals between the acts of micturition grow shorter and shorter, and symptoms of mild cystitis appear. This frequency of micturition is the symptom of stricture, next to gleety discharge, which is least often absent. A slight narrowing of the canal may occasion it, as where the meatus is congenitally small, and it may come on with any stricture, as pure irritability, undoubtedly attended by congestion about the neck of the bladder, but not necessarily by any true cystitis. The congestion of the urethra behind a stricture easUy becomes greater, is kindled into positive inflammation by dining out, a little excess in drink, or a chilling of the legs ; the mucous membrane swells up, the stricture closes, and the patient has retention of urine. If this retention is unrelieved, the bladder becomes overstretched ; after many hours a few drops of urine will escape from the meatus (overflow), and the patient thinks he is getting better. If this condition of over- distention is allowed to continue unrelieved, the contractile power of the bladder may be permanently injured (atony). Retention may he the only disagreeably prominent symptom connected with a case of stricture. The gleet may not have been noticed, the gradual decrease in the size of the stream may have been ignored, when, after exposure, excess, a carouse of beer, retention suddenly comes on. Some patients will have had several attacks of retention before they apply for relief. The spasm and inflammation which caused the narrow canal to become obliterated in these cases cease after a few hours, and then the patient goes on perhaps for a year or more, without having another retention, not suffering noticeably in the mean time. If retention does not come on, the inflammation, once aroused behind SYMPTOMS AND RESULTS. joq Stricture, gradually, sometimes rapidly, travels back through the pros- tatic urethra into the bladder, and we have cystitis of the neck. Now commences what was before absent, or, if present, only to a mild degree, a frequent desire to pass water, at first every three or four hours, once at night, and gradually at shorter and shorter intervals, until, whe'n the patient seeks relief, he may be passing water in a fine stream every half- hour or fifteen minutes, with great pain and straining. Blood sometimes flows with the urine at the beginning or end of the act. Mmmaturia may be, exceptionally, the most prominent symptom of stricture, indeed the only one noticed by the patient for a long time, as in the following case : Case XX.— In December, ISYl, , aged twenty-seven, came complaining of passing blood and having stricture. He had been married for six years, but his wife had not become pregnant. Twelve years previously had occurred his only gonorrhosa. It was attended by hsematuria, and got well in a month. Slight gleety discharge soon reappeared, and has continued in greater or less amount ever since. In the autumn of 1869, while perfectly well and at work, he noticed that his urine was bloody. He had no pain at the time, and did not know that his stream was smaller than usual. From that time to date he has never passed water untinged with blood ; often, to the unaided eye, it looks like pure red blood. He was treated medically, and finally for stricture, by the introduction of small instruments (up to No. 9), but all to no purpose. His stream became noticeably smaller ; he was obliged to pass water every hour, several times a night, but the urine was not decomposed or ammoniacal, and contained no appreciable amount of pus. He felt weak from loss of blood, but had absolutely no pain. The amount of blood in the urine varied from time to time, but from no appreciable cause. He stated that he used to pass large clots as big as his thumb at about the middle of the stream. These evidently formed behind the stricture, but were not able to squeeze through it until "the middle of the stream," when the force of the current was greatest and the dilatation most positive. Sexual power was unimpaired, the orgasm perfect, but no semen issued at the time. It dribbled away afterward. A hard, callous stricture was found to exist at six inches, admitting a No. 6 bulbous bougie. A filiform whalebone guide was introduced, over this Thompson's divulsor, and the stricture was stretched to No. 17 ; only a little blood followed ; after a week No. 16 was passed quite easily. The patient's intervals of urinating were twice as long after the opera- tion, and the amount of blood passed uniformly small. His meatus was cut, and finally No. 21 passed, but still the bleeding continued, the urine often looking like pure arterial blood, and the patient remaining blanched and unable to work, although passing a full stream at two or three hour intervals. The treatment above detailed extended over the space of about a year. This patient was finally cured by the application several times of solid nitrate of silver to the urethra behind the stricture. He is now fat and comparatively well, introduces No. 18 himself, and usually passes clear urine. Sometimes, however, it is still slightly tinged with blood for a few days, when it again clears up. Along with symptoms of vesical irritation, often before any actual inflamma,tion of the bladder has occurred, are found pains various in character and situation. Pain in the urethra, aching of the glans penis, or in the testicle, along the cord running up into the back. Pains across the lumbar region, in the perinseum, around the anus, and m the rectum, over the pubis, etc., and other obscure pains of a neuralgic sort. ^40 STEICTUEE OP THE UEETHBA. in the thiglis, legs, or in the sole of the foot ' (Brodie), all of which pains are cured by the dilatation of the stricture. Urination is often painful (sometimes excessively so), the pain being at the neck of the bladder, in the perinceum, at the point of stricture, or near the glans penis. Erections may be painful, the venereal orgasm attended by pain, the semen not being discharged during the sexual act, but often dribbling away after- ward, perhaps stained with blood, or running back into the bladder, to be discharged with the next flow of urine. Impotence sometimes ac- companies this condition. The sexual appetite is often impaired, some- times nearly obliterated, in old severe cases. But, in mild cases, the congestion kept up behind the stricture may be just enough to excite and irritate the patient, causing frequent erections, erotic fancies, noc- turnal emissions. The constant straining in urination keeps the hEemorrhoidal vessels congested. This results not unfrequently in an attack of piles, or of pro- lapse of the rectum ; occasionally, hernia occurs from the same cause. The straining may be so violent that the bowel will protrude at every eifort to empty the bladder, making it unsafe for the patient to attempt to urinate except upon a close-stool, for fear of the passage of issces at the same time with the flow of urine. The inflammation of the bladder caused by stricture is usually super- ficial, but it may become parenchymatous, perhaps accompanied by ab- scess in the walls of the bladder, or in the connective tissue around it. The bladder-walls, as a rule, thicken, while their dilatability diminishes, in cases of stricture (Fig. 54). The detrusor, constantly called upon to force the urine through a narrow orifice, becomes thickened and hyper- trophied, sometimes to the extent of one-half or three-quarters of an inch. Trabeculae of muscular tissue project upon the mucous surface of the bladder, and between these trabeculae the mucous membrane may pro- trude, forming pouches or sacculi. The bladder may contract to such an extent as to have its cavity almost totally obliterated, its muscular walls having undergone fibrous degeneration, which has rendered them non- distensible. In this condition (concentric hypertrophy) we may have a constant flow of urine from the urethra, which the patient cannot con- trol (incontinence), to be carefully distinguished from atony, with over- flow. Instead of incontinence, in this condition, the patient may be obliged to empty his bladder every few minutes, after a few drachms of urine have accumulated, which seem to be bursting the organ. The urinary salts sometimes deposit in vesical sacculi, or a smaU renal calculus lodges there, forming a nucleus for stone. The more obstruction there is in the urethra, the more pressure is brought to bear upon the sacculi, and the 1 Or in the great-toe. The pain is sometimes compared to uitenae heat, sometimes to icy coldness, sometimes it is actual pain over a given small area. SYMPTOMS AND RESULTS. 141 larger they become, so that sometimes they equal, or exceed, tlie size of the cavity of the bladder. As the sacculus enlarges, its neck remains constant, and, if stone form in it, the stagnant urine (for there is no sur- rounding muscular tissue to empty it) furnishes constantly fresh sup- phes of urinary salts to increase the size of the stone, so that finally the latter may fill up the sacculus, constituting what is known as en- cysted calculus. Instead of contracting, the bladder may (rarely) dilate. In these cases there has not been so much irritability, and the bladder has not been called into such constant use ; or overstretching may have been followed by atony, in which case overflow occurs, apt to be mistaken for incontinence. Inflammation of the mucous m.embrane is found, in these cases of eccentric hypertrophy also, together with the trabeculae of hy- pertrophied muscular tissue and the sacculi. These conditions of vesical and urethral irritation, or others, such as stone, are sometimes, but very rarely, attended by partial paralysis of some groups of muscles of the lower extremities, or indeed by para- plegia. These paralyses have received the name of reflex urinary paralysis, and seem to depend upon the morbid condition of the urinary organs, and to be relievable, sometimes even curable, by treatment of the urinary difficulty.* Not very infrequently mild syphilitic paraplegia is mistaken for urinary reflex paralysis, especially if the urethra or blad- der happen to show any trifling lesion. The urine, in cases of cystitis caused by stricture, is partly decom- posed and filled with blood, pus, crystals, etc., as occurs in cystitis from other causes. Phosphatic stone may form. The ureters enlarge in con- nection with old stricture, sometimes to the size of the thumb. Their walls become unevenly thickened and their calibre enormously increased by the retained urine (Fig. 54). The pelves of the kidneys undergo the same distention, the tubuli and secreting portions being pushed out and compressed by the accumulating urine. After the inflammation at the neck has involved the whole internal surface of the bladder, it may extend up the ureters and enter the pelves of the kidneys, bringing on pyelitis, or attack the secreting portion as a subacute nephritis with more or less suppression of urine, attended by symptoms of ursmia. Finally, and more rarely, may be mentioned abscess of the kidney with perinephritis. ExiBATASATiON. — ^The thinned and inflamed urethra behind stricture may ulcerate, and, during one of the violent paroxysms of straining, give way, and allow a little urine to escape into the cellular tissue around the canal. The patient is often conscious of something having " broken " in the urethra. The amount of extravasated liquid may be very small, or a sudden gush of urine is, perhaps, let out into the connective tissue. ' Brown-Sequard, "Lecture on Reflexed Paraplegia," Lancet, 1863; and " Lechirea on the Diagnosis and Treatment of the Principal Forms of Paralysis of the Lower iix- tremities," Philadelphia, 1861. j^42 STRICTURE OF THE URETHRA. In tlie former case we have abscess, or perhaps blind internal fistula, which may continue as such for many months. Its presence is indicated by a hard lump around the urethra, varying from the size of a large pea to that of an English walnut, usually sensitive to pressure, sometimes slightly painful at each act of micturition. This hard lump more or less rapidly enlarges, though it may remain stationary for an indefinite period, or even decrease in size ; urethral fever comes on, generally de- scribed by the patient as " dumb ague ; " the appetite fails, and the general health runs down ; finally, pus forms and finds its way out through the perinseum, leaving a fistula behind. Instead of this slow course, if the quantity of urine which escapes is a little larger, acute perineal abscess forms. The pus may burrow in all directions, and finally find an exit through the scrotum, along the body of the penis, upon the thighs, nates, or groins, or even upon the lower part of the abdomen. Sometimes the whole perinseum is riddled with holes through which the urine escapes, perhaps not one drop passing by the natural channel. In these cases the patient makes water sitting, the urine escaping as if through the sprinkler of a garden watering-pot. Civiale ' reports a case of urinary fistula with fifty-two external openings. The hard lumps outside the urethra, above alluded to, do not necessarily indicate that urine has escaped from the canal. An abscess may very rarely start outside the urethra near a stricture, just as pus may form near the anus, not primarily in connection with the gut. In the vast majority of these cases, however, the first lesion is upon the urethral mucous membrane, one of the dilated foUicles behind the stricture being at fault. A drop of urine is retained in a follicle, decomposes, and causes it to necrose and slough ; another drop of urine is then let in, more tissue is destroyed, and more inflammatory action set up in the neighboring tissue. This process goes slowly on, a drop of urine from time to time being let into the abscess through the mouth of the follicle, which is usually kept shut by the surrounding inflammatory swelling. The abscess now is not connected visibly with the urethra ; it breaks externally, and it is only after a few days that the swelling decreases sufficiently to allow a httle urine to get in at the fissure in the urethral wall, and to appear at the perineal opening. Much light has been thrown by Zeissl ^ upon the agency of this follicular necrosis in allowing extravasation of urine. Such abscesses forming around stricture may break internally and let in the urine in quantity, thus forming blind mternal fistula, or they may break externally, or point by both routes. Fistulee are conservative efi'orts of Nature to establish an outlet for the urine, the natural course being dammed up. They will not close until after the stricture has been relieved. They narrow down after a ' Op. cit, vol. l, p. 639 ' "Zur Perforation der Urethra,'' AUgem. Med. Wien. Zeilung, 1861, ii. EXTRAVASATION. , -o whOe into little pipes surrounded by callous inflammatory material. Sometimes a deposit of the urinary salts takes place upon their walls', and they become inorusted with calcareous matter. Sometimes they get blocked up, especially if the internal orifice is larger than the external ; then a little urine collects within them and a new abscess is formed which may burrow farther and find for itself a new outlet establishing another fistula. More rarely a small abscess may form in the prostate, and, going through the stages just narrated, opening into the urethra and into the rectum, constitute what is known as prostatic fistula ; or more rarely still some small ulceration in the floor of the bladder may give way into the rectum, making a vesico-rectal fistula. If, instead of a drop of urine escaping from the urethra into an ulcerated follicle or fissure in an ulcer behind the stricture, the ulcerated portion has given way largely, perhaps by necrosis of a group of urethral follicles, we have the serious complication known as infiltration of urine. More or less of the altered fluid escapes in these cases outside of the canal, and burrows at once extensively. It is a property of decomposed ammoniacal urine to destroy the vitality of Hying tissue wherever it comes into contact with it, unprotected by epithelium. This property does not belong to limpid healthy urine. Menzel ' demonstrated this fact experimentally. He first used acid urine, injecting it under the skin of a dog in quantities, varying from a drachm to an ounce without any bad effect in several experiments. He dissected up the skin of a dog to the breadth of four inches, and injected eight ounces of healthy human urine in four different cases. The urine was all absorbed within four days in three of the cases, in the other healthy pus formed. He repeated these experiments in the ischio-rectal fossa without bad results in five cases. To test the opinion of Simon," that the compression and distention of the tissues in urinous infiltration was the cause of gangrene, Menzel performed two experiments, injecting healthy urine into the tissues with such force as to raise a tumor of the size of the foetal head, and then prevented the escape of the fluid through the wound by means of suture. The quantity injected amounted to about half a pint, but in both cases it was absorbed without evil result within three days. The next experiment consisted in cutting down upon the urethra of a dog and sewing up the wound so as to obtain infiltration. At eacl angle of the wound a fistula formed, but there was no poisoning or ex tensive death of tissue. He repeated the same experiment, tying the glans penis so as to cause all the urine to flow into the wound. An im- mense tumor formed, which only subsided when the glans penis became gangrenous and separated. The dog got well, with simplj' a fistula. In other similar cases he obtained the same result. From these experiments Menzel concluded : ' Wien. Medhin. Wochenschrift, Noa. 81-85, 1869, and N. T. Med. Journal, 18V1. ^ " Chirurgie der Nieren." 144 STRICTURE OF TBM URETHRA. 1. That normal urine does not possess septic qualities, and does not produce gangrene by its ohemical properties. 3. That distention by infiltrated urine does not produce gangrene. 3. That gangrene, when it does occur (on infiltration of healthy urine), is caused by contusion or the accidental inoculation of septic matter. Menzel next experimented with urine containing soda or potash. Urine so alkalinized proved innocuous ; but urine rendered alkaline by ammoniaoal fermentation he found to be exceedingly poisonous, and, when injected, to cause large abscesses and cutaneous gangrene. He also injected putrid urine directly into the blood, and obtained symptoms of blood-poisoning. He further adds the clinical experience of Prof. Billroth in nine cases of infiltration. In one, the urethra was perforated by a catheter ; in three, there was a crushing injury to the perinseum; in another, laceration of the urethra by a splinter of bone from the pelvis ; in the rest, rupture of the urethra behind a stricture. Death followed in four cases, in two of which there was stricture, and the urine prob- ably ammoniacal. These results, experimental and clinical, correspond with daily ex- perience as well as with some (personal) experiments ' undertaken upon the human subject — since the evidence derived from dogs and rabbits has been doubted — to substantiate the fact. that healthy urine, injected into the connective tissue without contusion of that tissue, is as capable of absorption as the blandest fluid. This is true at least when a small amount is used (3 j), a quantity certainly sufficient to establish that healthy urine, per se, is not destructive to human tissues. Muron," an interne of Verneuil, stimulated seemingly by the results obtained by Menzel, performed a series of experiments by injecting urine under the skin of rabbits. His results corresponded closely to those reached by Menzel, only differing in one respect : for, while Menzel states that only urine in alkaline fermentation has destructive powers, Muron proved (upon rabbits) that urine strongly acid, dense, and full of salts, urates, etc., has the same powers to a less degree, attributable, he believes, to the density of the fluid injected, which by the law of osmosis attracts serum from the vessels instead of itself being absorbed into the latter ; and again to the fact that urine, rich in urates, is apt to decompose quickly ' ' Dr. Partridge, one of the surgical sta£F of the Charity Hospital, injected, at my suggestion, under the skin of negroes and white patients, on many different occasions, thirty and sixty minims at a time, of healthy urine, lunpid and taken indifferently from any source, the patient supposing that morphine was being injected. Absorption was perfect in every case. No abscess, no local death of tissue, followed any injection. Dr. L. A. Stimson informs me that, in the winter of 1873, he saw Vulpian, in Paris, inject healthy human urine into the blood-vessels of dogs, in one case three and one- half ounces, without disagreeable result.- — Ketes. ^ "Pathog6nie de I'lnflltration de I'Urine," Paris, 1812. ' That Muron is incorrect in ascribing necessarUt/ destructive properties to dense acid urine, rich in urates, I think must be granted. I obtained a specimen of urine from a child with acute inflammatory rheumatism. It was strongly acid, sp. gr. 1040, and de- EXTRAVASATION. j^g Hence it may be affirmed that healthy urine does not, per se, kill tissue, unless that tissue be contused and inflamed (absorption thus prevented and urine allowed to decompose in situ), and that, with infil- tration relieved by free incision, the prognosis is vastly better if the bladder were previously healthy. After urethrotomy, and operations for stone, how rare is infiltration, when the urine is comparatively healthy and has a chance to escape, although it passes over a raw surface on its way out 1 The practical deduction from the above is, to let out urine as soon as it has _ extra vasated, and the chances are that serious gangrene may be averted unless the urine was strongly ammoniacal and decom- posed before its escape, which is, unhappily, too often the case. In infiltration the urine may take any one of five directions : 1. It may when small in quantity get out of the urethra, but not penetrate Buck's fascia (p. 3), in which case it may long remain con- fined to one spot in the perinseum as a hard, rounded swelling — like the blind internal fistula already described. 2. It may find its way rapidly through the meshes of the corpus spongiosum and cause gangrene of that body, with sloughing of the glans penis, preceded by coldness and the appearance of a black spot upon the glans. 3. It may burrow inside of Buck's fascia, but outside of the corpus spongiosum, forming a fistula opening behind the glans penis or on the back of the penis near its root, a hard ridge marking the course of the fistula within Buck's fascia. 4. It may escape behind the triangular ligament into the cavity of the pelvis. 5. It may escape outside of the common fascia of the penis, in front of the triangular ligament; in which case it rapidly distends the peri- nseum, the scrotum, and the connective subcutaneous tissue of the penis, and mounts up over the abdomen, and may also, more rarely, perforate the deeper layer of the superficial perineal fascia, and descend upon the thighs. When extensive infiltration of this sort occurs, all the parts affected become oedematous ; gases form in the connective tissue, causing em- physema, and making the tissues crackle when pressed by the finger. Dark spots soon appear, indicating gangrene, and extensive portions of tissue may slough away unless relief be promptly afforded. The constitutional symptoms are those of shock. A chill usually posited, on cooling, a dense precipitate of pink urates which egieakd one-fourth of the volume of the liquid. A portion of this was taken a few hours after being passed, warmed until the urates dissolved, and injected by Dr. Partridge, of the Charity Hospital, into the subcutaneous tissue of the arm, in three patients, half a drachm being used in each case ; absorption was immediate and perfect. Twenty-four hours afterward three other patients were similarly injected from the same specimen, with the same dose ( J ss each)— only the urine was injected cold with the urates in precipitation. The bottle was shaken and the fluid resembled pea-soup. A little tenderness on pressure for a few hours marked the spot of the Injection, but absorption was prompt and complete in each case, without any suppuration. — Keyes. 10 £46 STRICTURE OF THE URETHRA. occurs, followed by great depression ; a cold, clammy skin ; feeble, quick, irregular pulse ; burried respiration ; furred tongue ; complete anorexia ; symptoms of septicsemia, and death. When the urine escapes behind the triangular ligament, which it does more rarely, it infiltrates deeply around the prostate and rectum well back in the perinteum, around the bladder and up behind the pubes, forming abscess in the cellular tissue of the hypogastrium, or perhaps deep pelvic abscesses. Rupture of Uladder. — Another very rare complication of stricture analogous to infiltration is rupture of the bladder. This occurs in the same manner as the escape of urine from the urethra behind a stricture. A comparatively healthy bladder will not rupture from retention (unless, of course, mechanical violence is added — as a fall). It wiU become im- mensely distended, and then be relieved by drops (overflow) through the urethra, the latter never being totally impervious to fluid, if time is allowed for inflammation and spasm to subside, and enough continued pressure is brought to bear upon it from within. In those rare cases, however, where a sacculus has become thinned, or an ulceration exists, the bladder may give way under the pressure of distention from reten- tion, and the urine escapes into the peritoneal cavity. The vesical tumor subsides. A fatal collapse usually soon closes the scene.' The urine may escape into the sub-peritoneal tissue, giving symptoms like those of infiltration behind the triangular ligament. The rarity of rupt- ure of the bladder in connection with stricture is shown by the few cases reported. Thompson says he never saw it, and quotes Sir Everard Home as ha,^-ing observed only two cases. Pitha refers to a case.' The kidney or ureter might be ruptured in the sam6 way through an ulce- rated spot, as they are subjected to a tension as great as that felt by the bladder. The prostatic Urethra is necessarily hypersemic, if not inflamed be- ihiad a tight -stricture, but, besides this, the substance of the prostate may undergo interstitial inflammation (abscess). The inflammation may extend down the ejaculatory ducts, seize upon the seminal vesi- cles, or, usually passing farther, involve the epididymis. Epididymitis is a very common complication of stricture. It may saffeet one or both sides, is usually very mild in character, and leaves be- •bind a good deal of knotty induration, which is slow in disappearing, :and may block up the canal and entail subsequent sterility. A certain amount of hypertrophy, with induration of the penis, and some oedema of the prepuce, is an occasional complication of stricture. Civiale ' ao- oountsfor these symptoms by the straining in urination, which prevents ■the return of venous blood, and keeps the penis congested. It is some- times due io lymphitis. ' For treatmeot, see Rupture of Bladder, ' Quoted from Mem. de la Soc. Chir., iii,, 3, 1853. ' Op. cit., p. 141. CONSTITUTIONAL SYMPTOMS. j^« in an Constitutional Distuebancb.— The constitutional disturbance Btricture is very variable. Just as one patient may have cystitis from „„ amount of contraction not capable of sensibly diminishing the size of hk stream, while another with a stricture only pervious to a fihform bougie, used with care, may pass limpid urine not more than three or four times daily, so also does the constitutional sympathy vary. As a rule the latter depends upon the complications of stricture; and a patient with very tight stricture, uncomplicated, may enjoy robust health. When, however, the urethra behind a stricture begins to inflame, and the blad- der to show symptoms of congestion of the neck, and cystitis ; when paroxysms of urethral fever become frequent; when epididymitis and abscess come on, then the whole organism shows signs of distress. The appetite and strength fail, the skin becomes dry, pale, and harsh, the mouth coated and shiny, and the patient runs down to a shadow, a liv- ing picture of misery, while his main business in life is to pass water. Causes of Death in Steictuee Cases.— Stricture is not often fatal, except in neglected cases, such as are sometimes encountered in hospitals. Death occurs in various ways. Not to mention the rare cases of sudden death following the simple introduction of an instru- ment, and only alluding to rupture of the bladder, and death following surgical operations for the relief of stricture, the causes of fatal termi- nation in cases of stricture are three : 1. Extravasation of urine, which, if extensive, kills at once by shook, or, later, by exhaustion ; and blood-poisoning with suppuration, abscess, gangrene, pyfemia. 2. Ursemia, from implication of the kidneys, by the extension of inflammation up the ureters. 3. Cachexia and exhaustion, attended by pain, loss of rest, and ina- bility to eat, due to the torment of constant unrelieved desire to urinate, and the agony and labor of the act. No more pitiable sight can be imagined than that of a man with peri-cystitis, trying to pass water every five minutes through an old tight stricture. Standing up, with his body bent forward, his head leaning against the wall, or on his knees, and half doubled up, his hands clutching at any thing within reach, he writhes and groans in agony, the sweat starting from his face, his whole body quivering and convulsed with pain. After a minute of this torture, he finds he has passed, perhaps, a teaspoonful of blcody, purulent, putrid urine, perhaps nothing at all, and he sinks exhausted upon his bed, only to renew the effort after five or ten minutes. No man can long endure torture of this sort. If the surgeon does not soon bring him relief, death will be more kind. Recapitulation of Symptoms of Steictuee. — The symptoms of stricture are, brieflj", narrowing of the canal, with dilatation of the ure- thra behind, blueness of the meatus, irregularities in the stream of urme, shreds of pus-corpuscles in the urine, pain, neuralgia of the urethra, US TREATMEXT OF STEICTCRE OF THE UEETHKA. retention of urine, overflovr, dribbling, imperfect erection, irritability of the bladder, hasmaturia, impotence — from urethral obstruction to escape of semen. The remoter results of stricture are cystitis, with various inflammatory, functional, and structural changes in the bladder, tu-eters, kidneys, rectum, often terminating fatally ; stone in the bladder, infiltra- tion, perineal abscess, fistula, rupture of bladder, epididymitis, and ste- rility — from obUteration of the canal of the epididymis. A word must be said here concerning the effect of the sexual ele- ment in aggravating the symptoms of stricture. This is especially true concerning all painful, nevu-algic, and functional disturbances. An un- married man frequently tortures himself with fancied ailments, which he ascribes to stricture ; or declares himself strictured when the canal is sound, imploring sympathy and demanding energetic treatment. Fan- cied stricture, next to fancied spermatorrhoea, is a very common hypo- chondriacal expression of perverted sexuality, such as is found among those who heedlessly allow the brain to stimulate their erotic fancies and sexual needs, without being able to set Nature at rest by satisfying her demands, or who, on the other hand, abuse themselves sexually by physical as well as intellectual excess. These patients require kind and gentle management. They must be put right about the cause of their troubles, and their sexual hygiene must be regulated. This can be accomplished only by marriage, or by purity of thought and absolute continence. CHAPTER Vni. TREATJ^EYT OF STRICTURE OF THE URETHRA, With Details for all Complications, and a Becapitolation. The treatment of stricture of the urethra, and of its results, may be considered imder three heads : 1. Treatment of TTncomplicated Stricture — (ff.) Of Large Calibre. {h.) Of Small Calibre, (c.) Of the Meatus. {cl.) Traumatic, (e.) Resilient — often irritable. a. Treatment of Stricture comiMcated hy — (a.) False Passage. (5.) Retention, (c.) Retention — the Stricture being impassable. UNCOMPLICATED STRICTURE— DILATATION. 149 {d.) Infiltration. (e.) Abscess. (/.) Fistula. (g.) Peri-cystitis. (A.) Enlarged Prostate. 3. Treatment of Fistula with Loss of Substance. 1. Teeatmest of Uncomplicated Steictuee. (a.) Of Large OaUbre.— The majority of strictures wliicli the surgeon IS called upon to treat are of large calibre. The symptom of whiclTthe . patient complains is persistent gleet, following gonorrhoja, or bastard gonorrhoea, with, possibly, some frequency in urination. These cases are of daily occurrence and often pass unrecognized, the gleet being treated, the stricture overlooked. Too much stress cannot be laid upon the importance of exploring the urethra, in such cases of gleet, with the bulbous bougie. One, two, or more strictures are found, the smallest, which is probably the deepest, allowing passage, perhaps, to a No. 9 bulb. Treatment here is most simple. After the diagnosis has been made, no further instrumentation is advisable (if the patient can spare the time), until the effect of exploration has been observed. The chances of urethral chill, after first examinations, must be remembered. The patient's general condition and habits must be studied, and his urine tested for acidity, or possible kidney-disease. He must be instructed in urethral hygiene, and the nature of his malady explained to him, and he should be informed at the outset, to forestall future disappointment, that, after his sj-mptoms have been removed by treatment, the per- manence of his cure will almost certainly depend upon his own regular and intelligent use of an instrument upon himself at proper intervals, with the view of preventing tendency to recontraction of his stricture. Being instructed not to mind the smarting at his next urination, and given such alkali, balsam, or injection, as the acidity of his urine and amount of discharge seem to call for, the patient is dismissed, to return in two days, to have his treatment commenced. The only treatment which gives satisfaction in the majority of these cases is dilatation vrith the conical steel sound. One of these instruments properly warmed is introduced in the manner already detailed (p. 32). Its size should corre- spond to that of the bulbous bougie, which has passed the stricture, and the utmost delicacy, care, and gentleness, should be used in its introduc- tion. The wedge and lever should not be forgotten, nor should we abuse power because we possess it. At the strictured and tender points a spasmodic contraction may occur, arresting the instrument. To overcome this, patience is better than force. As soon as the instrument nas entered the bladder it should be at once gently withdrawn. Nothing- is gained by leaving it even for a moment. During withdrawal the 150 TREATMENT OF STEICTUKE OF THE UEETHRA. stricture is usually felt to " grasp " the sound. This " grasping " is the result of muscular spasm provoked by the presence of the instrument. It will sometimes relax if the sound be allowed to rest a moment. After one sound has been withdrawn, a second and even a third may be introduced, if it is coosidered safe. No rule, nothing short of personal experience, can indicate how far' the dilatation may be pushed at one sitting. The tendency is always to hurry and to use force ; a course detrimental to rapid progress. It may be stated as a rule, subject to judicious exception, that if a conical steel instrument of any size larger than No. 9 will not enter a stricture by its own weight after a little delay, when held in proper j^osition, it should not be used. Every urethra, however, has its own temper, as it were ; some are aroused by the slightest disturbance, while others will bear considerable violence without protest. A surgeon should acquaint himself with the temper of a given urethra by gradual experiment, before he takes liberties with it. The mischief to be feared from the employment of large sounds with force, besides false passages, which are not apt to be produced by large instruments, is threefold — 1. The production of epididymitis, a common result of violence to the urethra and a complication, which suspends treatment and confines the patient for several days or, it may be, weeks. 2. The excitement of inflammation in the stricture, which aggravates its condition and defeats the end of the treatment employed. 3. The production of chill and urethral fever. In rare instances epididymitis may come on in spite of care. The complication must be properly attended to, and all treatment of the urethra suspended until the pain in the testicle has nearly subsided and the swelling of the epididymis has assumed an indolent character. It is not necessary to wait for the latter to disappear entirelj', and, if extra care be employed in resuming the use of instruments, there is little dan- ger of provoking relapse. While using instruments in the urethra, espe- cially at the beginning of a course of dilatation, the patient should be advised to wear a suspensory bandage to keep the testicles from exposure to injury, which would render them more liable to epididymitis. At each subsequent visit of the patient, the surgeon commences with a sound from one to two sizes smaller than the last instrument intro- duced at the previous visit, and carries the dilatation as far as possible, without the employment of force — this tUl the full size is reached. The most important feature in the treatment of stricture by dilata- tion is, a proper regulation of the intervals to be allowed between the sittings. The intervals usually recommended are too short. Occasion- ally we see patients who attempt to treat themselves, introducing a bou- gie into the urethra daily, or twice daily, perhaps at every act of urina- tion, aggravating every symptom, worrying the urethra and bladder into a state of inflammation, and wondering why the stricture does not get PKOPER INTERVALS FOR INTRODUCING SOUND. I51 well. Some surgeons, unfortunately, are guilty of the same error in a less degree. To solve the problem of the proper interval for reintro- ducing a sound through a stricture, it is only necessary to study the effect of a single introduction. Suppose a stricture which sensibly diminishes the size of the stream of urine, and is attended by gleet. Through this stricture a conical instrument is introduced, which is arrested for a moment, but gradually passes, stretching the stricture, and is distinctly "grasped" as it is being withdrawn. What follows such an operation ? At the next act of urination the stream is larger, and continues so during twenty-four hours. At the end of this time the stream is nearly as small as it was before the sound was used ; the gleet is the same, or possibly increased. Now, for twenty-four to forty-eight hours the stream steadily becomes smaller, while the discharge grows more abundant and creamy. During the third or fourth day, improvement commences ; the stream again grows larger, the discharge becomes thinner and less copious, and this improvement often continues through the fifth and sixth or even seventh days, or longer — after which the volume of the stream commences to diminish and the discharge to become thicker. In such a case, if the same conical instrument first used had been reintroduced at the end of twenty-four hours, it would have passed the stricture with about the same facility as on the day before ; if after forty-eight hours, it would enter with more difficulty ; if at the end of seventy-two hours, it would again enter as easily as on the first day ; if reintroduction were first attempted on the fourth day, the sound would pass more easily than at first ; if on the fifth, with more ease still, and it would not probably be so tightly " grasped " on withdrawal ; while in some cases the greatest ease of reintroduction is attained on the sixth, seventh, eighth day, or even later. This varies in different cases ; but it may be stated, as a rule, that it is bad surgery, in treating stricture hy dilatation, to reintroduce an instrument — unless it he filiform — hefore the lapse of at least seventy-two hours, and that more rapid progress will be made with the case by waiting till after ninety-six hours— often even until the sixth, seventh, or eighth day. The reason for tliis rule becomes clear upon studying the thera- peutic effect of pressure upon stricture-tissue. The first effect is mechanical (stretching) and sedative (quieting muscular spasm at the strictured point); this lasts twenty-four hours. The next efi'ect is reactionary (congestive and spasmodic), resulting in extra tightness of the stricture and increase of discharge ; this lasts from twenty-four to forty-eight hours. The final curative effect is absorptive. Absorp- •tion is excited by the increased activity of the circulation about the stricture, and continues for two or three days, or longer ; after which, contraction and growth of stricture-tissue recommence. It is just at the period where absorption ceases and recontraction commences, that a 152 TREATMENT OF STBICTUEE OF THE -URETHRA. dilating instrument can be reapplied most effectivelj, and this period is, in the majority of cases, on the fifth to the eighth day. In brief, inter- vals of a week, especially in cases of old stricture, are generally more beneficial than any shorter period. That absorption takes place during the cure of stricture by dilatation may be proved during life by examining the hard cartilaginous bands often found surrounding the urethra, and constituting stricture. These bands can be distinctly felt, over an instrument introduced through the stricture, and, during the treatment, they may be observed to become gradually smaller, until they become almost imperceptible. They rarely disappear entirely. As to the degree of dilatation which is to be aimed at, every urethra has its own gauge in the size of its meatus — provided that meatus be not congenitally small, or contracted by disease. If there is any cicatricial tissue in the circle of the meatus, or if a probe can make out any pouching below the lower commissure (Fig. 53), the meatus is strictured, and requires treatment. The normal meatus, however, is the smallest part of the healthy canal, and the object in view is, to bring all available pressure to bear upon a morbid narrowing of some other portion of the tube. To do this the meatus must be put lightly upon the stretch. When the meatus is stretched, the feeling is one of discomfort, which subsides after the instrument has been in place for a moment. If the meatus is over- stretched, a distinctly-marked, narrow, white line will be seen encircling the instrument upon the lips of the urethral orifice, indicating that the latter have been deprived of blood by pressure. So much distention is unbearable, but the greatest amount short of this should be aimed at. The average size of the adult urethra is No. 16, while 20 not unfrequent- ly passes with ease. As soon as a full-sized instrument will slip through a stricture by its own weight, all symptoms will usually have ceased, unless the stricture be very resilient ; but recontraction will inevitably take place, and the symptoms return in time, unless the cure be maintained by the patient. This is easily done, and no intelligent patient objects to it. He acquires the art of gently passing a sound upon himself in a few lessons, and he should be seriously cautioned to perform this trifling but important operation at first weekly, then fortnightly, then monthly, studying his own case to determine how long an interval he can allow without sensible recontraction of his stricture. In this way, in some cases, the use of instruments may be gradually abandoned ; in the majority it will have to be continued indefinitely, at intervals varying from a week to several months. In this way does the cure become radical. The sur- geon is responsible for the cure only on condition that the patient carries out this plan ; or, rather, the patient is responsible for the permanence of , his own cure, and this he must be made distinctly to understand. OF SMALL CALIBRE. -.gg (b.) Stricture of Small Calibre.~To this class belong strictures admitting any instrument less than No. 9. They are arranged under a special head, not because they require different treatment, but in order to emphasize the fact that by far the greater number of such cases are better treated with soft than with steel instruments. The danger of making a false passage in an obstructed urethra with a small metallic instrument cannot be overrated. No one can appreciate the ease with which false passage is made, until he has himself made one. Indeed, it is not very uncommon for a patient or surgeon, not well acquainted with the urethra, to make a false passage, and go on dilating it instead of the stricture, wondering meantime that the size of the stream is not in- creased or the symptoms alleviated. A surgeon who knows every line of the urethra may occasionally assume the risk of using a small metallic instrument in the canal without a guide, but only in exceptional cases. Below No. 9 soft instruments only should be employed, unless there be a guide through the stricture. Dilatation is carried on as already directed, steel instruments being used as soon as the stricture will admit 9. Progress is slower with soft than with steel instruments ; they usually give the patient more pain ; the intervals between their introduction may be somewhat shorter. Cutting (internal urethrotomy) and stretching (divulsion) operations are growing daily in favor in the treatment of strictures of small calibre ; yet, in a case of uncomplicated stricture, no matter how tight it may be, provided it does not prove resilient, and is not of traumatic origin, if any instrument at all can be passed, dilatation is still the best method of treatment. Scarification and divulsion are only helps. They are attended by danger. They do not cure radically. The sound must be used after them. When pursued with gentleness and care, the patient need not lose a day from business on account of treatment by dilatation, nor be confined an hour to the house ; while the risk of exciting com- plications is at a minimum. The treatment is longer surely, but, if the surgeon will imagine what would be his own wish were he in the patient's situation, he will not hesitate to adopt the safer but more tedious method. For the class of strictures (uncomplicated) now under consideration, exception may be made in favor of divulsion or internal urethrotomy in two classes of cases : 1. If the patient cannot give enough time to carry out dilatation properly. 2. If pretty severe urethral fever follows attempts at dilatation (Case XI.). In commencing the treatment it may be impossible to enter the blad- der with any instrument, either on account of the tightness of the strict- ure, or because the point of the instrument does not engage in the £5i TREATMENT OF STRICTURE OF THE URETHRA. latter, or is arrested by some fold or lacuna beyond. In these cases gentle perseverance and skill -vvill rarely fail of success. The different varieties of filiform bougies, with the different manoeuvres and expe- dients of introduction already detailed (p. 104), rarely fail to triumph over all difficulties. Sooner or later the bladder is reached,' and the case is under control. On the third or fourth day the same filiform in- strument will pass with greater facility, and a larger one will usually fol- low : the treatment by dilatation is fairly under way. In those exceptional cases just alluded to, where a filiform bougie only can be introduced after long and persevering effort, it becomes a serious question whether it is not better to utilize the guide thus intro- duced through the stricture, to conduct another instrument upon it, rather than to run the risk of retention from swelling of the stricture after the guide has been removed, and perhaps incur the necessity of operating under less favorable circumstances. The temptation to operate in these oases is great, but the necessity for it is often more apparent than real. True, if the stricture be very tight, retention may result from disturbing it, especially if the urine be acid, but this reten- tion yields to heat and opium, or the same filiform instrument, which caused the trouble, may usually be reintroduced ; finally, the aspirator might be used : in any case, after seventy-two hours, a larger instrument will rarely fail to pass, and dilatation has commenced to effect a cure. Hence, in all these cases, where the patient can afford the time, dilatation is the preferable, because the safer, treatment. In the so-called impassable stricture (uncomplicated), where urine passes out, but no instrument can be made to enter the bladder, a filiform bougie can invariably, with patience, be inserted into the orifice of the stricture. That it has entered is known by the " grasping " of the in- strument by the stricture. K now the bougie be left engaged during eight or ten minutes, the muscular spasm constituting the " grasp " may yield and allow it to advance ; if not, another attempt may be made in twentj'-four or forty-eight hours, when, if it will not pass, it wUl at least enter the stricture to a greater depth; finallj', skill will overcome it and the surgeon advances to higher numbers. Model bougies are useless. Whalebones are superior to all other means. In any of the above cases, if, after sufficient deliberation, it is decided to enlarge the stricture before withdrawing the guide, a choice of opera- tions must be made. If it is only intended to enlarge the stricture sufficiently to make its entrance by a dilating instrument more easy after a few days, if the guide be a soft filiform bougie furnished with a screw, a larger bougie or silver catheter may be screwed into it, and the compound instrument carried into the bladder; or, if the guide, ' In one (personal) case it required ten sittings, most of them over one hour long, be fore any instrument could be made to enter the bladder. On the tenth effort, the instru- ment passed. I entered the bladder and at once divTilsed the stricture. In two weeks the patient passed his own fuU-sized instrument. — Keyes. Oi' THE MEATUS URINAKIUS. 155 as is usually the case, be a whalebone bougie, a tunneled sound may bo slipped over it and gently but firmly carried through the stricture, a lit- tle force being used, but at the same time great care taken not to bend the guide in front of the advancing instrument (p. 104). If it is intended to relieve the stricture at once, the broad rule is — all strictures of the pendulous urethra, if operated upon, should he cut; all strictures of the fixed urethral curve should he dividsed— unless ex- ternal section is necessitated by circumstances. Bleeding from the pendulous urethra can always be controlled by direct pressure ; not so easily that from the bulb or membranous urethra. The operative pro- cedures have been detailed (Chapter VI). As for the result of these operations, either of them will afford immediate rehef ; shock seems to he about the same in either case ; neither will effect a radical cure, and that one is to be preferred which is most convenient and attended by the least pain and danger. This operation is divulsion with Thompson's instrument. If a stricture of the pendulous urethra is so small as to require im- mediate radical measures, it should first be stretched by Thompson's divulsor on a guide, until it will admit Civiale's urethrotome, or Mhi- sonneuve's urethrotome may be used at once. (c.) Stricture of the Meatus. — Stricture at or very near the meatus is usually made worse by attempts at dilatation beyond a certain limit, after which it becomes irritated, inflamed, and refuses to dilate. To a still greater degree is this true of congenital or cicatricial narrowing of the meatus. In all of these cases, the contraction must be cut with Civiale's concealed bistoury, scissors, or knife, toward the floor of the urethra alongside of the frsenum. The orifice should be cut a little larger than it is estimated to have been the original intention of Nature to make it, since slight contraction necessarily takes place in healing. Heemorrhage, in this operation, is considerable, if the corpus spongiosum be cut into. It may always be arrested, as already described (p. 120). Reflex irritation may produce spasmodic stricture in these cases, so that the next attempt to urinate is perhaps ineffectual. Removing the collodion, dipping the penis in warm water, and reassuring the patient, will invariably bring a flow of urine. A meatus, properly cut, remains open indefinitely, without the necessity of dilatation. Where the narrowing of the meatus depends upon an extensive cica- trix, left behind by soft chancre or other ulceration, and where meatot- omy is unable to keep off subsequent gradual recontraction, the opera- tion of CoUes ' should be substituted for simple incision. This consists in dissecting off whatever parts of the frtenum or prepuce remain attached, and slitting the floor of the urethra for half an inch. The mucous mem- brane of the canal is now dissected up on both sides, a portion of corpus spongiosum is cut away, and finally the mucous membrane is attached laterally on either side by points of fine suture. ■ " Practical ObaerFations on the Venereal Diseases," London, 18S1. i;g treatment of steictuke of the ueethea. [d.) Traumatic Strictures are not usually amenable to treatment bj dilatation. They are so exceptionally tough, hard, and retractile, that a splice or splices must be put into them, by rupture or section, in order to keep them open. Since the days of Syme, it has been customary to consider perineal section indicated, wherever stricture of the membranous urethra was of traumatic origin. This rule has ceased to hold good since the improvement of urethral instruments. On the contrary, it may be af&rmed that permeable uncomplicated traumatic stricture is best treated by divulsion, if it be deep-seated in the urethra, by internal inci- sion, if it occupy the pendulous portion of the canal. The following case shows the toughness of traumatic stricture, and substantiates the above assertion : Case SXI. — A healthy farmer's boy, of seventeen, was brought to New York in June, 1869, for relief from retention, with overflow. Two years previously he had injured his perinseum by a fall upon a board. Gangrene followed. When the slough separated, his physician saw " both ends of the urethra separated by more than an inch." Sounds were passed at first, but, after six months, the patient ceased putting the instrument into his bladder. At date of application, no instrument had entered the bladder for eighteen months. A week previously, the patient had complete retention. He was then etherized by his physician (Dr. Case) for the purpose of operation. Under ether, the bladder par- tially emptied itself, and nothing was done. Overflow continued ; there was not much cystitis ; the patient was brought to New York for operation. After careful manipulation, without ether, for two and a half hours with all varieties of instruments, Thompson's probe-pointed catheter was at last passed into the bladder, by the exercise of some force, and clear water flowed through it. Not a drop of blood flowed during the two and a half hours' manipulation. The instrument was withdrawn, and a similar one of larger size passed. This was followed by Thompson's divulsor with- out a guide, a strong instrument, selected by Thompson himself, manufactured by AVeias. This was screwed up, but brolce at 15. It broke just where a properly-made instrument always does, if it break at all, one blade snapping just where the two are joined. The stricture, however, fortunately cracked just as the instrument gave way. The divulsor wag withdrawn without trouble, and a No. 14 conical steel sound introduced into the bladder. On the following day, a full-sized (15) sound passed easily, and the patient started for his home (one hundred and fifty miles distant), where he arrived safely. His physician, who was in New York two years later, stated that the patient had continued perfectly well, introducing No. 15 every week. Here was a stricture as dense and hard as it was possible for a strict- ure to be — hard enough to break an instrument of the best make — yet cured by divulsion. As a general rule, however, if the rigidity and extent of stricture be particularly great, if it be complicated by numerous or large fistulte, or if the stricture be impassable, it is advisable to operate externally, as this gives the surest chance of relief. {e.) .Resilient Stricture. — Strictures which are thoroughly resilient will not dilate (Case XV.). In such cases, if a given instrument be introduced, the stream becomes smaller at once, and on the fourth day the same instrument enters with more difficulty, or perhaps will not pass at all. These strictures are frequently irritable as well as resilient, COMPLICATED BY FALSE PASSAGE. 157 and always demand divulsion, with the employment of enough force to crack the stricture, or internal urethrotomy. Many strictures, however, which respond to dilatation at first, fail to do so after they have reached a certain size. To this class belong all strictures at or very near the meatus, and many at other portions of the canal. In these latter cases, although a full-sized conical sound may readily pass, yet a bulbous bougie, many sizes smaller, introduced immediately after the withdrawal of the sound, is arrested by the stricture, while the symptoms (gleet, etc.) fail to disappear entirely. In these cases Otis's divulsing urethrotome is the best instrument to use, to put a splice into a stricture which has received all the benefit dila- tation could give it, without being made quite large enough. 3. Treatment of Steictuee complicated by — (a.) False Passage. — False passage, as already stated, results from rough or unskillful use of small instruments in an obstructed urethra. It may be due to " forced catheterism," a barbarous procedure, con- FlG. SS.—iDitUl) demned by its name alone, which consists in passing a metallic catheter up to the obstacle, and then forcing it along in the supposed course of the urethra, until urine flows through it, if haply this occur at all. It is not used at the present date. False passages start from the bottom of lacunse (Fig. 30), from the front face of a stricture, from in front of the triangular ligament, or from some abscess (Fig. 55). When a surgeon 158 TREATMENT OF STRICTURE OF THE URETHRA. makes a false passage, he may be unconscious of the escape of the point of his instrument from the canal, but he •will soon perceive that it is behaving unusually. It does not glide along as if in a healthy urethra ; it is obstructed, but yet not held in the same manner as if in the grasp of a stricture. The point, moreover, seems often to be turned out of the median line, and, after the instrument has been introduced far enough to have reached the bladder, a rotary motion, imparted to the shaft, will show that the point is fixed in the connective tissue, and not freely movable, as it would be in the cavity of the bladder. In such a ease a finger in the perineeum, or, better still, in the rectum, will almost cer- tainly feel the point of the instrument just outside of the waU of the gut, at the apex of the prostate, or perhaps lying between the prostate and the gut. On withdrawing the instrument, blood flows freely from the meatus. The treatment for a fresh false passage of this sort is, to let it alone absolutely for two weeks, if the patient can make water, and is in no pressing need to have his stricture relieved. Blood will flow for a day or two, then pus for a few days, and at the end of two weeks, in favor- able cases, the passage opened by the instrument will have closed. Occasionally it remains open, suppurating for a much longer time. Urethral fever, with or without the formation of abscess, is not an un- common result of false passage. Infiltration of urine is exceedingly rare. The great danger in these cases is in recommencing instrumenta- tion too soon, entering the false passage before it has healed, and thus keeping it open indefinitely. In avoiding an old false passage, which is the seat of chronic sup- puration, its position must be accurately studied out, by observing at what point in the urethra an instrument engages in it, and from which wall of the canal (upper or lower) it starts. The orifice of a false pas- sage once accurately located, may be subsequently avoided by making an effort to present the beak of the instrument at a different portion of the canal, when passing the dangerous point. A new false passage does not grasp an instrument like a stricture, and in this way can often be distinguished from the latter. An old false passage, however, so far as its pathology is concerned, is a traumatic stricture. It has hard walls, and the unstriped muscle of the erectile tissue around it will " grasp " like any other stricture, thus depriving the surgeon of a very valuable means of deciding whether he is in the strictured canal of the urethra or not. Another means, already alluded to, of avoiding a false passage when searching for the orifice of a narrow stricture, consists in filling the ure- thra with whalebone filiform bougies, thus mechanically filling up the false passage, until some instrument will glide bj' its orifice, and enter that of the stricture. This course, or that of using a spiral-pointed whale- bone bougie, with its point out of line (Fig. 39), should be employed in COMPLICATED BY KETENTION. 159 entering the stricture, whenever the symptoms are urgent, and false pas- sage exists. When a guide has passed the stricture, the latter may be divulsed, or cut, immediately. The size of the beak of the full-sized instrument, subsequently passed, will insure it from entering the false passage. If it is impossible to get through the stricture, and there is retention, it becomes a matter of personal judgment to decide whether to perform external perineal urethrotomy without a guide, or to use the aspirator, and endeavor to pass the stricture at another sitting. (b.) Retention. — A patient, with stricture, may be enjoying good health, when suddenly, after exposure to cold, after a dinner or a ca- rouse, or after the passage of a small instrument through his stricture, he finds that he cannot pass water. If he does not get rehef, his blad- der will fill up, and after twenty-four to thirty-six hours, most of which are passed in acute suffering, a little urine will force its way through the stricture, and he will have overflow, often inaccurately styled incon- tinence. Such an over-distention of the bladder is liable to give rise to atony and cystitis, and, if the patient is seen before it has occurred, every means should be employed to avert it, and to preserve the bladder from an injury the effects of which are always more or less permanent. The most frequent cause of retention in stricture cases is sudden acute inflammation of the membrane lining the stricture, by which the already narrow canal becomes occluded. In this condition, as a rule, a fine catheter, or filiform bougie, can be introduced through the stricture, by the exercise of patient gentleness and skill. If the bladder can be reached, a flow of urine will follow the withdrawal of the instrument. If the bladder cannot be reached, the patient should be placed in a hot bath, more hot water being added after he has become accustomed to the first heat, and this carried as high as is bearable. He should re- main in the bath from fifteen to twenty minutes, and will often be able to empty his bladder while in the water. Another excellent expedi- ent is the use of the sitz-bath, at a temperature of 100° to 104° Fah., more hot water being added after the patient has entered the bath, which should be continued only for about three minutes, and may be repeated after an interval of fifteen minutes. If the heat is suSicient to induce nausea or faintness, it is more likely to produce the desired effect of relaxing the stricture.' A piece of ice in the rectum every few miu utes may be tried (Cazenave). Failing in these expedients, if percussion reveals a bladder only slightly distended, reaching not more than half-way up to the umbilicus, opium may be given, one grain being administered every hour until relief is afforded. The nervous excitability attending retention is relieved by opium. The pain will soon cease, the patient's fears will be- ' In a robust and full-blooded subject, it might, perhaps, be advisable to take blood from the perinseum by a number of leeches. 160 TEEATMEXT OF STEICTUEE OF THE TJEETHKA. come quieted, and after the fourtli or fifth grain urine will generally flow. Twenty-drop doses of the sesquichloride of iron, administered every fifteen minutes, for a couple of hours, at the same time with the opium, seem to facilitate relaxation of the strictiu-e. Finally, an instru- ment can often be introduced under the entire relaxation of anaesthesia. In a case of retention, if a filiform bougie can be passed into the bladder, the advantage so gained should not be lost, but the stricture should be divulsed at once, if the history of the case show an advanced srricture, and there are no evidences of kidney-disease. If no instru- ment can be passed, we have impassable stricture, with retention, which requires other means for its reliet In drawing off the urine from a bladder suffering from overflow, it is w^se never to empty the viscus en- tirelj', at first, if it has been long over-distended. Fatal collapse has been caused by such a course, and subsequent inflammation of the over- stretched mucous membrane is more likely to run high if all the tension be taken from it at once. Half or three-quarters may be withdrawn, the bladder being emptied entirely on the following day. This fear of col- lapse from emptying an over-distended bladder mainly applies, how- ever, to old subjects suffering from enlarged prostate, and stagnation of urine. (c.) Retention, the Stricture being impassable. — No stricture (eon- genital atresia excepted) is impervious unless the urethra has been cut across and united anteriorly, all the urine escaping behind it, or unless stricture has gone on contracting for an indefinite period, the urine escaping through large fistulse. Where a drop of urine can pass, the stricture is pervious, but nevertheless it may be impassable to any in- struments we may use, or any skill and patience we may bring to bear upon it, and that, too, where the urine flows in a considerable stream. Treatment of impassable stricture without retention has been already described (p. 154). When, hqwever, there is retention, the question immediately arises. Is it better to operate on the stricture at once, or to puncture the blad- der and wait till the following day, in hope of operating then under the more favorable conditions of a guide through the stricture ? This is a point which requires the best judgment, aided by considerable experi- ence, to decide correctly. Here there is no question of any other com- plication. The surgeon is in face of an impassable stricture, and the patient has retention, and must be relieved, or his bladder will suffer. If the patient has had retention before, his experience then will aid in forming a judgment. If the surgeon is acquainted with the temper of the urethra, and the character of the stricture (resiliency, traumatic origin), he may found his opinion on such previous knowledge. If the patient is difficult to manage, and there is fear that, once relieved from his present necessity, he may not submit to treatment, it would be only a kindness to him to take advantage of his misfortune to insist upon COMPLICATED BY EXTRAVASATION. iQi perineal section at once, and put him in the way of passing a laro-e in- strument and keeping off further trouble, thus relieving retention, and iubjecting the stricture to effective treatment by one operation. But external perineal urethrotomy without a guide is an exceedingly liffioult operation, and is not to be undertaken unadvisedly. If it is the patient's first retention (brought on by exposure), and if he was pre- idously passing a moderately good-sized stream, if the bladder is not ilready too full, it is .always well to try warm baths and opiates to relieve retention and to leave the stricture for subsequent treatment. A.gain, if the bladder is very full, and there is still no absolute necessity 'or external perineal urethrotomy, the bladder should be punctured ibove the pubis, with the aspirator, and a filiform bougie engaged if possible in the orifice of the stricture, and left to act by continuous dila- tation (p. 165). On the following or next following day the filiform bou- gie will generally pass into the bladder, and then the stricture will be under control. [d.) Infiltration of Vrine. — In stricture complicated by extensive in- iltration of urine, we have a condition requiring prompt action on the part of the surgeon. The stricture must be relieved. The infiltrated irine must be drained off, or extensive abscesses, with sloughing, will bllow, and the patient's life be placed in imminent perU — results which nay ensue in spite of all precautions. When the infiltration has oc- 3urred behind the triangular ligament and is confined to the cavity of ;he pelvis, but little can usually be done, except to keep up the strength jy brandy, carbonate of ammonia, and beef-tea, trusting that Nature Afill set up a plastic inflammation and thus limit the burrowing of the nfiltrated fluid, and allow its escape by the formation of abscess (peri- iystitis). Even in these cases, however, desperate as they are, where ;he escape of urine has been sudden and in considerable quantity, early )peration is often the only chance. They ar^ similar to, and must be ireated like, cases of rupture of the bladder, the neck of the bladder jeing cut into, as in the lateral operation for stone, all stricture-tissue seing divided and a chance given for the infiltrated urine to escape, ^hile further damage from infiltration is rendered impossible. If infiltration occurs along the course of the urethra outside of the ;riangular ligament, and is slight and circumscribed, the urine not having Denetrated Buck's fascia, but manifesting itself in a hard, circumscribed Derineal swelling (p. 142) behind the stricture, no surgical interference s called for, so long as the hard lump is not rapidly increasing, and the jatient can empty his bladder. Should retention occur under these cir- (umstances, or the hard lump commence to enlarge rapidly, external )erineal urethrotomy is the only proper resource. In this variety of in- iltration there is often time to build up the patient's general condition )y the judicious employment of hygiene, air, tonics, etc., and sometimes o avert the consequences of long-continued abuse of stimulants, includ- 11 £62 TREATMENT OF STRICTURE OF THE URETHRA, ing delirium tremens, often imminent in cases encountered in hospital practice. Should external perineal urethrotomy be performed, the hard lump must be incised in the median line, and the stricture thoroughly divided. But these indurations do not necessarily suppurate externally. They usually remain stationary for a long time, often get better under treat- ment, sometimes (rarely) spontaneously suhside, probably by discharging internally through a small orifice.' • When a large quantity of urine has suddenly escaped, burrowing into the subcutaneous tissue of the perinaeum, scrotum, thighs, and abdomen, large, free incisions, calculated to insure effective drainage, should be made well down into the subcutaneous tissue, wherever oedema or em- physema is felt, and external perineal urethrotomy must be performed. A thorough division of the stricture prevents further infiltration. If the scrotum be infiltrated, it should be split into two lateral halves, while other incisions may be made freely into its substance. Too free inci- sions are not to be feared ; the error is on the other side. Incisions must be bold, deep, numerous, and should extend over all the surfaces involved by infiltration. The operative indications, in cases of extensive infiltration, are three : 1. To stop progressive infiltration by extensive dependent incisions. 3. To provide an escape for urine constantly collecting in the blad- der, by free central incision of the urethra behind the stricture. 3. To divide the stricture thoroughly, although this may be left for a subsequent operation. In making incisions, a finger in the rectum should search for boggy spots, which, when found, should be opened into. Brandy and carbonate of ammonia, freely administered in small, frequent doses, will bring down the pulse as the patient rallies from shock. The subsequent treat- ment must be sustaining in every way. Erysipelas is apt to come on. Gangrenous spots appearing after incision should be poulticed with charcoal or yeast, and linseed-meal until they separate, and the raw sur- faces afterward dressed with simple stimulating applications until they heal. Recoveries after infiltration seem sometimes almost miraculous, and life is not to be despaired of even in cases of the most extensive sloughing. Too much attention cannot be bestowed upon keeping up the patient's strength. This is his salvation ; it must be maintained at all hazards. (e.) Abscess, complicating stricture, has already been described as perineal abscess (p. 79), and as a hard, circumscribed swelling in the ' Dr. E. A. Banks, of New York, brought a patient for inspection, who with tight stricture had two of these deep perineal indurations, one as large as a pigeon's-egg, evi- dently firmly attached to the urethra. Before agreeing to external section, which was advised. Dr. Banks tried " continuous dilatation," with the effect of overcoining the strict- ure, and causing the disappearance of the indurations after a few weeks. The treatment, however, provoked epididymitis, and caused some urethral irritation. COMPLICATED BY FISTULA. jg3 periniEum attached to the urethra (p. 143). For all these, when oomph- cating stricture, the treatment which usually yields the best results is external perineal urethrotomy, including the abscess and the stricture in one free median incision. The opening should be made before fluctua- tion can be detected, at any time if the bladder is suffering. Success of treatment usually depends upon the earliness and freedom of the in- cision : cut deeply in the median li?ie. There is nothing to fear. Haemor- rhage can always be restrained by tying spurting points or plugging the wound if necessary around a " shirted canula," or by a piece of fine sponge through which a female catheter has been passed. (/.) Fistuloe, as complicating stricture, are important just in propor- tion as they are large, long, or numerous. A simple fistula with one or two openings, which allows a few drops of urine to escape at each act of micturition, need not be regarded. Such a fistula will close sponta- neously, in the vast majority of instances, as soon as the stricture has been dilated fully, as Brodie pointed out. The first and essential step in the treatment of all fistulce complicating stricture is, to remove ob- struction to the free escape of urine, and then to treat the fistulae, if they do not get well spontaneously. Such after-treatment will rarely be required unless there has been loss of substance. If, however, after full dilatation has been maintained for some months, the fistulas still allow urine to pass during micturition, the following expedients may be resorted to : Dilatation being maintained, the patient should be further taught the use of a flexible (French) olivary catheter of medium size. This he must introduce at intervals, passing no urine except through the cathe- ter, if it can be done without producing urethritis. If this fail, after thorough trial for a month or more, where the stricture has been fully dilated and is not resilient, the hard edges of the fistulous tract should be incised and cleaned, and the fistula left with its external larger than its internal orifice. If the edges are not callous, and particularly if the fistula is long and deep, cauterization is sometimes effective. This is best accomplished by galvano-cautery, a wire being introduced, suddenly raised to white heat, and instantly withdrawn. Eed-hot iron is not reliable, as it becomes cooled on introduction, and produces least effect where most is required, i. e., at the internal orifice of the fistula. An- other expedient is to bend a silver probe until it readily traverses the whole length of the fistula, coat it with fused nitrate of silver, introduce it rapidly, and rotate it during- withdrawal. It must not be forgotten that these means last detailed are only accessory to the sound, and by no means in themselves reliable for cure. During their use the catheter and full-sized sound should be continued unremittingly. In general, the capacity of the urethra is underrated, and fistute which do not get well owe their intractability to the fact that the stricture has not been brought to the full size of the canal. If 164 TREATMENT OF STEICTUEE OF THE URETHKA. the urine can flow out freely enough, it will choose the larger and neglect the smaller channel, allowing the latter to heal. Tonic con- traction of the urethra in front of stricture, due to long inactivity of the canal, seems to be the obstacle in some cases. A search, in the track of fistulse which refuse to close, wiU sometimes reveal stone as the cause. Where from the mismanagement of previous abscess there are nu- merous fistulffi, opening in all directions around the penis, scrotum, and perinseum, running through indurated tissue, and, perhaps, lined by calcareous matter ; or where fistulse coexist with abscess in the peri- nseum, or a lumpy induration of some extent around the urethra — in any of these conditions sound surgery calls for external perineal urethrot- omy. The incision should be central, all abscesses and fistulous tracts being opened into this, and every thing forced to heal from the bottom. When a fistula has one opening in the rectum, the obstacle to suc- cess of treatment is often the passage of fecal matter and gases into the urethra. If, after cure of the stricture, simple means (cautery, in- cision) fail, Sims's silver suture with forced dilatation of the sphincter ani might become necessary. {g.) Peri-cystitis, or Advanced Interstitial Cystitis. — In nearly all cases of stricture there is necessarily more or less cystitis (inflammation of the mucous lining of the bladder), especially about the neck, but, in the majority of cases, the bladder complication does not influence, in any degree, the treatment which the general conditions of the stricture call for. Where, however, active interstitial cystitis complicates a tight stricture, or where the muscular substance of the bladder and surround- ing tissues are much involved, rest must be given to the bladder, and this is usually best effeted by external urethrotomy, if any active meas- ures are allowable; otherwise a supporting and stimulating general treatment gives Nature the only chance (and that a poor one) of bring- ing the patient safely through. Particularly in aU cases of cystitis is it necessary to make the urine unirritating as it flows from the kidney, to alkalinize it through the stomach, that it may be less alkaline at the meatus. G. Owen Eees ' has demonstrated the possibility of doing this, by giving alkalies by the mouth, thus rendering the urine alkaline or neutral at the kidney. Alkaline urine, with a fixed alkali, does not irri- tate the bladder, and consequently less mucus is secreted (than when the urine was acid), to act as a ferment, decompose the urea, and give rise to the formation of carbonate of ammonia, that powerful volatile alkali which is the agent in decomposing urine most active in irritating and inflaming the bladder, and which, indeed, gives the alkaline reaction to the urine of chronic cystitis. Lemon-juice in quantity, and benzoic acid, will render the urine of a healthy individual acid ; not so when the ' On the "Pathology and Treatment of Alkaline Conditions of the Urine," Gny's Hospital Reports, Third Series, vol. i., 1885, pp. 300, SOI. COMPLICATED BY ENLARGED PROSTATE. jg- bladder is inflamed ; then alkalies are more Ukely to produce the desired effect. (A.) Enlarged Prostate.— The complication of stricture by enlarged prostate is not of common occurrence. The situation is always grave when the two conditions coexist, if the enlargement of the prostate is sufficient to interfere with the passage of instruments into the bladder and the stricture is situated as deep as the bulb, or beyond it. The tighter the stricture the more serious does the complication become and should retention supervene, the difficulty of the situation is apparent at once, whether the obstacle to the escape of urine be situated at the strictured point or in the prostate. If the stricture is in the pendulous urethra, it mav be dealt with by nearly any one of the means already described. It may be kept dilated with a straight steel sound of proper size, very conical, and not over five inches long (Fig. 56), while the proper treatment is applied to the bladder laboring under prostatic obstruction. If the stricture is PiQ. 66. deep-seated and not very tight, but if neither short instruments nor the short curved sound will pass the prostate, a silver catheter of long curve should be selected, which will enter the bladder through the en- larged prostate, and steel conical dilating instruments should be con- structed of the same curve. When the urethra has been dilated, the sound may be replaced by the catheter to be habitually used. If the stricture is not large enough to materially obstruct the urethra, and re- tention occurs at the neck of the bladder, the prostate would require all the care, and the stricture might be subsequently attended to, after pas- sage for some instrument into the bladder had been established. If the stricture is very small, so as to admit only a filiform bougie, there still being no retention, a course may be followed which has been recommended at one time or another for nearly every condition of tight stricture, but which, indeed, is rarely advisable, as we have so many that are better, namely, the tying in of an instrument which has passed through the stricture. Jt is known as "continuous dilatation." Continuous Dilatation. — The execution of the treatment and its ac- tion are as follows: A filiform bougie, whalebone or soft, is passed through the stricture, which "grasps" it tightly, and is tied in (Chap. X.). The first action of this instrument upon the stricture is to cause irrita- tion. The muscular fibres of organic life which surround the urethra at the point of stricture contract tightly upon the instrument, producing the "grasping" so often referred to. This continues for awhile and 166 TKEATMENT OF STRICTURE OF THE URETHRA. then subsides ; mean time, if the patient tries to pass water, he finds himself unable to do so. Soon the spasm relaxes and the urethra widens notably, so that a few hours later the patient can make water easily outside of the instrument. A knowledge of this fact relieves all fear of retention in connection with this style of treatment; the fear is, indeed, on the other side, for if a soft filiform instrument has been tied in, no matter how tightly it was embraced by the stricture at the mo- ment of introduction, the chances are that at the second or third mic- turition it will be doubled up and washed bodily out of the canal by the volume of the stream of urine. This is not so apt to happen where there is also enlarged prostate, on accoimt of the smallness of the stream and the atony of the bladder frequently attending that condition. After the instrument has been tied in for twenty-four hours, the stricture will readily admit a larger bougie. This should be tied in the same way. The stricture ulcerates superficially, but widens with great rapidity. After it has reached a certain size, it may be treated by dilatation as described above. There are objections to the treatment of stricture by continuous dilatation. Some patients suffer torments if an instrument is tied into the urethra, while urethral fever and epididymitis are often caused by it. On the other hand, some patients support it with perfect impunity, even while walking around. If severe chills come on during continuous dilatation, it is prudent to withdraw the instrument ; if the chills are mild, they may be disregarded. Strictures enlarged by continuous dila- tation commence to recontract at once with great rapidity, unless they are kept dilated by the occasional use of the sound. Finally, if the stricture is exceedingly tight, perhaps impassable, and retention has come on, caused either by the stricture or the prostatic enlargement, there is but one course left open. If warm-baths, etc., do not bring relief, and the bladder is found to be fully distended, the op- eration of tapping above the pubes must be performed, either with the aspirator or by incision, leaving a canula tied in (p. 130), the choice of the former operation resting upon the probability of an easy and speedy efiective cure of the stricture, the urethra and prostate being treated after the bladder has been relieved. In these cases external perineal urethrotomy is too severe an operation, for the patients are all old men with more or less cystitis, coexisting with prostatic enlargement. 3. Fistula with Loss of Substance.' Fistulae of the urethra with loss of substance may result from gan- grene, abscess, phagedenic ulceration, simple ulceration (the tying in of a silver catheter for a length of time). They are seen usually as the result of infiltration and abscess complicating stricture. In this variety of fistula a hole exists in the floor of the urethra, through which its roof is visible. As has been shown, small fistulae close on dilating the ure- ' All large fiatulsB are considered here, whether complicatiBg stricture or not. FISTULA WITH LOSS OF SUBSTANCE. jg^ thra. The same law whicli causes a traumatic stricture to close entirely if all urine escape through fistulae behind it, wiU the more certainly close a small fistula, unless from obstruction in front of it, and consequent distention of the urethra during urination, fluid be forced into its in- ternal orifice. With loss of substance, however, dilatation of the urethra, though necessary for cure, will not alone suffice. If the opening is larger than a pea, its closure is often difficult, especially if it lie anterior to the peno-scrotal angle. The causes of failure here are three : 1. The thinness of the natural tissues furnishing only narrow edges for the union of flaps. 2. The difficulty of avoiding contact of urine with the cut edges. 3. The disturbance of the wound on account of changes in size of the organ (erection). Where loss of substance, however, is not very great, if there be no urethral obstruction in front of the fistula, repeated cauterizations may effect a cure. In this way Sir Astley Cooper ' closed a fistula as large as a pea with nitric acid, after two operations with harelip pins and interrupted suture had failed. He states that this plan will not succeed unless the integument is loose, and the scrotum forms part of the orifice of the fistula. Dieffenbach ' prefers a concentrated tincture of cantharides for small openings, which he applies as follows : The urethra is distended over a full-sized bougie, and the tincture applied with a small brush to the inner border of the fistula. This manoeuvre is repeated several times in the twenty-four hours. The epithelium as it loosens must be scraped away, and the tincture applied to the raw surface until healthy granulations have sprung up, which seem capable of closing the opening. Faihng once, the treatment may be repeated. If this is not sufficient, or if, at first, the opening seemed too large to warrant the simple application of caustic, its use may be combined with that of Dieffenbach's lace suture (Schntimaht), which is applied as follows : After the epithelium has been removed by the application of the tincture of cantharides, as just detailed, and a large, soft bougie has been passed into the urethra, a small curved needle, not cutting at the sides, carrying a stout (waxed) silk ligature, is introduced with a needle- holder at about three lines from the border of the fistula. The point of the needle must not enter the urethral canal, but, after traveling a short distance in the substance of the corpus spongiosum, it is made to emerge through the integument at a point also about three lines distant from the edge of the fistula. The needle is reintroduced at the same punc- ture whence it emerged, and the same stitch is repeated often enough to carry the thread around the fistula at a distance of about three lines from it, and to make it finally terminate through the puncture in the integument where it first entered, thus leaving the two ends of the 1 "Surgical Essays," London, 1819, p. 205. ' " Die Operative Chirurgie," Leip.^ic, 1845. 168 TREATMENT OF STRICTURE OF THE URETHRA. thread emerging from the same cutaneous orifice, the thread itself lying in the corpus spongiosum, and the irrethra not having been punctured by the needle. By gently pulling upon the two strings, the raw edges of the fistula are now brought together. The ligature is tied, the knot sinking into the cellular tissue; the sound is withdrawn, and water-dress- ing employed. The patient urinates through a catheter. In three or four davs the ligature is cut and gently drawn out. Two operations may be required, the first rendering the fistula smaller, the second obliterating it. This procedure is applicable to all fistulas of the spongy urethra of less than one-sixth inch diameter. Where the opening is larger, urethro-plasty is required. Urethro- plastic operations are very unsatisfactory in their results, even in the hands of the best operators, for the reasons already given. For the proper method of operative procedure each case must be made a study by itself, and the flap so chosen that it may be ample in size and sufficiently thick. In the present treatise it is impossible to give even by name all the operations which have been proposed, much less to describe them. For such detail those interested are referred to Dief- fenbach,' where fourteen different methods are described. The excellence of one operation, however, the sliding flap or bridge method of DiefFenbach, and variously modified by N^laton and others, is worthy. of outline from its frequent applicability to small fistulse ante- rior to the scrotum. A large bougie is introduced into the urethra, and upon it the integument of the penis is incised transversely or longitudi- nally, by two parallel incisions, situated respectively nearly an inch from the edges of the fistula. The fistula is made somewhat elliptical by incisions which freshen its edges. The integument between the inci- sions is now thoroughly detached from the corpus spongiosum, commen- cing at the fistula. When the incisions have been transverse, the flaps are also well dissected up laterally, so that the edges of the fistula may be approximated laterally without causing tension of the edges after they are united. The advantage claimed for transverse over lateral in- cisions is that, if urine escape from the urethra, it may more readily find its way out without detaching much of the flap. The flaps approxi- mated laterally are united by the twisted suture at once, or may be left to granulate and brought together by pins, after a few days, for the pur- pose of getting secondary adhesion. By this operation two raw, flat surfaces are brought together laterally instead of two thin edges. A soft catheter of moderate size should be introduced four or five times daily, but on no account should a catheter be tied in, as this is more likely to defeat than to further the object for which it is used, as shown by Thompson.' For although a catheter, when first introduced, may fill the urethra, yet soon if begins to act by " continuous dilatation," and the urethra becomes larger. Then capil- ■ " Die OperatiTe Chirurgie," Leipaio, 1845. ' Op. cit. SUMMARY OF TREATMENT OF STRICTURE. Jgg .ary action begins between the wall of the urethra and the outside of the catheter, and a little urine is sucked up, necessarily wetting every portion of the urethral wall and coming into contact with the wound. Regarding the success to be expected in operating upon fistulse with loss of substance, it may be stated, as a general rule, that, the farther they lie from the neck of the bladder, the more difficult are they to close. In the perinseum the natural thickness of the tissues is of great advan- tage. If an attempt is made to close a very large fistula anterior to the periniEum by a plastic operation, it would always be advisable to follow the suggestions of S6galas and Rioord,' namely, to open the urethra through the perinseum, as the first step of the operation, and allow the urine all to flow by that route, or to pass a catheter into the bladder through some preexisting fistula in the perinseum. The advantages of such a course are obvious. StrmMAKY OP TREATMENT OF STEICTTJEE. 1. Alkalies, diluents, and rest, are serviceable in most cases of strict- ure — sometimes indispensable if there be any serious complication. 2. All uncomplicated strictures, not highly irritable or resilient, should be treated by dilatation with soft instruments up to No. 9, coni- cal steel sounds afterward ; reintroductions being made every fourth to eighth day — the older the stricture the longer the interval as a rule, and intervals of one week being most serviceable in the majority of cases. 3. All strictures ab or near the meatus must be cut. 4. Resilient, very irritable, and, as a rule, traumatic strictures are best treated by divulsion, if they lie below four and one-half inches from the meatus, otherwise by internal urethrotomy. When a resilient stricture cannot be divulsed, it should be cut — internally. 5. Impassable stricture may usually be overcome — where there is no retention — by time, patience, and skill, with whalebone bougies. If finally proved impassable, the treatment is external perineal urethrotomy. 6. Retention is treated by hot baths, ether, opium, tincture of the sesquichloride of iron ; failing these, by puncture above the pubis with the aspirator or through the rectum to gain time ; or by external peri- neal urethrotomy without a guide. 7. For stricture complicated by abscess, infiltration, or many and large fistulas and for extensive traumatic stricture, external perineal urethrotomy. 8. For infiltration, free incisions, stimulants, supportives, with thor- ough external division of the stricture. 9. For fistula with loss of substance, local cauterization, lace suture, or plastic operation. Where there is no loss of substance, complete dilatation of the stricture is soon followed bv closure of the fistula ' Monthyon Prize of French Academy, 1841. £Y0 DISEASES OF THE PROSTATE. •URETHRAL CASE OF INSTRTTMENTS. It is advisable to introduce here a list of such instruments as will be necessary to make up a case suitable to meet the requirements of such maladies, demanding instrumentation within the urethra, as are ordina- rily encountered by the general practitioner : Gauge. Conical steel sounds, Nos. 9 to 20, inclusive. One long and two short whalebone filiform guides. Thompson's probe-pointed catheter, modified by Otis. One silver catheter, short curve, size No. 13. Two silver catheters, with long prostatic curve, sizes No. 10 and 16. Thompson's divulsor, tunneled, Civiale's concealed bistoury. Civiale's urethrotome. Gouley's catheter- staff, size No. 10. Urethral forceps. Cupped sound, size No. 13. Four English yellow elastic catheters, assorted. Conical (not olivarj') soft bougies, sizes Nos. 1 to 13, inclusive.' Half-dozen different-sized olivary French catheters.' Four Mercier's elbowed catheters, assorted.' Bulbous bougies, sizes Nos. 3 to 30, inclusive.' CHAPTEE IX. DISEASES OF THE PROSTATE. Anatomy. — FuBctloD. — Deformities. — ^iDJuries. — Atrophy. — Hypertrophy. — Ear at the Neck of the Blad- der. — Symptoms and Eesults of Hypertrophy. — Course of Symptoms from commencing Irritability up to Eetention, Atony, Stone, Urffimia, Death. Anatomy. — The prostate (npoardrrig, standing before), somewhat improperly called a gland, is a body composed mainly of unstriped mus- cle, placed like a sphincter around the first inch of the urethra and the neck of the bladder. It contains multilobular mucous glands in its sub- stance, and is tunneled by the two ejaculatory ducts — the common canal formed by the union of the duct of the seminal vesicle with the vas def- erens on either side. The ejaculatory ducts open, in the floor of the prostatic urethra, on the sides of the little crest in the median line called veru montanum. Here, also, most of the ducts of the mucous glands of ' These instruments should not be kept in the general case, as they are liable to soften and stick together in -warm weather. ANATOMY OP THE PROSTATE. 171 the prostate open. The latter secrete a bluish mucus, which serves to dilute the semen. Both the glands and their ducts, in late adult life, habitually contain certain small solid deposits, called prostatic concre- tions, formed in concentric layers, which seem to have no special signifi- cance, though they often exist in vast numbers, and of considerable size. They are occasionally encountered in the urine. The lower part of the prostate is surrounded by a few striped muscular fibres — the external vesical sphincter of Henle. The prostate is a muscle. Its main function is to contract on the semen after the latter has collected within and distended the prostatic sinus. This contraction is coincident with the venereal orgasm. It is spasmodic in character, throwing out the seminal fluid in successive jets. The seat of the venereal orgasm is in the nerves of the mucous mem- brane lining the prostatic sinus, as proved by the fact that it is some- times excited by the passage of a sound through the prostate, and is not destroyed by amputation of the glans penis. The prostatic utricle, the analogue of the cavity of the uterus, is a little depression lying in the floor of the prostate beneath the veru mon- tanum, opening by a small vertical slit in front of the summit of the latter. This cavity and the orifices of the mucous follicles, dilated by hydrostatic pressure in cases of tight stricture, are apt to catch the fine points of filiform bougies introduced through a stricture. The base of the prostate embraces the neck of the bladder, and sur- rounds the vasa deferentia and necks of the seminal vesicles. The prostate lies below and directly in front of the neck of the bladder, inclosed by a fibrous capsule, in relation with the pubes in front, the rectum behind, and held in place mainly by the pelvic fascia — or pos- terior layer of the triangular ligament — and the pubio-prostatic ligament in front. There is never any fat between the rectum and prostate. A large plexus of veins surrounds the prostate in front, and above as well as (partly) below. The prostate is composed of two lateral lobes, and only two. They form one symmetrical body, and never continue distinct in man, as they do in some animals. Thompson," quoting Morgagni, Santorini, Hunter, Cruveilhier, and others, as well as concluding from his own minute in- vestigations, decides absolutely against the existence of any third or median lobe in the healthy prostate. In shape and size the organ resembles an Italian chestnut. Its weight is about half an ounce. It lies with its apex looking forward, and may be readily felt during life through the rectum. The finger can always reach above its posterior border, unless the organ is decidedly enlarged. The prostate is a genital, not a urinary organ. Like the rest of the genital apparatus, it is small before puberty, and becomes notably de- ' " The Enlarged Prostate." 1^72 DISEASES or THE PROSTATE. veloped during that epocli. Its average diameters in tlie healthy adult ' are, longitudinal 25 to 30 millimetres, transverse 33 to 4=0, thickness 20- 25 ; or, roughly, 1^, 1^, | inch. The urethra usually tunnels its upper part, but occasionally its lower portion, in which case it is only slightly separated from the rectum, a circumstance which exposes the latter to injury in the cutting operation for stone. The prostatic urethra is surrounded by a small amount of erectile tissue. The arteries of the prostate come from the vesical and middle hemor- rhoidal. Its veins discharge into the surrounding venous plexus, which is made up by their union with the dorsal veins of the penis and the veins of the bladder. The lymphatics communicate with the lymphatic glands on the sides of the pelvis. The nerves come from the hypogas- tric plexus. DEFOBMITLES OF THE PROSTATE. Deformities of the prostate are exceedingly rare. Its roof is open in extrophy of the bladder, but its floor never seems to fail. It is never wanting except in connection with extensive lack of development of the whole genital system, particularly with non-development of the testicles. After complete castration on both sides, the prostate has been seen to disappear.' INJUKIES OF THE PROSTATE. The prostate by its position is well protected from ordinary casual- ties, and rarely suffers unless the general injury is very extensive, in which case its implication may be considered unimportant. TTie wounds of the prostate are incised wounds mad^ in the opera- tion for stone, lacerated wounds in the same operation from introducing dilating instruments, or extracting a large, rough stone, and penetrating wounds (false passage) made by accident or design in trying to pass a metallic instrument of an improper curve through an obstructed urethra. The prostate is a patient organ, and bears all these injuries well. Heal- ing after stone-operations is exceptionally rapid, and the prostate may be punctured by a catheter without necessarily any evil consequence, unless it be the seat of chronic disease. Injuries to the prostate get well, usually, if let alone, even where abscess forms in the organ, and abscess is not frequent even after pretty extensive laceration, although the parts are constantly bathed in urine. Injuries of the prostate do nob excite much constitutional derangement. Very different, however, is the case if the injury extends beyond the limit of the fibrous capsule of the gland. In such cases the worst complications are to be feared (pel- vic infiltration, abscess, peritonitis), and if the patient escape with his life he is fortunate. These consequences are more apt to occur in the operation for extraction of very large stone. The only treatment con- ' CruTeilhier, op. cii., p. 395. ' Civiale, quoted by Pitha, op. cit., p. 121 ItROPHT. -.no sists in seeing that the urine is thoroughly drained off, and supporting the patient's strength, keeping him at rest, and using opium as requured. ATROPHY OP THE PROSTATE. Atrophy of the prostate is rare, but is occasionally encountered. Among the recognized causes may be mentioned the atrophy of old ao-e, coinciding with general atrophy of the rest of the body. Here tlie glandular rather than the muscular constituent disappears. Thompson, in his admirable monograph, which obtained the Jaoksonian prize, in I860,' has, by laborious investigation, established the fact that the pros- tate does not necessarily enlarge with age, nor does it necessarily atro- phy. As a rule, it continues about of normal size, but it may occa- sionally atrophy, physiologically, like other structures in old age, just as it may, and often does (pathologically) hypertrophy. Atrophy of the prostate, during general wasting disease, especially phthisis, has been noted. Pressure from a tumor, or cyst, or stone, within or near the prostate, may cause its atrophy, as may also the constant pressure of urine behind a tight stricture. Atrophy, after double castration, is possible. Atrophy of the prostate has no symptoms except, possibly, lack of force in the ejection of semen. It is an unimportant affection, and has no direct treatment. If the cause can be discovered and removed (press- ure), the tendency to atrophy may be overcome. HYPERTKOPHY OP THE PROSTATE. The morbid condition to which the prostate is most liable is hyper- trophy, either general, partial, or by the development of circumscribed tumors. In general hypertrophy the glandular elements, instead of be- ing hypertrophied, often become atrophied by the excessive growth of fibrous and muscular tissue between them. In marked cases they are completely destroyed, and the prostate is converted into a homogeneous fibro-muscular tumor. The isolated, circumscribed prostatic tumors, however, always show new formation of gland-tissue." Cause. — The cause of hypertrophy of the prostate is totally un- known. The numerous hypotheses which have been advanced by au- thors need not be discussed : they do not cover the ground. No known diathesis, or combination of circumstances, can account for the affection. It is not venous stasis, or excessive use of the organ, or sedentary life. All that can be said is, that the disease does not occur before middle age — rarely before fifty ; Thompson says fifty-five. Hypertrophy of the prostate, although a disease incident to old age, is not caused by old age. Thompson's minute and laborious investiga- ' " On the Diseases of the Prostate," 4th ed., 1873. = Kindfleisch, " Path. Histology," Amer. trans., p. 646. 174 DISEASES OF THE PEOSTATE. tions' have demonstrated that prostatic hypertrophy is pathological, and not a physiological condition attaching to advanced life. The ma- jority of prostates of old men, taken at random, will be normal in size ; a few, perhaps five per cent., will be atrophied, whUe many will be found hypertrophied. The prostate is analogous to the uterus in the female in regard to the nature of the muscular tissue which composes it, and this analogy is further borne out by the tendency of both organs to develop fibrous tu- mors (so called) after middle life. Velpeau " suggested this analogy, and justly. The portion of prostatic tissue which hypertrophies is the muscular and not the glandular (or only to a small extent), and although general or partial enlargements of the prostate are the rule, yet it is rather rare for any considerable hypertrophy of the organ to be found without the coexistence of one or more circumscribed tumors, which correspond to the circumscribed fibrous tumors of the uterus, also com- posed mainly of unstriped muscle. Bayle says that twenty per cent, of women, after thirty-five, have fibrous tumors of the uterus, the cause, of course, unknown. Thompson ^ says that thirty per cent, of males, after fifty, have fibrous tumors of the prostate. He states that moderate en- largement of the prostate may be expected in one out of three men ; after fifty, marked enlargement in one out of every eight, but rarely be- fore sixty. Thompson believes that the aifeotion rarely commences after seventy. He quotes, from Beith,* the case of an old man who died at one hundred and three, where the only abnormal conditions found were hypertrophy of the prostate and a sacculated bladder. Size and Shape. — No positive limit in size can be named. The prostate may be encountered of the size of a man's fist. Thompson has seen the transverse diameter exceed four and a half inches. The weight of twelve ounces has been reached. This excessive amount of enlargement, however, is rare — a prostate as large as a small orange being infrequent. The mass may take any shape, depending upon the part of the organ involved. Smooth and round in general hypertrophy, it becomes more or less irregular in unsymmetrical overgrowth, or from circumscribed tumors. The portion most frequently involved, either alone or (usually) as- sociated with more or less general hypertrophy, is the posterior median part, known since Sir Everard Home ' as the third lobe. This nomen- clature, however, is inexact. The prostate has no third lobe, and what Home, from his dissection of diseased prostates, named the " third lobe," is, in reality, a pathological formation, and is now more correctly styled median centric hypertrophy. It consists of that triangular part ' Op. at. ■' "Lemons Orales," vol. iii., Paris, 1841, p. 478. ' Op. cit. 4 >. Trans. Path. Soo.," 1850-'51, p. 124. = " Philosophical Transactions," 1806, paper viil. It was not discovered by Homa It was accurately described by Santorini in 1739, and mentioned by Morgagni. HYPERTKOPHT. 175 ■ the prostate lying between the ejaculatory ducts, and overgrowth in lis situation is believed to be due to the absence of capsule here. It ay be found with little or no enlargement elsewhere. In form it is iually an oval, rounded tumor (there may be two or more), which :ows up from the floor of the back part of the prostatic urethra j^nd its out posteriorly into the cavity of the bladder. It may reach the ze of a small pear, and in- ;ed resemble a pear in shape, lowing a tendency to pedun- ilation. When hypertrophy invades le lateral lobes, only one may 3 affected, but usually both, ore or less general enlarge- ent corresponding with the cal overgrowth (Fig. 57). nder these circumstances the jrriform central tumor tends fill up the internal orifice of e urethra, leaving a passage 1 either side along its floor, r the urine. The mucous embrane on either side of the ntral mass is often drawn up, itween it and the hypertro- lied lateral lobes, forming a escentic bar at the neck of e bladder. Embedded in the hypertro- lied mass, it is usual to find veral small circumscribed tu- 3rs, dense, hard, seemingly fibrous in character, easily enucleated and istic, so that, when cut through in a clean section of the organ, the t surface of the tumor overrides the general smooth plane of the in- iion, as if the little mass had previously been compressed. They 3 formed of unstriped muscle with some new glandular tissue, and are nsidered analogous to mammary glandular tumors, or to tlie glandu- ■ bodies which develop (pathologically) in and around the thyroid, lese tumors, usually small, may become as large as a marble ; many 3 found of the size of a pea. Other localized hypertrophies of the prostate are more rarely en- iintered in the shape of distinctly pedunculated tumors, which grow im any portion of the posterior margin of the prostate, and hang into 3 cavity of the bladder. They may surround the neck of the bladder e a fringe. Median centric hypertrophy may take this form, consti- FiG. 57. — (Coulson.) Showing Enlargred Prostate with "Third Lobe," through the Base of which a False Passag;e has been made. 276 DISEASES OF THE PROSTATE. tuting a sort of ball-and-socket valve at the neck of the bladder. Finally, there may develop in the thickness of the bladder-walls small supernumerary outlying prostatic glandular tumors, varying in number and in size, but only existing coincidently with one of the ordinary forms of overgrowth. BAR AT THE NECK OE THE BliADDEB. This affection has become classical since the investigations of Guth- rie,' who described the muscular bar formed by hypertrophy of bladder- tissue just behind the prostate, and the bar of mucous membrane already alluded to. All the varieties of bar, of which there are three, may be considered at once, in connection with prostatic hypertrophy : 1. Centric median hypertrophy, where a transverse bar of hyper- trophied tissue is formed, instead of the usual oval tumor ; this form is rare. 3. The lifting up of a fold of mucous membrane between unsym- metrical lateral lobes, or between the so-called third lobe and hyper- trophied lateral lobes. 3. The form of bar to which Guthrie specially called attention. This latter may (rarely) exist without prostatic hypertrophy. Its seat is in the muscular fibres which run transversely across the trigone, behind the prostate. These fibres sometimes hypertrophy greatly, the trigone becomes contracted laterally, the orifices of the ureters approach each other, while the hypertrophied bands of fibres stand out like a bar, forming an obstruction, but an obstruction totally unconnected with any prostatic overgrowth. Symptoms and Result of Enlarged Prostate. — Hypertrophy of the prostate (like stricture) does harm mechanically, and provokes lesions in other parts. Its symptoms, pure and simple, are unimportant, and do not call for treatment, unless the enlargement be sufficient to obstruct the free outflow of urine, and occasion disease of the bladder (cystitis and its consequences). A description of the special variety of the latter, due to prostatic hypertrophy, finds its place here more naturally than under the head of Diseases of the Bladder. The immediate result of hypertrophy of the prostate is a deviation in the direction, and usually a diminution in the size, of the prostatic urethra. As the prostate enlarges, its antero-posterior diameter elon- gates, and with it the length of the prostatic urethra necessarily in- creases. Thompson has seen it three inches long. The urethra, more- over, tends to become a vertical slit, as its calibre is encroached upon from side to side by the increased size of the lateral lobes. If isolated fibrous tumors grow up from the floor or sides of the prostatic urethra, the course of the latter becomes by so much the more devious. When one lateral lobe is hypertrophied alone, or to a greater degree than its fel- ' " On the Anatomy and Diseases of the Urinary and Sexual Organs," 1836. MEDIAN POSTERIOR HTPERTEOPHT. -i^h low, the urethra is pushed toward the opposite side. When there is pos- terior median hypertrophy (as occurs in the majority of cases applying- for treatment), we have the greatest degree of obliteration of the canal for the least amount of overgrowth. Most cases of prostatic hypertrophv probably never come under the surgeon's notice, in consequence of therl being no obstruction to the outflow of urine. Many an old man goes to his grave with enlarged prostate, the existence of which has never been suspected. Of those cases which are seen, median hypertrophy exists in a large proportion. This median central part of the prostate lies at the neck of the bladder directly in the vesical orifice of the urethra (Fig. 58). As it grows upward and backward, it fills the mouth of the bladder, and converts its naturally rounded orifice into a crescentic slit, convexity upward. The floor of the prostatic urethra is also unnatu- rally tilted up, to override this bulk-head which has sprung up in its course. Fig. 59 shows the efiect upon the course of the urethra of this so-called third lobe, and suggests at once the two great facts which are the key-notes to a correct understanding of the pathology of hypertro- phied prostate, and of the means of relieving its most prominent symp- tom — ^retention. These facts are — 1. That such a growth occupying the vesical orifice, and jutting out behind and above it, must obstruct the free outflow of the urine from the bladder. 2. That an instrument of ordinary curve, introduced from without, must strike against this obstacle, and refuse to enter the bladder. 12 178 DISEASES OF THE PROSTATE. Consequently, a modification in the shape of the instrument is called for. The bar at the neck of the bladder constitutes an obstruction of the Fig. 59. — Posterior Median Hypertroplij. same sort. If several posterior tumors exist, instead of one, the vesical orifice is correspondingly modified. If a single pediculated tumor grow anywhere around the mar- gin of the lu-ethral outlet hanging into the cavity of the bladder, it may act like a ball - and - socket valve, causing retention where there is very little general hypertrophy. To follow pathologically the natural history of hy- pertrophy of the prostate, it must be borne in mind that the blood, returning through the vesical veins, finds its way back into the general circulation through the venous plexus lying around the prostate; con- sequently any enlargement of the latter tends to press upon this plexus, and by so much to obstruct the venous circulation, and establish a constantly-increasing venous con- FiG. 60.— Healtliy Prostate. HYPERTROPHY. j/rg gestion of the bladder walls and membranes. Then, again, the devia- tion in the course of the prostatic urethra, and its decrease in size, mainly due to posterior central enlargement, obstruct the free outflow of the urine, and call for constantly-increasing efforts on the part of the bladder to force out its contents. From these two circumstances, venous congestion and the need for an exercise of greater muscular power, the bladder walls go on to hyper- trophy. The bundles of fibres of the detrusor urinse increase in size, and jut out into the cavity of the bladder, like the columnas earner of the heart. But these thickened bundles of muscular tissue do not propor- tionally increase the expulsive power of the bladder, for they are con- stantly congested, and working at a disadvantage. The muscular fibres of the base of the bladder are not able to contract sufficiently to bring the floor of the viscus above the level of the dam at its mouth, and hence a little urine is left behind after each act of micturition. This residuum (as it is called) announces itself by no symptom, and is un- noticed. It becomes mingled with fresh supplies of urine coming down the ureters, and is partialy passed off and replaced by fresher fluid. After a time, however, the mucus, from the slightly congested membrane around the base of the bladder, being in part retained in the residuum, acts upon the latter, setting up decomposition of urea and liberation of carbonate of ammonia. The carbonate of ammonia irritates the mucous membrane of the bladder, increases its congestion, and calls forth a new supply of mucus, which, in its turn, acts as a fresh ferment, alkalinizing and decomposing more urine. The natural acidity of the urine still further tends to keep up and aggravate the already-existing congestion. Under these cir- cumstances — ^the membrane becoming hyperaemic, and thickened around the already - contracted mouth of the urethra — more obstruction to the outflow of urine is occasioned, and the quantity of residuum is in- creased, while the laboring detrusor urinse is forced into still greater hypertrophy in its fruitless efforts to overcome the increasing obstacle. In this way the bladder becomes gradually distended, the amount of residual urine increasing from month to month, and the bladder getting less and less able to empty itself. Hence with hypertrophy of the blad- der-walls there is, usually, also dilatation of its cavity. Finally, retention comes on, most often excited by a chilling of the legs, the " cold " which the patient has taken " settling," as it were (where the circulation is already weakened), upon the prostate and neck of the bladder, and superadding an active inflammatory congestion to the already-existing enlargement — this congestion (as in the case of stricture) being sufficient to shut up the urethra completely. The new hypereemia may subside in a few hours, if the patient keeps quiet in a warm place, and with its disappearance the power of voiding urme returns ; or surgical relief may be afforded, or the accumulation may 180 DISEASES OF THE PEOSTATE. go on to over-distention, and, finally, overflow. This stretching of the hypertropliied but weak fibres of the detrusor takes away more or less of their power of contraction, and the bladder is apt to be left in a con- dition of atony. After a retention, if it has not lasted too long, the bladder may go on expelling the excess of urine above the residuum, just as it did before, but now the amount of residual urine is greater, and the power of the bladder less. The congested membrane around the vesical neck and in the prostatic urethra is kept irritated by the partly-decomposed urine, and it takes but a slight cause, a chilling or an excess at table, to bring on another retention. Af- ter each attack the bladder is left in a more helpless condition. Besides distention of the bladder with hypertrophy of its ■walls, sacculi may be developed and grow greatly with each suc- ceeding retention. The efforts which the hypertrophied fibres of the detrusor are obhged to make, to expel the m-ine, cause the mucous membrane to be pressed out between their mesh- es into little pouches, and if re- tention come on, these parts, being weaker than the rest of the bladder, suffer most, and may become enlarged into supernu- merary bladders composed of mucous membrane, connective tissue, and peritoneum, but cov- ered by no muscular coat (Fig. 61). Sometimes, though rarely, one of these sacculi may be found larger than the bladder itself — usually they are only shallow depressions between the raised bundles of muscu- lar fibres, occasionally little sacs with constricted necks. These sacs have no muscular tissue, and consequentlj' no power of emptying them- selves ; hence the urine tends to stagnate in them, and to undergo decom- position, depositing crystals of triple phosphate with more or less amor- phous phosphate, etc., all of which become glued together by mucus, and thus form a nucleus for stone, which, increasing in size, may finally fill up the sacculus even with its narrow neck (encysted calculus). These changes are all the more certain, if some kidney-stone lodge in a sac- culus, instead of passing oflF. Any foreign body remaining in the blad- der becomes incrusted by urinary salts and becomes a nucleus for stone, as is well seen when a catheter is tied in for a length of time. I^G. 61. — iOrome) HYPERTROPHY. -j^gj This process of stone formation, which goes on so readily in a sacou lus, also takes place in the bladder when its floor is depressed behind a third lobe, in what is known as the " bas fond," or lower bottom. Here too, the urine stagnates and deposits its salts, as crystals and amorphous dust, to be glued together upon a nucleus (kidney-stone), or, as is more usual, to become themselves consolidated by the cement of mucoid pus. In all cases of enlarged prostate, where there has been any considerable amount of residuum, stone is liable to form. Stone is the logical se- quence of obstruction to urinary outflow. A stone, or several, may exist under these circumstances without giving rise to any symptom. They are usually smooth, and do not scratch or irritate the floor of the bladder greatly, nor do they add much to the already existing pain. The fibres of the weakened detrusor can- not, during micturition, force a stone thus formed against the sensitive tissues at the neck of the bladder and produce the striking symptoms which characterize vesical calculus, when found in a healthy subject. Enlarged prostate, by obstructing the free outflow of urine and dam- ming up the bladder, tends to distend the cavity of the latter, gradually to dilate and congest the ureters and pelves of the kidneys, and ulti- mately to excite and maintain a mild inflammation of the cortical and medullary structure of the kidneys — which exists, as a rule, in all old cases. This kidnej' complication is easily aggravated by any increase in the bladder congestion; and any inflammation of the latter organ is apt to run rapidly up the ureters and further congest the kidneys, bring- ing on symptoms of mild ureemia, with more or less fever, hot, dry skin, loss of appetite, and a particularly diy mouth and tongue. In these cases there is no suppression of urine, but on the contrary a marked polyuria, as a rule, occasionally attended by a trace of sugar, and usually showing an occasional cast, a little more albumen than the pus and blood in the specimen wiU account for, and a sp. gr. of about 1006 to 1016. Swelled testicle sometimes accompanies one of these exacerbations of inflammation, but more usually follows the introduction of an instru- ment. The pressure of the enlarged prostate occasions also congestion of the hemorrhoidal vessels, while the violent straining not infrequently brings on some prolapse of the rectum. The distress attending this group of morbid changes is often so excessive that the patient's life be- comes a burden to him. The urine is that of catarrh of the bladder, and this catarrh, the in- evitable accompaniment of prostatic enlargement at some period of its existence, is usually limited to the vicinity of the neck. Its tendency is to involve more and more of the mucous lining of the body of the organ, from the action of such causes as cold, over-acid urine, retention, etc. The urine is alkaline, or, even if faintly acid, it has an ammoniacal odor, and often a fetid, sickening smell, which occasionally disappears. When 182 DISEASES OF TKE PROSTATE. the urine is acid, it is so because it comes down strongly acid from the kidneys, and all of its acidity has not been neutralized by mingling with the alkaline residuum. Whatever urine has been alkaHnized, deposits crystalline and amorphous phosphates, so that, even in those cases where the urine is stiU acid, it is murky, cloudy, filled with little strings and clots and clouds of pus, and with gouts of ropy muco-pus (pus agglu- tinated and made translucent by ammonia). A few blood-corpuseles will nearly always be found, and more or less amorphous urate or phos- phate (perhaps both), with (pretty certainly) crystals of triple phosphate entrapped in the " stringy mucus," and, possibly at the same time, crys- tals of uric acid, oxalate of lime, or others. The above detail represents the course of changes as they occur in a majority of instances of enlarged prostate ; but there may be varia- tions. Thus the whole prostate may be enormously enlarged without any median posterior hypertrophy, and consequently without any appre- ciable diminution in the calibre of the urethra or obstruction to the out- flow of urine. In these cases there is no residuum. The patient can empty his bladder entirely ; but the obstruction to the return of venous blood from the bladder-walls, produced by pressure of the enlarged pros- tate, keeps up a congestion about the floor and neck of the organ none the less. Hence the symptom, known as irritability (constantly-recur- ring desire to urinate), is pretty sure to be present, sometimes to an in- tolerable degree. The bladder hypertrophies, but, instead of dilating, as is the rule, it may contract, and, as there is little or no residuum, sac- culi do not form and atony does not come on. This condition of things, unfortunately, may occur even where there is some median hypertrophy and a small, constant residuum, and may even be found occasionally after the bladder has been overstretched by retention. This is always to be regretted. A bladder that is thoroughly atonied, so that it can only slowly force out the urine through a cathe- ter, is far preferable. Such a bladder is patient and uncomplaining, giving its possessor but little uneasiness. It is slow to take on inflam- mation, while the other form (where full contractile power remains, and irritability is present) is usually a torment to its owner as well as to the surgeon. The bladder contains little or no residuum, the urine continues acid and only slightly murky in appearance ; but the calls to urinate are incessant, night and day, and the bladder cannot be made to contain more than an ounce or two of urine without feeling as if it were split- ting. Thompson speaks of an old gentleman whose prostate formed an " enormous tumor" when examined by the rectum, yet repeated explo- rations failed to find a drop of residual urine. The patient was tor- mented by an incessant desire to pass water, and experienced great diffi- culty in the act. Besides the two conditions already aUuded to — namely, dilatation with great tolerance, and contraction with irritability — ^in the one case HYPEETEOPHT. jgg tlie patient urinating rarely, unless there are atony, a large residuum, and overflow ; in the other, great frequency of urination being always pres- ent — ^besides these two, there is one other condition, possible but rare namely, true incontinence. Occasionally, the unsymmetrical develop- ment of the prostatic lobes leads to a slightly patulous condition of the internal orifice of the urethra, and causes true incontinence, the patient being unable to prevent a slight, constant dribbling away of the urine. In nine cases out of ten such dribbling is the result of overflow ; but still the possibility of true incontinence must be borne in mind. A distinc- tion between the two is easy. Empty the bladder by means of a cathe- ter : if dribbling recur at once, we have incontinence ; if only after some hours, overflow. Course of /Symptoms. — During all the time that these pathological changes have been going on, a period of many months, perhaps years, ever since there began to be a little hypersemia around its neck, the bladder has been getting gradually irritable. The patient does not readily notice it, and will never be able to fix a precise date for the com- mencement of his troubles. An old man does not sleep soundly or pay the strictest attention to the performance of his habitual functions, and he so gradually acquires the habit of getting up a little earlier than usual in the morning to empty his bladder, that he pays no attention to it. Soon he finds that he wakes up once at night, perhaps twice, with a feeling of fullness in his bladder. He passes water, and goes to sleep again. He is also troubled a little more frequently than usual in the daytime, but he looks upon it as a condition natural to advancing life. He has learned that the little ills of the flesh, if let alone, usually regu- late themselves. He has passed water without trouble for fifty or sixty years, and he thinks that he ought still to be able to manage it without applying to his surgeon. He shrinks from acknowledging a weakness, which he must admit to be, if nothing more, a symptom of advancing age, and so he goes on lulled to security, making water at intervals which gradually but steadily become shorter, getting up perhaps every hour at night, and constantly annoyed by a faint, obscure sense of weight and heaviness about the lower part of his belly, with, perhaps, a fullness in the rectum, and a dull pain behind the pubes. The bladder, now, is never empty ; but the patient does not know it. Only an excess above a certain residuum can be passed ofi^ The old man notices also, perhaps, that he has to wait a little while before the urine begins to flow, that the stream is small, and is not projected away from him with any force, and that, perhaps, a part of the urine dribbles down perpen- dicularly from the meatus, while the rest flows as a continuous stream. Possibly he cannot make the « coup de piston," the final spasmodic clearing of the urethra, and finds that a few drops dribble away upon his clothes after each urinary act. He does not experience quite as much ease and relief as usual, after micturition ; but this has come on so 184 DISEASES OF THE PROSTATE. gradually, that lie disregards it. He finds, however, when he is jolted through the streets in a carriage or car, that his calls to urinate are even more frequent than usual. At this juncture he dines out, and drinlts a glass or two of wine more than usual, or he neglects a call to urinate, or gets a wetting, or his feet and legs get chilled (the latter a very common cause of trouble), and suddenly he finds that he cannot pass water at all. After vainly trying at intervals for a number of hours, if he does not seek svirgical relief, at last the urine wiU begin to dribble away from him. The bladder has been distended to its utmost, the mouth of the urethra has been dragged open slightly, and the excess of urine trickles involuntarily away. This is overflow and not incontinence. Meantime the patient has been suf- fering the torments known only to those who have had retention, and he hails the overflow with delight, believing that his sufferings are about to cease. The hope is vain. The congestion of the bladder neck, brought on by the use of liquor, or by the chilling, and which, added to the already large prostate, has swollen it sufficiently to shut up the urethra entirely, subsides shortly. Gravity, and the contractions of the abdominal muscles, and of the diaphragm, are together able to dispose of a certain excess of urine, which the overstretched bladder, now in a condition of atony, is unable to void. The patient, perhaps, recovers from his overflow, but his residuum is greatly in excess of what it was before his attack of retention, his calls to urinate are more frequent, he is disturbed more often at night. All his former feelings of uneasiness and pain about the hypogastrium and perinsBum are increased ; digestion is impaired ; the appetite fails ; and, worn out by loss of sleep, inability to eat, and constant uneasiness amounting to actual pain, the sufferer vuns down, aging rapidly, and becoming fretful and irritable, losing all interest in business, and nearly all pleasure in life. A second and third retention come on, and aggravate the situation. Perhaps a stone is forming, as is always apt to be the case. The bladder may ulcerate, and peri-cystitis ensue, and death finally close the scene, the most common mode of death being by uraemia, induced by a little extra congestion of the secreting portion of the kidneys. The foregoing clinical history is that of a type case. It may be va- riously modified, according to the pathological condition of the bladder and prostate ; there may never be any retention ; on the contrary, there may be constant true incontinence, or the bladder may take on acute inflammation, after an over-distention, with retention, and carry off the patient with acute febrile symptoms. Pyelitis or peri-nephritis may come in as complications, and quickly close the scene, or certainly precipitate the catastrophe. HYPERTROPHY. 185 CHAPTER X. DISEASES OF THE PROSTATE. Hypertrophy (continued).— Diagnosis ; Description of Instruments and Mauojuvres employed in their Use.— Examination of Patient— Methods of retaining Catheters in the Bladder.— Methods of decidin" upon the Character and Extent of Prostatic Deformity as aifecting tho Course of the Urethra. Treat- ment.— Treatment of Complications.— Internal Eemedies in Prostatic Disease.— Natural Mode of Death due to Hypertrophied Prostate. Diagnosis. — When a patient of over fifty comes to seek relief for fre- quent micturition, suspicion falls at once upon the prostate. It is rare that stricture causes trouble for the first time so late in life ; moreover, with enlarged prostate, the inconvenience will, as a rule, have been first noticed at night — the reverse of what is observed in stricture. As the first step in the examination, the patient should be. placed upon his back, with the knees elevated and abdomen relaxed, and a digital examina- tion made through the rectum. By this means alone general prostatic hypertrophy can always be demonstrated. In place of the soft, chestnut- like body, hardly recognizable except by the skilled touch, the finger will encounter a rounded, dense mass, smooth and symmetrical, or vari- ously distorted and nodulated. The median fissure between the lobes may be more than usually perceptible, or may be wholly obliterated ; while the finger passed up on either side, between the prostate and the walls of the pelvis, recognizes a deepening of the sulcus, and any undue prominence in size of one or the other lobe. Forcing the finger well up the rectum, it may be impossible to hook the last phalanx above the posterior margin of the enlarged prostate, while the seminal vesicles can usually be made out on either side, partly embedded in the general hypertrophy. Perhaps rectal examination may reveal none of these positive evi- dences of enlargement, median hypertrophy existing none the less. In such a case the finger readily detects the bladder, if it be distended, beyond the prostate ; the latter apparently not at all or but little larger than normal. Pressure through the rectum upon an enlarged prostate does not cause pain, unless there be some inflammation about the neck of the bladder. It often, however, provokes a desire to urinate. The next step in the examination is to make out the condition of the bladder by palpating and percussing the hypogastrium. Usually this method does not throw any light upon the condition of the prostate, unless it is exceedingly large, when pressure upon it through the rectum may be recognized by the hand upon the hypogastrium. The same j^gg DISEASES OF THE PROSTATE. occurs in those rare cases of excessive hypertrophy of the bladder- walls with contraction of its cavity (concentric hypertrophy). As a rule, hypogastric palpation only reveals the fact that pressure above the pubes excites a desire to urinate — from transmission of the force to the sensitive neck of the bladder. Sometimes, however, an oval tumor is found, as large as a child's head, filling up the lower part of the beUy, perhaps as high as the umbilicus, flat on percussion, and causing a desire to urinate when pressure is made upon it. This tumor, formed by the over-distended bladder, can often be plainly seen, but the pa^ tient is usually unconscious of its existence. If the finger in the rectum can reach beyond the posterior border of the prostate, fluctuation can be felt between it and the other hand pressed upon the hypogastrium. The patient is now asked to stand up and to pass water into a glass vessel. A little gleety discharge may be often found at the meatus, originating from the congested surface of the prostatic urethra. Occa- sionally, if questioned, the patient will confess that he is troubled with frequent erections, the cause of which lies in this same congestion. Sometimes, on the other hand, erections are absent. As the urine is flowing off, it will be noticed that it commences tardily, and in a small stream, which gradually enlarges. There is very little force to the flow. There may be two streams, the one projected, and the other dribbling perpendicularly from the meatus, indicating an obstacle at the outlet of the bladder to the escape of urine. If there is retention, the urine will not flow at all, or comes away only by drops. While the stream is flowing, if the patient be requested to strain, in- stead of becoming larger or flowing with greater force, the stream may be diminished in size and power. Under these circumstances a ball-and- socket arrangement, or some valvular condition of the overgrowth, may be predicated, which, when acted upon by the pressure of the abdominal muscles through the mass of accumulated urine, tends still further to occlude the internal urethral orifice, so that the stream flows fastest when the least effort is made. If the bladder be inflamed, there may be severe tenesmus and pain during the attempt to urinate, and the rectum may protrude or faeces be passed during the act. Hernia may be occasioned by the violent strainmg. At the end of urination the stream gradually dribbles away into drops, and often the final jet or " coup de piston" is wanting, although the latter may be perfect or even ex- aggerated. If the urine which has been voided be now held up to the light, it •will be found to be cloudy, troubled, perhaps bloody, badly smelling, and to contain white floccuU of pus, or perhaps gouts of stringy muco- pus, or again it may be perfectly clear. The condition of the urine in- dicates the amount of cystitis present, whUe its quantity (in residuum) and the force of its flow, after the catheter has been introduced, allow an estimate of the degree of atony. There may be considerable irrita* HYPERTROPHY. 187 bility, with little or no cystitis, and in such cases the urine is nearly or quite clear, generally strongly acid, and of high specific gravity. Usually there is more or less pus present, indicating cystitis, and, when the latter is of a high grade, the fluid is often ammoniacal, or has a fetid odor of decomposition, is filled with pus, more or less blood, fluid or in clots, and stringy mueo-pus, which is often gritty from containing large quantities of triple-phosphate crystals. When the patient has voided all the water he can, he is again placed upon his back, and a full-sized silver catheter of short curve passed gently down toward the bladder. The instrument will usually go smoothly along (perhaps halting for a little coaxing at the triangular ligament) until it has reached a depth of from six to eight or more inches, when it will stop. On no account should the least force be employed. A finger is now again introduced into the rectum to feel whether the instrument is in a false passage, which may have been made in some previous attempt at catheterization. If it is found to be in the canal and in the median line, the finger can readily appreciate the approximate increase in thickness of that segment of the prostate ly- ing between the instrument and the rectum ; and a diagnosis of ob- struction in the floor of the urethra at the neck of the bladder is estab- lished. In examining a patient for the first time, it should never be lost sight of that we are dealing with an old man whose urinary pas- sages are in a more or less irritable condition, and probably unused to local disturbance. Any examina- tion which is at all rough or too prolonged is pretty sure to be fol- lowed by some aggravation of the symptoms, and, unless the condition be urgent (retention), it is often advisable to make only a partial exploration at the first sitting, leaving the rest for another day. If made worse by his first examination, the old man becomes far less docile for future management. If, however, there is retention with or without overflow, it becomes the surgeon's duty to make judicious use of all available means to enter the bladder with a catheter. The next step in the examination is, to determine the nature of the obstruction in the urethra, and some instrument must be found which Fio. 62.— (Thompson,) 188 DISEASES OF THE PROSTATE. will enter the bladder. Unless the " third lobe " rise very abruptly from the floor of the urethra, the bladder may be entered by a sUver catheter with an extra long curve. Such an instrument should be of large size. The surgeon should be provided with several of tiiem of diiferent sizes (from No. 10 to 16), and with varjang curves (Fig. 62). One of these instruments will usually slip into the bladder, a flow of urine announcing the success of the operation. Generally the amount of residual urine is small. The degree of irritability is not proportionate to the amount of urine which cannot be voluntarily passed, indeed it may be greatest where the residuum is at a minimum. It is always a favorable sign for prognosis, as far as the future comfort of the patient is concerned, to find a copious resid- uum upon the introduction of the catheter. Such cases are always more easily managed than others, provided only the patient can be taught to introduce a catheter for himself, since, by keeping his blad- der from overfilling, he can avoid his most disagreeable symptom — con- tinuallj'-recurring desire to urinate. Should the silver instrument fail to enter the bladder, a small conical olivary French catheter, with a slender neck and a long fixed curve in its woven structure, designed to keep its point in contact with roof of the urethra, will sometimes override the obstacle and effect an easy entrance. Failing in this, Thompson's method may be employed. A medium, smooth, blunt English catheter is selected, its stylet removed, and itself bent into an exaggerated curve, the last inch of the curve being more accentuated than the rest. When the instru- ^ ment has been shaped (Fig. 63), it is held for a moment in cold water, which causes it to retain the curve it has received until it again becomes warm. The instrument so curved is oiled, and, without a stylet, rapidly introduced, so as to allow the heat of the urethra to act upon it as little as possible. It reaches the floor of the prostatic urethra be- fore the point has lost its exaggerated curve, and this point, following the roof instead of the floor of the canal, readily surmounts any median hy- pertrophy and passes over the " third lobe " into the bladder. Another excellent method of over- riding median hypertrophy with an English cath- eter is, to introduce the latter armed with a sty- Tis. 6S.—(_Tkompson.) ' , . let of exaggerated curve. When an obstacle is encountered, the stylet is slightly withdrawn. This manoeuvre causes the beak of the catheter to tilt upward suiBciently to surmount the ob- struction. Another instrument devised by French ingenuity, and capable of rendering valuable service, where perhaps no other catheter will pass. HYPERTROPUY. 189 is a catheter known by the name of its inventor, Mercier. It is an elbowed instrument, having a fixed angle (Fig. 64, A), or two angles (Fig. 64, JB), in the woven material of which it is constructed. The Eng- lish now make similar instruments, usually colored brown, sometimes black. They are generally too stiiF and their angle is too obtuse ; con- sequently, though more durable, they are not so useful in difficult cases as the black French instrument. This catheter (similar instru- OTra A REYNDERB Via. U~A. OTTO t HEYNDERS. FlQ. Mr~£. ments, with one or two angles, are also made of metal) is avowedly constructed to override obstructions in the floor of the urethra, such as posterior median hypertrophy. The point follows the roof of the canal or strikes any obstacle upon its inclined surface, and at an angle which allows the instrument to ride over the obstruction. For difficult cases these catheters are invaluable. The instruments already described suffice for general enlargement and for cases of " third lobe," but occasionally the canal may be so Fie. 65. deviated, by irregular lateral overgrowths, that even these instruments fail to effect an entrance. For such cases there are several instruments left. Phillips's catheter, open at both ends, introduced over a two-foot 190 DISEASES OF THE PKOSTATE. guide (p. 104), must not be forgotten. It is capable of rendering impor- tant service. Another instrument is a simple soft-rubber catheter, look- ing like a piece of ordinary rubber tubing, shut at one end, with holes in the side (Fig. 65). This is oiled and introduced without a stylet, like a ramrod into a gun, and will sometimes find out and pass through the sinuous windings of a prostatic urethra where all other instruments fail. Similar instruments are now made in England, colored a dirty pink, known by Thompson's name. They are smoother than the French, more durable, of larger calibre, and easier of introduction. Holt's self-retain- ing catheter is similar to these instruments, but is provided with two wings (Fig. 66, A) of soft rubber near the eye, which do not materially interfere with introduction (in any case where a metallic instrument of long curve will enter), and which wings, once in the bladder, fly out and retain the catheter. Holt's catheter is introduced by the aid of a long stylet. The instrument has been modified as shown in Fig. 66, Ji. All of these in- struments of soft rubber may be worn in the bladder for a considerable length of time without (in many cases) producing much uneasiness or becoming inorusted by urinary salts, if the bladder is washed out with warm water pretty regularly. Holt's catheter is sometimes objection- able on account of its wings — which indeed often fail to hold the instru- ment in — hence, in retaining in the bladder a soft-rubber catheter, one B.TIEMANN-Ca. FlO. 67. of two other devices may be employed. A tube of any hard material, an inch long, may be pushed over the outside of the catheter or a small one within its calibre, at that point of the shaft which will lie just out- side the meatus after the instrument has entered the bladder. Around this a thread may be tightly tied, knotted again, and tied beneath the corona, or fastened one thread on either side under a small piece of ad- hesive plaster. This method originated with Thompson. The catheter- holder,' however, is the most convenient apparatus for retaining any in- strument in the urethra. It is simply a sort of m-uzzle for the penis, made of flat bands of soft rubber. Where the bands cross over the meatus they are perforated by a minute hole. This being very elastic, admits and firmly holds any instrument passed throusjh it, while the strap of the muzzle surrounds the body of the penis (Fig. 67). American ingenuity has supplied a metallic instrument to follow the sinuous curves of a distorted prostatic urethra. It was devised by Squire, of Elmira, and consists of a straight silver tube, terminated by ' It is of French origin. HYPERTROPHY. 191 silver segments of small size, not united together, but held in contact by a little flexible chain, running through the hollow of the catheter, and attached firmly to the last segment, which contains the eye (Fig. 68). The central chain terminates in a wire which appears at the mouth of the cathe- ter in the shape of a screw, furnished with a circular nut. By loosening STonnimii pnmc sen. Fig. 68. the nut and pushing down the wire, all the segments making up the end of the instrument fall apart ; by tightening it they are stiffened up and brought into place, being left in a condition more or less flexible, accord- ing to the tension of the central chain. This instrument, pushed down into a tortuous canal, is capable of assuming any curve, and foUowino- the windings of the passage. It has proved serviceable in some cases. The objection to it is, the temptation to employ force in its manipulation. Another ingenious instrument of Mercier's may be useful. It is de- signed to avoid false passages. A silver tube, of long curve, is furnished JTio. 69. with a central woven catheter, which may be protruded and pushed on through an aperture in the concavity of the instrument near its point (Fig. 69). The solid beak of the instrument enters the false passage, the soft catheter is protruded, and passes onward in the urethra into the bladder. Methods of estimating the Size and Chakactee of Prostatic OvEEGROWTH. — It is Sometimes desirable, for accuracy of diagnosis, or other object, to get an approximate idea of the exact situation and size of the overgrowth, together vnth the direction and amount of the devia- tion of the prostatic urethra, perhaps for purposes of rough comparison from time to time, to decide what advance is being made by the disease. A good deal of information, in a general way, may be gained on these points. In introducing the silver catheter of long curve, if the prostatic urethra be deviated to the right or left by the undue development of either lobe, the point of the instrument will be correspondingly deviated, and the degree may be roughly estimated by noticing the movements communi- cated to the handle. The increase in the antero-posterior diameter of 192 DISEASES OF THE PKOSTATE. the prostate may be rudely calculated witli the same instrument, by noticing the depth to which, the eye has to penetrate before it finds water — instead of seven or eight inches, perhaps ten, eleven, or more. In studying out the form of overgrowth at the neck of the bladder, all the in- formation necessary may be obtained with a short-beaked, solid sound of the curve known as Leroy d'EtioUes's, or Mercier's, or with the similarly shaped metallic instrument known as Thompson's stone-searcher (Fig. FiQ. 70. 70), the advantage of the latter being that it is a catheter as well as a searcher, and that, after the introduction, the bladder may be emptied, injected full or distended to any desired extent, so as to facilitate ex- amination, all of this without removing the instrument. The bladder should always contain a few ounces of fluid when this instrument is used. There is rarely any difficulty in introducing it through an en- larged prostate. Like Mercier's catheter, it is peculiarly adapted to glide over obstructions in the floor of the urethra, and this is the variety of obstruction which exists most frequently, and which most often opposes an obstacle to the entrance of rigid instruments, or those of ordinary curve. In examining an old case of atonied bladder, with enlarged prostate, for stone (and this examination should always be made whether there are symptoms of stone or not), Thompson's searcher is the best instru- ment to use, and during the search the condition of the internal orifice of the urethra should be examined. In introducing the instrument, if it is necessary to depress the handle greatly, in order to get through the last part of the prostatic ure- thra, it is because the beak of the searcher must rise gradually over a posterior median enlargement. If the beak seems to strike ab- ruptly against a bulkhead, and on a little manip- tdation, perhaps, to slip, with a start, suddenly into the bladder, the obstruc- tion is probably a bar. When the beak is in the bladder, it is retracted until it hooks the upper margin of the urethral orifice. The shaft is nnxir li/^lrl npnrlv Imri^nntnllv n.nrl flip inQ+rmnpTif rnfa+Arl /^Thp Vtlfl.Hnfir Fig. 71.— (77iomp«£m.) HYPEETKOPHY— TREATMENT. I93 must contain a few ounces of fluid.) If the prostate be healthy, or the obstruction a bar, this rotation can be performed without sensibly alter- ing the direction of the shaft of the instrument. If there be a tumor jutting out anywhere from the prostate (posterior, median, or other enlargement), the beak becomes arrested, and the direction of the handle has to be changed in order to make it override the obstacle. Such deviation will give the approximate position and size of the out- growth. Finally, in withdrawing the instrument, if the prostate be healthy, it may be retracted easily with the beak downward, while it will hook against any posterior median enlargement (Fig. 71). With the searcher the hypertrophied trabeculse of muscular tissue of the bladder may be also recognized, and their size and number roughly estimated. Treatment. — In the present state of our knowledge, hypertroph}' of the prostate is not curable by any means that have 3'et been used — by iodine, bromine, electricity, or pressure. The advocates of these and other methods have failed to establish their claims. Inflammatory in- crease in size may be successfully combated, hypertrophic apparently not. But still a vast deal of comfort may be aiforded to patients ; they can always be greatly relieved, sometimes cured, that is, freed from every subjective symptom. It is only necessary to remember that hyper- trophy of the prostate is a mechanical malady obstructive in its charac- ter, in order to appreciate at once the great object and end of treatment, namely, to overcome by art the obstruction erected by Nature to the free outflow of urine. The catheter is the natural specific for enlarged pros- tate, just as the steel sound is for stricture of the urethra. The catheter is no novelty in surgery. A need for its use has been recognized for ages, probably in just these cases of old men with enlarged prostate. Very good specimens of lead, copper, and bronze catheters (of long curve) have been found among the ruins of Pompeii. But, to be effec- tive, the use of the catheter must be intelligent, and other means must assist its employment, while, in very rare instances where there is no residual urine, it is of little or no service. To take up one of the most common class of cases first, where, after a few months or perhaps years of gradually increasing inconvenience, a surgeon is finally applied to. Here the patient will complain, perhaps, that he passes too much water, that he is disturbed at night, has certain obscure pains or uneasy feelings in the perinseum or rectum, and is a little feverish, with a warm, dry skin and a very dry tongue and mouth, which, he says, depends upon the fact that he is " bilious." He is con- fident that he empties his bladder at every act of urination, and says that the difficulty is, that his bladder has become too small, that it will only contain a little urine, and then calls for relief. Here the amount of residuum is probably large, and the bladder often perceptible in the hypogastrium, to the eye as well as the hand. The patient may have 1 9 J. DISEASES OF THE PROSTATE. suffered from one or more attacks of retention, whicli possibly came to a spontaneous end. In such, a case, after due examination, and wlien the patient has passed all the urine he can, voluntarily, he may be placed with his back against the wall, a small (No. 7-9) French olivary catheter, with a slight curve woven in its texture, oiled and given to him, without a stylet, and he may be directed to insert it into his urethra, and to push it slowly down the canal. In a majority of instances, this somewhat theatrical procedure is brilliantly successful, and the patient is unable to refrain from expressions of extravagant surprise to see a pint or more of urine flow out of a bladder which he supposes he has just emptied. This point gained, the patient becomes at once docile and manage- able. There is no feature about the treatment of so much importance, or any more difficult to accomplish, in many cases, than this one of over- coming the natural repugnance of an old man to pass an instrument into his bladder. If he is made to do it for the first time, and the operation is made light of, if he succeeds he is so charmed by the result, and his pleasant feelings afterward, that the victory over his symptoms is half gained. If he faUs, and his failure is laughed at, he is all the more eager to try again, with another instrument. There is little or no dan- ger in passing a catheter upon an old man in the erect position, for the first time. They do not faint when the instrument is traversing the prostatic urethra. This accident is to be feared only in young men, whose sexual tracts are always liable to be in a more or less hyperaes- thetic condition. In drawing off residual urine, for the first time, whether the patient is suffering from retention or not, if the quantity is large (over a quart), it should never be all drawn off at once. At any time during its escape, if there is complaint of the least faintness, the catheter should be at once withdrawn, and the patient placed upon his back, with the head low. Cases are on record where death has followed at once upon the sudden withdrawal of all the urine from an habitually over-distended bladder, and, where this result does not ensue, the patient is exposed to the danger of a subacute grade of cystitis, attacking the mucous lining of the body of the bladder, from the sudden and complete removal of tension upon its walls, which had been kept up pretty constantly for months, perhaps years, by an habitual over-distention with urine. The first and main step in the treatment of any bladder disease affecting an old man is, to get his entire confidence and cooperation, otherwise he will often frustrate the best-directed efforts, by errors of omission, if not of commission. Another essential point is, that the patient should he able to empty his own bladder at will. He has lost the power of doing this in the natural way, and, unless he learns to do it by art, he is never safe. The repugnance which old men have to commencing the use of a catheter is extreme, and the main difficulty is often to get them started. HYFERTKOPHT— TREATMENT. 195 If tliey make the start in tlie manner above narrated, not knowing what they are doing, or what they are doing it for, the surprise at their success, the ease with which it was accomplished, together with the feeling of re- lief experienced afterward, will be the strongest arguments which can be presented of the efficacy of continuing the use of the instrument. If the patient fail to introduce the instrument, the surgeon must find one that will enter, but the patient must sooner or later learn to pass an instru- ment for himself. A metallic catheter should not be used by the patient, if any of the soft varieties can be made to pass. With a soft instrument, without a stylet, it is difficult for an old man to do himself any consider- able injury — with a silver instrument it is very easy. There are cases, however, where a silver instrument, with a special curve, may be abso- lutely necessary. The patient having acquired the ability to introduce an instrument for himself, is now instructed in urethral hygiene and given some gentle laxative, if necessary — a little infusion of pulvis sennse co., or some con- fection of sennee at night, together with a mild alkali, such as the citrate of potash (gr. x-xxx) three times daily. He is directed to cover him- self with merino in summer and flannel in winter. His feet and ankles must be especially well protected with suitable woolen stockings. The feet lie farthest from the heart, the source of heat. From their pendent position, the venous blood has great natural difficulties in getting out of them. They are that part of the body most easily chilled, yet habitu- ally they are the least well protected, especially by old men. A knowl- edge of these facts indicates the natural means of remedying the evil. An ordinary case requires no change in diet. Exercise should be taken at will, but not on horseback, or of a kind attended by much jolting, as this tends mechanically to increase the congestion about the base and neck of the bladder, and leads to an aggravation of the symptoms (irri- tabihty). The catheter should be used by the patient more or less often, according to the quantity of residuum, normal intervals of urination being observed as nearly as possible. In ordinarily mild cases, where the frequency of urination comes on mainly at night, emptying the bladder once thoroughly just before re- tiring may be all that is required. After this, the patient will sleep quietly until toward morning, when the residuum will have re-collected, and then the desire to pass water will again return. Where the residu- um is large, a pint or more, it is far better for the patient to rely entirely upon the use of the catheter, introducing it three or four times daily, perhaps five or six, and never attempting to pass a drop of urine with- out its aid. This becomes necessary where there is a valvular condition of the vesical orifice, or such other deformity as makes it impossible for the patient to pass any water. Here, if the catheter enters easily, the patient is perfectly safe. He goes around carrying his instrument with him. He becomes proud of his ability to introduce it, and does it bettei J 96 DISEASES or THE PROSTATE. tlian any one can do it for Mm, with an apparent recklessness fron which is sometimes almost painful to witness. Patients sometime! in this way for ten or twenty years, never passing a drop of urine through the catheter. Such patients usually state that their condi an enviable one. Their atony may be so complete that they nev any desire to urinate. They pass the catheter at stated interval regularity, and are never uneasy when they are obliged to rem company for a length of time. These cases are fortunate ones. There is no irritability, the b is capable of large distention, and is very patient and uncomplf With them no medicine, except possibly an alkali, is of the leai vice. There is a mechanical obstacle to the flow of urine, and mechanically relieved. All that is necessary is for the patient t( his bladder clean, by injections of warm water, once or twice da prevent the formation of stone, or the lighting up of inflammation decomposing urine, and to keep himself supplied with catheters. The question now naturally arises. Is it advisable to instruct a p with enlarged prostate in the use of the catheter, if he has a very amount of residuum or none at all ? Most assuredly. Yes. If tl no residuum, still, with the slow advance of the disease, a time is sure to come when there will be a certain quantity, or when, fro effect of cold, irritating urine, or other cause, retention may coi It is a rule with no exceptions, that a patient with hypertrophied tate is never safe unless he can pass a catheter for himself, any than is a patient with hernia who does not wear a truss. Hence, cases, the patient should be taught the use of a soft catheter, h vided with an instrument, and instructed in the manipulation of w£ out the bladder, both for purposes of cleanliness and so as to be ei to employ medicated injections. If the amount of residuum is sm that no material relief is afforded by the mere draining off of the which the patient cannot pass, still the force of the above reason applicable, and the utility of washing out the bladder is equally : sary, since the liability to the formation of stone exists as well whe residuum is small as where it is large. If no instrument can be made to enter the bladder, and there is tion, the aspirator should be used twice daily above the pubis for a meanwhile attempts being made to reach the bladder with the cat If all efforts finally fail, a permanent opening must be established the pubes (p. 130). The washing out of an hypertrophied and dilated bladder, whe: mucous membrane is habitually congested, and secreting an over-s of mucus, is a point of treatment of cardinal importance. By this i the last drops of residual urine, with the pus and stringy mucus they contain, are diluted and drained away, and no ferment is le hind to decompose the health3r fluid as it comes down the ureters. EYPEKTEOPHY— TREATMENT. 197 formation of stone is prevented, and the congestion existing around tte neck of the bladder is soothed and kept from any aggravation which would increase the irritability — that distressing symptom so closely linked with the pathological changes incident to enlarged prostate. The best method of washing out the bladder is as follows : The soft catheter through which the residuum has been drawn off is used. A double-cur- rent catheter is not advisable, for with such an instrument no distention is brought to bear upon the bladder-walls, and the whole mucous sur- face is not brought into contact with the cleansing fluid. Warm water should be used, since it is soothing as well as cleansing, and does not excite the bladder to speedy contraction upon being thrown into its cavity. A temperature of about blood-heat should be aimed at — a little below 100° Fahr. The best style of syringe is a rubber bag holding about four ounces, provided with a metallic nozzle tapering to a iine point (Fig. 73), so that it may readily enter the calibre of any catheter, Fia. 73. and with a stop-cock which works smoothly for convenience of manipu- lation. An ordinary syringe is not advisable, since it is more difficult to keep in good working order, harder to employ with one hand, and be- cause the patient is apt to communicate the shock of driving the piston home, through the catheter, to the neck of the bladder, already con- gested and sensitive. The bag is filled by exhausting the air, and inverting it into the ves- sel containing the water. By removing the nozzle from the water and slightly compressing the bag, with the nozzle held uppermost, whatever air remained within it will be first expelled, and then the water will jet out. Now the stop-cock is to be turned, and the nozzle once more sub- merged, the stop-cock being again turned on. The bag will now fill itself completely, and there is a certainty of no air being present in it. Finally, the stop-cock is turned ofi^, the nozzle being still under water, and the bag is ready for use. At this stage of the operation the patient (or surgeon) introduces his soft catheter, and drains off the residual urme. As soon as the last drops have been evacuated, the nozzle of the bag is gently inserted into the catheter and the stop-cock once more turned on, while gentle, continued pressure with the hand is applied to. 198 DISEASES OF THE PKOSTATE. the bag, forcing its contents in a steady stream into the vesical cavity. As soon as a slight feeling of distention is experienced by the patient, the bag is removed, and the injected fluid allowed to drain off. A sec- ond washing is executed if necessary in the same manner, and perhaps a third, until the water which flows out is nearly or quite clean, the bag being refilled if necessary. These simple manipulations are easily learned by a patient, and often constitute the only treatment which his case re- quires. The washing is performed once or twice daily for the remainder of the patient's life, or more frequently if the secretion of pus by the congested mucous surface is abundant. At the commencement of treatment in many cases where the irrita- tion of using the catheter keeps up or increases the mild cystitis already existing, and causes a free and continued secretion of pus, it is advisable to pass from simple water to the use of medicated fluids in injection. These may be first employed by the surgeon, afterward intrusted to the patient. Nothing better can be suggested than the formulis al- ready advocated by Thompson — acetate of lead, from one-sixth to one- third of a grain to the ounce of water, or one to two minims of dilute nitric acid to the ounce. For a continuous soothing injection — one which has power to allay irritation and check the pus-formation — the following combination of Thompson is excellent : B. Sodae biborat., |j. Aquae, Glyoerini, aa § ij. M. S. One tablespoonful to a four-ounce injection. Chlorate of potass is also serviceable, in the strength of from five to fifteen grains to the ounce. Silicate of soda is at present vaunted by the French, in the strength of one per cent., to arrest pus-formation. These injections are sufficient for all cases. Nitrate of silver of any strength is difficult to use, and rarely of any service. Carbolic acid does not yield good results. In certain very rare instances it may be deemed advisable to tie in a catheter (p. 190). None but a soft instrument should be so employed, preferably one of pure caoutchouc, as they will remain longest in the bladder without becoming incrusted with urinary salts. Cases requiring the tying in of a catheter are those in which introduction is exceedingly difficult, and the patient lives at a distance from the surgeon, or where the neck of the bladder is very tolerant of an instrument, and it is de- sired to prevent the irritation of frequent reintroduction, and the spasm of the muscles of the bladder and perinaaum, which such reintroduction occasions. Wherever an instrument is left tied in, whether the patient is walking about or on his back, the cavity of the viscus should be thoroughly washed out with warm water several times daily, and the ' instrument removed if it appears to be causing irritation. Sometimes HYPERTROPHY— TREATMENT. 199 a caoutctouo instrument may be •worn for months, and removed still clean, * if the bladder has been syringed out regularly. In those rare cases where there is real incontinence (not overflow), ■where the patient is constantly leaking slightly, either continuously or by little jets, caused by involuntary spasmodic muscular contractions, or, finally, in anj' case where the patient's calls recur at short intervals, and the nature of his occupations is such that he is not sure of always being able to reach quickly a place where he can relieve himself, he should constantly wear a urinal. Of the many varieties of this instrument found in the shops, only one accomplishes the two necessary objects of being safe as well as com- fortable. The urinal referred to (Fig. 73) was devised by a private gentleman of this city, suffering from true incontinence. He was ac- customed to dine out frequently, and related with enthusiasm the satis- faction he experienced, when conversing in the evening with a lady guest, to feel the urine trickle down his thigh, with the conviction that it was going to the right place, and could not disgrace him. The construction of this urinal is most simple. It is made of white rubber, in the form of a large pouch, capable of receiving the whole scrotum as well as the penis, and large enough to allow a free circulation of air around the parts, thus preventing sweating or excoriation. From this pouch two broad bands of rubber extend up flat- wise, one over the belly, the other over the nates to the waist, where they are attached by but- tons to the suspenders. Below, the pouch ter- minates in a long, flat bag, attached by tapes to the thigh and leg, and reaching nearly to the ankle, so that no urine collecting in it can possi- bly spill out during any ordinary motion. A metallic cap at the bottom unscrews to drain off the urine, and clean the instrument, which should be washed out daily with a mild solution of per- manganate of potash. Treatment of Complications. — During the use of the catheter, one or both testicles may swell. This is not a matter of serious impor- tance, and may be overcome by the treatment for epididymitis. If the pain is severe, or if position alone relieves the pain, as it usually will do, there is no necessity for any thing further ; introduction of the catheter may be continued, and the swelling will subside. What is liable, however, to give most trouble early in the treatment by repeated catheterization is, the congested condition of the neck of 200 DISEASES OF THE PROSTATE. the bladder. In most cases, especially where retention has come on, this congestion is considerable, and is readily aggravated, the slight violence done in oatheterism lighting up a little cystitis about the neck, or increasing what already existed. Cystitis announces itself by in- creased uneasiness when the bladder contains only a slight amount of urine, tendency to spasmodic contraction of the bladder-walls, unless they are atonied, increased amount of pus in the urine, and, almost always, by the presence of blood in greater or less quantities. This amount of cystitis is most apt to come on during treatment of a bladder already somewhat irritable, where there is not much atony, or after re- tention. Old oases, where the organ has been over-distended by a very large residuum for years, are not liable to suffer much from the introduc- tion of the catheter, provided the bladder is judiciously (not too sudden- ly) emptied. When cystitis of the neck comes on, calls to urinate will become more and more frequent, the last part of the urine drawn through the catheter will be tinged with blood, perhaps blood will con- tinue to flow into the bladder after the withdrawal of the catheter, so that the next urine passed or drawn will resemble pure blood, or may be nearly as black as ink, if it has been retained for some time ; or, again, if blood flows freely and quickly into an empty bladder, it may fill it to a certain extent, clotting into a solid mass in its cavity. None of these conditions need cause alarm. If the flow of blood is excessive, and the bladder has power to empty itself, it is expedient to intermit the use of the catheter for a time, otherwise it must be contin- ued, employing the utmost gentleness of manipulation. Unless cystitis of the neck becomes a prominent complication, the bleeding, on the use of the catheter, will cease in a few days, and then the patient may be allowed to get out of bed and gradually to resume his ordinary habits of life, relying on warm-water injections to keep the bladder clean and the residuum from decomposing. When the flow of blood and irritation around the vesical neck are considerable, opium, in suppository, is advisa- ble for a few days. If the bladder becomes filled by a clot, no attempts to break it up or dislodge it are admissible. It will gradually soften, dissolve, and come away in the urine, which should be kept abundant and alkaline. In the great majority of cases the above treatment will cover the ground, and afford all the relief the patient can hope to find, general hy- giene being regulated, exposure to cold particularly avoided, the urine kept from becoming too acid, and the patient being made his own phy- sician. Some patients cannot get along without the occasional insertion of an anodyne suppository, but the use of such means of relief should never be placed in his hands unless he is made fully aware of the danger of abusing his power. In some cases, after retention, the bladder will gradually reacquire its contractile power, and the amount of residuum will be lessened, but this is rare. The atonied, over-stretched bladder flTPERTROPHT— TREATMENT. 201 of an old man does not recover its tone like that of a youth, and indeed it is better that it should not. The patient should be encouraged to rely entirely upon his instrument, and not to strain to use his bladder. Where considerable prostatic obstruction exists, happy is the man whose bladder resembles a passive sac, never fretting at the presence of urine, no matter in how great quantity. Here the patient uses his catheter regularly, at stated intervals during the day, vvaslies out his bladder, and is in a condition to be envied by ordinary mortals, pro- vided only he can keep himself supplied with catheters which will pass. Such patients are in the habit of picturing to themselves what would happen in case they suddenly found themselves unable to pass any cath- eter, and it is, indeed, their wont to select some surgeon near whom they live, and to keep themselves constantly informed of his movements, so that they may not be left in the lurch when in need of aid, if the time should come. Some cystitis almost invariably exists, in a greater or less degree, before the patient applies for treatment, and it is, in fact, often for relief from the symptoms caused by it that he so applies. The cystitis gives rise to his frequent calls to urinate, and supplies the pus and stringy mucus with which his urine abounds. A mild degree of cystitis will subside spontaneously, as a rule, under the improved condition of the bladder produced by draining off its residuum and washing out its cavity. If this should prove inefficient, medicated injections may be used as already described, when detailing the manoeuvres of injection (p. 198). The temperature of the injection should still be about blood- heat. A medicated injection should not be thrown into the bladder until its cavity has been washed out. Then from one to two ounces may be injected, retained a. moment, and allowed slowly to drain away. This may be repeated from one to three times daily. It is useless to inject anodynes into the bladder, as their action is uncertain. Internal Remedies in Cases of Hypertrophy. — When the cystitis seems to be getting unmanageable, when the calls to urinate are frequent and painful, or, in any case, when the amount of pain is considerable, it is better to use an anodyne suppository, which may best consist of codeine (gr. j-^ij), watery extract of opium (gr. ss-ij), or morphine (gr. -J-j). Camphor is occasionally added to these suppositories for the purpose of obtaining more effect with the employment of less opiate, or, more often, extract of belladonna, vidth the alleged object of allaying spasm. The efiBcacy of both these latter agents is overrated. The object is to allay pain, and pain only justifies us in using opiates. The frequency of calls to urinate may be great, but, if there is not pain as well, there is no indi- cation for anodynes. The amount used should be barely sufficient to con- trol the pain, and should be subdivided into many small doses (four to six in the twenty-four hours), rather than given all at once, or even night 202 DISEASES OF THE PROSTATE and morning. Laudanum or other fluid may be used instead of solid suppositories. The reason why anodynes are of no service by injection into the bladder is, that only a small amount is absorbed, unless the solution injected be concentrated, while the bladder epithelium is entire ; but, should an abrasion or ulcer exist, the amount absorbed may be very considerable, producing more effect than was desired. Atropine or belladonna, in sufficient doses, will lengthen the intervals of urination, and modify pain ; but the agent is in many cases uncertain in its action and difiEcult to manage — in some cases it acts well. One twenty-fifth of a grain of sulphate of atropine in water is a proper dose to commence with, increasing gradually until an effect is obtained, and watching the patient for symptoms of poisoning. When cystitis, accompanying enlarged prostate, becomes consider- able, enough to require the use of anodynes, the recumbent position Fig. 74. should be insisted upon. The patient should lie upon his back with a hair pillow under the hips, so that they may be raised higher than his shoulders, in this way relieving the bladder from some of the intestinal pressure, and favoring a drainage of venous blood from the pelvis. The head may be raised, but the shoulders must be low. The skin of the hypogastrium should be kept slightly reddened by the application of a hot, light poultice, containing a sprinkling of mustard, or more neatly by the use of moistened mustard-paper, and a flat rubber bag, contain- ing hot water, which may be laid upon it. Heat, applied also to the perinaeum, is agreeable to the patient. To meet the demand of heating HYPERTROPHY— TREATMENT. 203 the pennaium and hypogastrium at once, there has been constructed a rubber bag with a long, hollow prolongation to pass between the thighs (Fig. 74), the whole to be fastened on by suitable straps, and to be filled with hot wat«3r. These bags afford great comfort. The rectum should be kept empty by the daily use of a hot enema. Water, as warm as can be borne in the rectum, often exercises a decidedly soothing effect upon the inflamed bladder. The only internal remedies which seem to be of much service are the different alkaline diuretics and diluents. Of the former, citrate of potash, in gr. xx-xxx doses, three or four times daily, according to the concentration and acidity of the urine, is perhaps the best. It may be alternated with bicarbonate of soda, acetate of potash, or liquor potas- sse. The alkali may be given in carbonated water, flaxseed-tea, or in whatever diluent is selected. The variety of this latter class of reme- dies is innumerable. All of them are doubtless of value, but none pos- sess specific qualities. They should be taken largely. The one per- haps most generally useful as well as agreeable is ordinary flaxseed- tea flavored with lemon-peel (lemon-juice is to be avoided) and sugar, and taken cold or warm, to the extent of from one to three pints in the twenty-four hours. Buchu, so popular in this country, may be combined with it in infusion, from three to six ounces daily. Thompson speaks well of a decoction of the underground stem of the Tnticum repens^ made by boiling two ounces of the root for a quarter of an hour in a pint of water. This is strained, and the whole taken in four doses dur- ing twenty-four hours. If the patient tire of one decoction or infusion, it may be changed for another — pareira brava, uva ursi, etc. The old combination of hyosoj'amus and liquor potassse, chemically incompatible, is clinically often of decided service. The old form of prescription made with the tincture is not so useful, on account, possibly of the alcohol it contains, as the same made from the extract of henbane. The following formula has proved quite efficient in moderating frequent and painful micturition : 5 . Liq. potassse, 3 ij - 1 ss. Extr. hyoscyami, 3 j - 3 it. Syr. aurant. cort., J or, Mist, acaciae, Aquae cinnam., aa f iij. ) Aquse, aa J iij. M. S. A tablespoonful iu some diluent every eight hours. As has already been several times stated, the urine coming from the kidneys, in these cases of bladder-disease depending upon obstruction to the free outflow of urine, is nearly always acid, over-acid indeed, be- coming alkalinized in the bladder, and the object of giving alkalies by the mouth is to render the urine less irritating to the sensitive lining membrane of the bladder. Hence the impossibility, and indeed the inappropriateness, of endeavoring to render the urine acid by adminis- tering acids. ' " Diseases of the Urinary Organs " 204 DISEASES OF THE PROSTATE. By the emploj'ment of the above means, aided by a large share of patience, the washings of the bladder being regularly and gently at- tended to, cases of vesical catarrh depending on prostatic obstruction will gradually get well up to a certain point, not incompatible with the exercise of all his functions by the patient, and, provided only he attend scrupulously to keeping his bladder clean by warm-water in- jections, leaving him capable of enjoying a life as long, as comfortable, and as useful, as if his bladder were sound. This statement, of course, does not apply if either of the three complications, so common with this form of disease, exists : namelj', stone, mild pyelitis, or fatty atrophy of the kidneys. Where stone is present, it must be removed. There are cases, however, where a stone of considerable size existing in an old man may cause but little irritation, and, where such calculus cannot be dealt with by lithotrity, it may be imwise to subject the patient to the risks of lithotomj-. If stone be not present, the use of daily washings wtH prevent its formation. Mode oe Death ds" Cases of Htpeeteopht. — The not very infre- quent complication of a low grade of inflammation of the ureters and pelves of the kidneys is always a serious matter. This becomes easUy aggravated by cold or imprudence in diet, developing at once symptoms of mild ursemia, with hot, dry skin, loss of appetite, sleeplessness, great restlessness, dry, red, or pasty tongue, parched mouth, tendency to de- pression, headache, tendency to wandering of the intellect, constipation — all this attended, as a rule, by polyuria, a little albumen and a few pale casts in the urine. A fatal termination of these symptoms is a not un- common mode of death in cases of prostatic disease. The complication is best treated by confining the patient to bed, in a room where the air can be frequently renewed, and the temperature kept high, at 80° Fahr. or thereabouts ; exciting the action of the skin and bowels ; giving dilu- ents in abundance, and a mild (mQk) diet. The combination of potash and hyoscyamus acts well upon these cases, and some mild stimulant is not only admissible, but necessary to keep up the general strength, imtil kidney congestion has subsided, These evils are more easily avoided than cured. CONGESTION OF THE PROSTATE. 205 CHAPTER XI. DISEASES OF THE PROSTATE. Congestion.— Parenohymatoiis Prostatitis.— Terminations ; in Eesolntion, Chronic Prostatitis, Atjscess.- Treatment. — Gonorrlioeal Prostatitis. — ^Prostatic and Peri-prostatic Abscess. — Treatoent of all Forma of Abscess.— Follicular, ProstatitiB.— Its Liability to be mistaken for Stone in tbe Eladder.— Treat- ment.— Tubercular Prostatitis. — Cancer of the Prostate. — Prostatic Concretions. — Prostatic Calculi. — Neuralgia of the Prostatic Urethra. — Syphilis of the Prostate. Congestion of the prostate occurs physiologically during venereal excitement. If such excitement be unduly prolonged without being- gratified, even sometimes v?ithout erection, if tbe imagination be given up to erotic fancies, the mucous follicles of the organ secrete more or. less of a peculiar, viscid, bluish mucus, without odor, which, mixed with urethral mucus, finds its way out at the meatus. This phenomenon is perfectly natural. Physiologically it is analogous to the watering of the mouth of a hungry individual, at the sight, smell, or even thought of food. Many individuals, however, whose sexual requirements are not met, live in such a state of mental inquietude, particularly in regard to the genito-urinary organs, that this drop of mucus appearing during erection excites in their minds the most lively alarm, and they hasten to their surgeon to demand his aid for spermatorrhoea, stating that thej' never have an erection without the involuntary emission of seminal fluid. Of this idea it is often hard to dispossess the patient's mind, but an honest explanation of the whole subject will rarely fail to convince him ; while the observance of pru-ity of thought and the avoidance of occa- sions of sexual excitement, or, better still, marriage, to place him in natural sexual relations, will prove, infallibly, effective of cure. If this physiological hypersemia be kept up for a long time (several hours), the prostate is liable to remain congested, throbbing slightlj^, feeling full and hot, giving rise, perhaps, to frequent calls to uiiuate, and attended by a very slight gleety discharge. If the patient urinate frequently, straining to empty the bladder of its last drops, the prostatic congestion is maintained and aggravated. All these uncomfortable feel- ings, due to prostatic congestion, are relieved by rest ; more quickly by a cold sitz-bath, or by a very hot sitz-bath of short duration. The desire to urinate produced by the contact of water should not be yielded to. Slight congestion of the prostate frequently complicates gonorrhoea, stricture, etc. It is usually ephemeral in character, announcing itself only by a little increased frequency of urination, or it may continue on to actual inflammation. Congestion may be excited in the prostate by sexual ex- 206 DISEASES OF THE PEOSTATE. cess, masturbation, etc., and this, being kept up and often repeated, may lead to cbronic follicular prostatitis, -without passing through any acute stage. The hypersemia attending hypertrophied prostate has been already considered. PROSTATITIS. Inflammation of the prostate is of two kinds : 1. Parenchymatous. 2. Follicular. 1. PABEiTCHTitATors Peostatitis. — Spontaneous (primary) inflam- mation of the prostate is rare ; inflammation, traumatic, or extending to the prostate from contiguous parts, is not uncommon. Causes. — Among the causes of prostatitis may be enumerated gon- orrhcea, stricture, extreme and prolonged sexual excitement, concen- trated acid urine, cold, violence from instruments, stone fragments, etc. ; chemical irritants, strong injections, cantharides internally, etc. Gonor- rhoeal inflammation, after the first week, may run rapidly down the ure- thra and involve the prostate, particularly if the patient indidge in liquor, sexual intercourse, or take violent exercise, or use strong injec- tions, throwing them deep in the canal. Sometimes, during gonorrhoea, without appreciable exciting cause, the prostate inflames. The inflam- mation behind a stricture may run back and involve the prostate, in the same way. Sexual hypersemia, too much prolonged, or too often repeated, may lead to it. Cold, acid urine, violence from instruments, rarely are efficient, except in combination with other causes. The chemical irritants act directly. CoTJESE. — Prostatitis commences as congestion. Passing on to true inflammation, it terminates by resolution, exudation of pus on the free surface, perhaps by croupous exudation ; by abscess, or peri-prostatic formation of pus; or, finally, it may linger indefinitely as a chronic (fol- Uoular) inflammation, mUd in degree, occasionally becoming aggravated. Symptoms. — The organ swells rapidly, putting the capsule on the stretch, and often reaching the size of a small orange. It may feel square (Yidal), or be unevenly enlarged. The exploring finger in the rectum strikes at once against this mass, which juts into the cavity of the gut, is very tense and hot, and can be felt distinctly to pulsate. It is exceedingly sensitive to pressure — unlike prostratic hypertrophy, which is not sensitive unless inflammation be present. In prostatitis the lightest touch, even the presence alone of the finger in the rectum, at once excites a desire to urinate. Pressure over the pubes brings on the same desire. The patient is conscious of something protruding into the rectum, and may experience an unnatural desire to go to stool. If he endeavor to do this, he strains ineffectively, causing himself pain, but getting no relief, even if he succeed in forcing out a little fecal sub- stance, after suffering great distress in the effort. The perineum feels hot, and is sensitive to pressure. The subjective sensations, locally, are ACUTE PKOSTATITIS. 207 heat, weight, throbbing. There is a sort of dragging feeling over the lower part of the abdomen, as well as in the penis and scrotum. There may be pain in the back and limbs. If gonorrhoea be the cause, or strict- ure with profuse gleet, the urethral discharge ceases at once, or becomes very scanty and thin. It returns, however, as the prostatic inflammation subsides. The stream of urine is small and is passed with effort. The prostate may swell to such an extent as to obliterate the prostatic ure- thra entirely for a time, causing retention. Thompson believes this to be the cause of all retentions which occur during acute gonorrhoea ; in fact, of all retentions supposed to be produced by so-called inflammatory stricture. With this swelling of the prostate is almost invariably associated congestion of the vesical neck, thickening of the membrane at the in- ternal urethral orifice, and a constantly-recurring-, never-satisfied desire to urinate. If retention comes on, as it rarely does, this feeling exists as a matter of course ; but, even when the bladder is entirely empty, it feels partly filled, there is no sensation of relief after voiding the urine, and, when a few drachms have re-collected, the urgency of the sensation forces the patient to another effort, equally unsatisfactory. The urine causes pain on its passage, but the pain is most severe as the last drops are being expelled, when the circular fibres at the bladder's neck squeeze the tender prostate. It is now that blood is often discharged from the overloaded vessels, coloring the last drops of the stream. A pain like that occurring with stone is experienced, both in the perinseum running down the urethra and, often with greatest intensity, on the under surface of the penis in the urethra, at about three-quarters of an inch from the meatus. Coinciding with all these features which stamp out the disease so plainly that it is impossible to mistake it, there is general febrile disturbance, with usually the utmost concern, appre- hension, disquietude, and depression with excitement of mind, such as is rarely caused by inflammations of much greater magnitude and attended by far more severe pain elsewhere. The patient is irritable, despondent, and suspicious ; often, in fact, wild to an extent amounting to mild acute mania. He cannot sleep, he will not eat, and it is with dilficulty that he can be kept quiet. Fortunately, his feverish condition induces him to drink abundantly. The inflammation may subside before the malady has reached this point. Resolution may come on at any time, even after the above extreme has been reached ; the throbbing pain and heat disappear, and usually a little discharge appears from the prostatic sinus. This dis- charge may continue for a considerable period (follicular prostatitis), or may rapidly cease while the calls to urinate grow less frequent, and the sensation after the act approaches the full relief felt normally. If the inflammation has extended into the seminal vesicles, there may be spermatozoa in the discharge. A false membrane may form in the 208 DISEASES OF THE PROSTATE. prostatic sinus, but this is exceedingly rare. Finally, the inflammation may extend down the vasa deferentia, linger in a chronic form in the seminal vesicles, or pass on to light up epididymitis. If the inflammation, instead of undergoing resolution or passing to a chronic state, continue, abscess is the result. Resolution usually .takes place between the fourth and twelfth day, and recovery is complete in from one to three weeks. Possibly, instead of recovering or continuing as a distinct folliculitis, chronic interstitial inflammation may remain behind, leading to induration and general tumefaction of the gland which may persist for months or years, and may even be described and treated as hypertrophy. This kind of (false) hypertrophy gives good results with pressure, electricity, etc., namely, absorption of the in- flammatory product, and thus is excited the vain hope of a simUar result where true hypertrophy exists. Treatment. — No point of treatment is so essential as rest in any con- gested or inflamed condition of the prostate. Repose, as nearly abso- lute as possible, may bring about resolution where otherwise suppura- tion would have ensued. The tripod of safety for a patient with pros- tatitis is rest in bed, some alkaline diluent for the luine, and enough anodyne to control severe pain and excessive action of the bladder. The rest should be in bed, the patient lying upon his back -with the hips raised. The bladder should be restrained from contracting as much as jiossible, by the exercise of the will, while forcible efforts at emptying the last drops of urine — to which the patient's feelings impel him — should be interdicted. For the same reason cathartics should not be administered. Copious enemata of hot water carefully given are pref- erable. The jutting out of the tense prostate into the rectum gives the patient a constant idea that the lower bowel is occupied by faeces, and of this notion it is difficult to divest him. He must not be allowed, however, to indulge in straining at stool, as this action aggravates his condition. As for medicine, none is needed in a mild case except plenty of bland fluid — fiaxseed-tea, infusion of triticum repens, etc., with some citrate of potash or Vichy water. By these means the irritating proper- ties of the urine are counteracted. The combination of liquor potassffl with extract of hyoscyamus (p. 203) seems to suit certain cases. Watery extract of opium, codeine, or morphine, may be used in suppository, gently introduced, in sufficient quantities to modify the urgent desire to urinate. These means, combined with a light diet, will bring on resolu- tion in a few daj-s in most cases. GoifOEEHCEAL Peostatttis. — If the prostatic affection comes on dur- ing a gonorrhoea, all active treatment of the latter must be abandoned. It is particularlj- essential to discontinue urethral injections. If the onset of the affection has been especially severe, and the exploring fin- ger detects a prostate unusually tense, throbbing, and painful, early in the attack, leeching of the perinagum may be resorted to. If this is PROSTATIC AND PEEI-PKOSTATIC ABSCESS. 209 attempted, it sbould be thorough. From ten to fifteen vigorous leeches should be placed upon the perinseum, and the bleeding be encouraged by the subsequent application of hot water to the bites. Hot fomentations to the perinaBum and hypogastrium tend to modify pain. The skin over the hypogastrium should be kept constantly reddened by sprinkling powdered mustard upon the poultice there applied, or, more neatly, by the use of mustard-paper over which is applied a flat rubber bag, con- taining a thin film of very hot water (Fig. 74). If possible, a gen- eral hot bath, or hip-bath (100° Fahr.), should be administered once or twice daily. Sleep may be encouraged at night by full doses of the bro- mide of potassium, or sodium alone or combined with some bitter syrup (orange-peel), with from gr. v-xx chloral hydra t. Eepeated rectal exami- nations of the prostate are to be avoided, and on no account should any instrument be passed into the bladder unless there is retention. In such a case a small French olivary catheter should be gently used, as sel- dom as possible consistently with comfort. Failing with the soft instru- ment, a silver catheter must be employed, with suitable regard to the inflamed and tender condition of the parts. Cases might occur wher ■ the aspirator would be preferable to catheterism. PROSTATIC AND PEEI-PKOSTATIC ABSCESS. If pus form during parenchymatous inflammation of the prostate, we have a continuance, in a high degree, of all the symptoms of that inflammation, except that the local throbbing is more considerable and that the pains become less tense and of a more lancinating character. A sharp chill or a series of rigors announces the commencement of sup- puration. As the pus forms, it presses upon the already narrowed canal of the urethra, and finally, unless the abscess is very small, obliterates it entirely, bringing on retention. There may be one or more purulent foci, or the whole substance of the prostate contained within the fibrous capsule may fall into suppuration. These abscesses, left alone, discharge into the urethra, bladder, rec- tum, or through the perinseum, or may find outlet by two or more of these routes at the same time. They are often tardy in opening spon- taneously, on ^account of the dense nature of the fibrous capsule of the gland. When such an abscess is opened or bursts, all pain and discom- fort are relieved as if by magic. Retention disappears, the heat and throbbing cease to be annoying, and a continuous flow of pus is often the only reminder of the terrible torment which the patient has endured. The pus may exceptionally burrow among the tissues of the perineum, or, stiU more rarely, into the pelvis, giving rise to local and then general peritonitis. In exceptional oases, where the purulent focus is small, it may never point ; but, with subsiding inflammation, the pus may be gradually absorbed, leaving behind a calcareous mass, of a size propor- 14 210 DISEASES OF THE PROSTATE. tionate to the quantity of pus which it represents. These concretiona are not usually discovered till after death. They are rarely of sufiBcient size to interfere materially with the contractile function of the gland. After the pus has escaped from a prostatic abscess, if the cavity is small, it usually granulates slowly, fills up, and becomes cicatrized ; the rapidity of the process of repair being often interfered with, if not pre- vented, by a communication of the cavity with the bladder or rectum — or even the urethra, from which urine rugurgitates during every act of micturition. If the cavity of the abscess is very great, if, for example, it involves the whole contents of the fibrous capsule of the prostate, the termination may be fatal. Sometimes a slow repair sets in, but it is rarely if ever perfect. More or less of a cavity is left behind, lined with a new-formed, imperfect mucous membrane, discharging more or less pus, and, as a rule, remaining permanently in fistulous connection with the rectum, urethra, or bladder. In these cases urine may escape by the rectum, and fseces and intestinal gases by the urethra, while the con- stant condition of irritation of the remnant of prostatic substance in- volves the neighboring neck of the bladder, giving rise to more or less cystitis, and tormenting the patient by frequent calls to urinate. A small purulent collection in the prostate may empty itself gradually into the m-ethra by a minute opening, and its existence consequently not be made out. The prognosis in small abscesses of the prostate is good, but, where the collection of pus is very extensive, the prognosis must be guarded. Analogous to the above are the peri-prostatic abscesses which occa- sionally come on during the course of gonorrhoea, or in cases of strict- ure. Here the seat of the purulent collection is found to be in the connective tissue around the prostate. The symptoms are, in the main, those of prostatic abscess ; but they are less marked, less intense, and the malady is apt to run a slower course. QEdema, perceptible to the finger in the rectum, is the best distinguishing mark between existing or imminent peri-prostatic collections of matter and abscess within the prostatic capsule. Such collections of pus finally press upon the neck of the bladder and cause retention. They may be easily felt by the ex- ploring finger in the rectum, masking the prostate and jutting into the cavity of the gut. If not opened by the surgeon, they maj' point spon- taneously in any of the directions named for prostatic abscess, and sub- sequently behave in a similar manner. Epididymitis, terminating in suppuration, is liable to complicate prostatic abscess. Abscess of the prostate rarely leads to infiltration of urine. Treatment. — With an abscess, peri-prostatic or prostatic, near the posterior wall, whenever fluctuation can be felt through the rectum, puncture with a trocar should be practised at once, to arrest further destruction of tissue, to relieve suffering, and to prevent retention. FOLLICULAR PROSTATITIS. 211 After puncture, such abscesses usually do well under hygienic sup- portive treatment. Where the abscess bursts spontaneously, the treat- ment is purely symptomatic. Where the coUeotion is prostatic, and, bulging into the urethra, produces retention, without )delding fluctuation through the rectum, either of the three following courses may be followed, preferably the first : (1.) Pneumatic aspiration of the abscess through the rectum; (3.) The use of the same instrument several times daily above the pubes, to evacuate the urine "waiting for the abscess to break; or, (3.) Careful attempts to relieve the bladder with a silver catheter passed through the urethra. The abscess is pretty sure to be broken during attempts at catheterism, and the urine flows freely immediately after the pus. Where a large cavity in the prostate is left behind by an abscess, it may be washed out daily with a very short-beaked silver catheter, hav- ing its eye near the tip, and, after the washing, injected with some astringent solution to stimulate granulation. For the treatment of rectal fistulas, see p. 164. After an abscess breaks or is opened, relief is always prompt, and the cure often effected by the unaided eiforts of Nature. FoLLicuLA-E Peostatitis. — In this disease, the mucous surface of the sinus of the prostate and of the mucous follicles and ducts is in- flamed, while the parenchyma of the organ for the most part escapes. The aiFection is familiarly known as prostatorrhoea. It can hardly be said to exist in an acute form, so prone is it to run a chronic course. It may come on during gonorrhoea after the inflammation has reached the deeper portions of the urethra, attended at first by symptoms of parenchymatous congestion. The latter soon subside, and the prosta- torrhoea alone remains, with (perhaps) some congestion about the vesical neck, and consequent irritability of the bladder. The main feature of the disease is a slight oozing from the meatus, muco-purulent in charac- ter. This discharge is apt to be more profuse during the passage of hardened fseces through the rectum at stool. Defecation may be pain- ful. The patient usually believes the discharge to be semen. It does not contain spermatozoa, but is muoo-purulent, full of fatty debris, leu- cocytes, epithelium, and often prostatic concretions. This discharge is exceedingly rebellious to treatment. If, with follicular prostatitis, as is often the case, a certain amount of chronic parenchymatous inflammation coexist, then we have an affec- tion not common but exceedingly obstinate and difficult to manage. It is evidenced by a combination, in a mild degree, of the symptoms of both maladies. A peculiar weight is felt, dragging down toward the peri- neum, with painful feelings in the prostate ; walking becomes painful ; crossing the legs decidedlj' increases the pain, as does finally the sitting posture, and especially the muscular contractions made in raising the body from the sitting to the standing position, or the reverse. 212 DISEASES OF THE PROSTATE. Added to these are symptoms almost identical with those of stone in the bladder. There is the same frequency of urination, less urgent on some days than on others ; the urine contains pus and blood ; blood some- times flows at the end of the stream ; pain is felt on urination, both at the neck of the bladder and, especially toward the close of the act, at the end of the penis, along the under surface of the urethra ; the patient has a tendency to pull and tickle the prepuce and urethra ; the tender pros- tate, squeezed at the end of urination by the contracting bladder, is the seat of extreme sensibility. The bladder is liable to expel its contents spasmodically. The cut-off muscles of the membranous urethra partici- pate in the general irritability of the part, sometimes interrupting the stream suddenly. As a rule, however, this " cut-off" does not come until near the end of the act of urination, and is a sort of premature coup de piston. With these symptoms the patient is feverish and irritable, unable to get about, as all motion aggravates his symptoms. He chafes under confinement, is perhaps listless and depressed ; perhaps has an excellent appetite, and very little constitutional disturbance. In chronic cases the mental depression is a feature of the disease out of aU proportion to its gravity. A slight gleety discharge accompanies this condition. It may escape observation, from the fact that the frequent acts of urination wash it away before it has had time to collect sufficiently to show itself at the meatus. The finger in the rectum may find slight enlargement and heat of the prostate, and at times detect extra sensibility. The ele- ment of hj-persesthesia of the cut-off muscles often accompanies and outlasts this form of prostatic inflammation, keeping up the symptoms perhaps after the parts have returned to a nearly normal condition. In these cases it is sometimes impossible to decide that there is no stone. Search for stone should be instituted. None will be found, but the pros- tatic lu'ethra will manifest extraordinary sensibility, and the patient will be much worse after the search than before. Treatment. — In follicular prostatitis no remedy is so eiEcacious as repeated mild bUstering of the perinseum. It is best applied by paint- ing cantharideal collodion upon one side of the perinseum, confining the patient for forty-eight hours to bed, and painting the other side of the raphe, as soon as the soreness of the first application begins to subside. This course, aided by alkaline diluents, will usually master the afifectionin a few weeks. In applying the collodion, great care is necessary to avoid involving the scrotum and anus, as the former drops over the blistered portion, while the serum from the blister runs down over the latter. This is best accomplished by binding the scrotum up tightly, and cover- ing the blistered surface from the start with cold cream and lint, anointing also the anus and scrotum. ^Yhere the disease is of particu- larly obstinate character, and of long duration, the blisters may require to be continued for many weeks. The rectum must be kept unloaded TUBERCULAR PROSTATITIS. 213 in chronic prostatitis. With blisters should also be combined a sup- porting diet and tonics. Bumstead speaks highly of drachm-doses o£ dilute phosphoric acid containing a small amount of strychnine in solu- tion. If the affection prove obstinate, injecting the prostatic sinus with a mild solution of nitrate of silver, five to ten grains, with an appropri- ate instrument (Figs. 22, 23) may perhaps be of service, or the applica- tion of tannin with the cupped sound (Fig. 130). TuBEECtJLAE Pbostatitis.' — A form of chronic prostatitis occurs in tubercular, scrofulous, debilitated subjects, the chief feature of which is cheesy degeneration, situated primarily in the ducts and follicles of the organ. True miliary tubercle does not seem to occur in the prostate. It may be that opportunities of observing it have not presented them- selves. The cheesy nodule has thus far alone been found. The disease is rare. The symptoms are those of severe chronic prostatitis. If the cheesy matter be small in extent, and situated around the prostatic sinus onlv, it cannot be diagnosticated; but if the same deposit abound in the substance of the organ, so that the contour of the latter can be felt to be lumpy from the rectum, or, as is more commonly the case, if the course of one or both vasa deferentia can be traced out as an infiltrated hard tube, joined to a distinctly-enlarged, knobbed, indurated seminal vesicle, then we may safely assert that tubercular prostatitis exists. In such cases one or both epididymes are also usually the seat of so-called tubercular deposit, and there may be tuberculoid foci in the lungs or elsewhere. Tuberculization of the prostate not uncommonly follows similar morbid changes in the kidneys. 27ie course of tubercular prostatitis is very slow. From time to time the symptoms become spontaneously better or worse, but the general tendency is toward steady aggravation. The cheesy masses ulcerate out, form abscesses which break in all directions, leaving open cavities or fistulsB. Such cavities evince no tendency to heal. Slight hsemorrhage from the urethra from time to time is a pretty constant symptom, but the haemorrhage is followed by no relief (see Case XXXVII.). Prognosis is bad. Death occurs from the gradual running down of the patient, or from tubercular disease elsewhere ; the latter, perhaps, being of the true miliary type. Occasionally recoveries are made under the continued efficient action of hygienic conditions and proper food. The course of the malady is always exceedingly slow. ' The term tubercular disease is retained in this treatise, whether the lesion be miliary tubercle or not. Histological pathologists are still discussing the merits of cheesy degen- eration versus tubercle. That cheesy degeneration may occur where there has been no tubercle is undoubted ; but that, because no miliary granulations are found in a given case, there has been no tubercle is not always so clear. In the testicle, for example, it would seem that cheesy epididymitis is often truly a tubercular neoplasm (Rindfieisch), even where no miliary masses are found. Clinically there is a connection between certain cheesy degenerations and tubercle ; and, for the present, it is perhaps better to abide by the classical titles (tubercular prostatitis, tubercular testis, etc.) than to originate others resting upon a foundation not yet clearly defined. 214 DISEASES OF THE PROSTATE. Treatment. — Curative treatment consists of general rather than local means. For local treatment, the same rules apply here as those laid down for chronic follicular prostatitis. The general measures are hygiene, fatty food, tonics, proper clothing, life out-of-doors, traveling, change of climate, anti-strumous medication. These means, intelligently combined, sometimes effect a cure. CAlfCEE OF THE PROSTATE. Primary cancer of the prostate is exceedingly rare. More usually it is secondary to advanced malignant disease elsewhere — especially in the kidney or testicle. As to the relative frequency of this disease, Tan- chofl,' out of 8,389 cases of fatal cancer, sets down only three for the prostate. Scirrhous, melanotic, and medullary disease, have aU been noted ; the latter most frequently. Cancer occurs chiefly in advanced life, sometimes as a complication of already existing hypertrophy, and doubtless some of these cases have not been recognized. Medullary cancer, as a primary affection, has been observed in the prostate of young children. Pitha saw one fatal case in a stout man of thirty. Symptoms. — The symptoms of cancer of the prostate are at first simply those caused by the increased size of the organ, obstruction to urination, frequency of the act, and pain. Increase in size does not occur as rapidly, or with as acute symptoms, as dees inflammatory enlarge- ment ; but more painfully and more rapidly than senile hypertrophy. MTien cancer becomes engrafted upon an hypertrophied prostate, its diagnosis dtuing the early stages is impossible. The diagnosis with hj-datids or cysts (dilated follicles — of quite common occurrence, but of no pathological importance) is made by the progress of the affection. The symptoms, then, of cancer of the prostate are not pathognomonic at first, but there are certain important aids to correct diagnosis. Thus, if the affection be scirrhus, the peculiar hardness will be significant ; if medullary cancer, the enlargement felt through the rectum is usually less uniform than in hypertrophy, and certain spots may often be felt softer than others, sometimes amounting to a feeling of deep fluctuation. The pain on pressure by the rectum is less decided than in inflammation, but more positive than in hypertrophy. The glands in the pelvis and in the groin sooner or later enlarge, and assume cancerous characters. Hence the existence of obscure swellings along the course of the iliac vessels, felt through the abdomen, is an important aid to diagnosis. Cancerous cachexia is slow to appear. Its presence clears up any doubts which may have existed. The importance of the existence of cancerous growths elsewhere is evident, and especially is this true of cancer of the testicle or kidney. The pain felt in cancer of the prostate is noticed largely in the rectum ' Quoted by Pitha, op. eit. PEOSTATIC CONCRETIONS. 215 and about the sacrum, or radiating into the back, or down the thighs. Haemorrhage from the urethra is a symptom liable to appear both early and late in this affection. The blood flows freely, is arterial in character, and often excessive in amount. It may appear spontaneously, or, more frequently, during urination. A certain amount of relief to the symp- toms is apt to follow such haemorrhage. The urine is troubled, purulent, often containing considerable debris of tissue. Sometimes a shred of tissue of considerable size is passed, or pulled away in the eye of a catheter. From such a shred a diagnosis of cancer can sometimes be made by the microscope. Diagnosis based on finding so-called cancer- cells in the urine is entirely unreliable. Retention is apt to occur from obliteration of the prostatic urethra by cancerous growth. In such cases catheterization is difficult and exceedingly painful, while the operation is pretty sure to provoke considerable bleeding. Hypertrophy of the bladder with dilatation, and perhaps stone, may come on, as in other obstructive prostatic disease. The duration of the disease is set down, from first appearance of symptoms to fatal termination, at from one and a half to five years for adults, three to nine months for children.' Treatment. — This is symptomatic, and consists in the careful em- ployment of the catheter, if required, or even the establishment of a per- manent opening above the pubes, with alkaline diluents, tonics, and anodynes in suppository, and by the stomach. Patients do not recover from this disease. Simple cysts in the prostate are not uncommon ; hydatids are rare. PROSTATIC CONCRETIONS. The adult prostate contains certain bodies known as prostatic con- cretions. They are visible with the microscope at any time after pu- berty, but do not attain considerable size until adult or advanced age. Thompson ° has described them minutely. They are not to be con- founded with stone of urinary formation. They are often found of very small size in the voided urine. In such cases they have no pathologi- cal significance. During their- forming stage (when they measure from the one-thousandth to the one-hundredth of an inch) they appear under the microscope of an oval or slightly angular form, of pearly lustre, and in varying shades of light-yellow color. This color increases in the larger concretions to a deep orange. They have a cellular appearance, but no nucleus, and, as they become larger, exhibit concentric rings of different thickness. Often, in the larger concretions, many of the smaller bodies seem to have been lying together, and to have become surrounded by concentric layers of yellowish material to form one mass. Often, lines are seen radiating from the centre toward the circumfer- ence, and in the direction of these lines cleavage takes place, when the ' Holmes's " System of Surgery." ^ " The Enlarged Prostate." 21(5 DISEASES OF THE PROSTATK masses are subjected to pressure. "S^Tien young they are very soft, but, as they increase in size, they become exceedingly hard and stony. The young cell-like bodies are not affected by acids, or alkalies, or ether ; but the larger dark bodies are rendered somewhat more translucent bj' alkalies, whUe the mineral acids (especially sulphuric) usually occasion liberation of bubbles of gas (carbonic acid) and some shrinkage in size, sometimes disintegrating them into a mass of amorphous matter, ■which stUl retains its color and bulk. Hot nitric acid dissolves them, produ- cing a faint yellow color. The larger concretions consist of a protein substance, with phosphate and carbonate of Hme. They are often found, visible to the naked eye, in the urethra, around the veru montanum, chiefly after the age of fifty. It may be necessary to make a section of the prostate to find them, placing the milky fluid scraped from the cut surface under the micro- scope. In one case, Thompson estimated the number to be seen by the naked eye as amounting to several thousand. These bodies occupy, anatomically, the ducts and follicles of the secreting structure of the prostate. The earthy salts are added to them as they grow. They sometimes attain the size of a pea or small nut. As they enlarge by new accretions upon their circimiference, they press upon and cause the absorption of the duct or follicle in which they originated, and several of them may be found adhering to each other in a single sac or cyst. From the above description it may be gathered that these concre- tions resemble salivary or biliary concretions rather than true stone. When they become large enough to constitute sources of irritation, dense, opaque, earthy matter deposits upon them, and they then become true prostatic calculi, and may go on indefinitely increasing in size. These prostatic calculi are met with of all sizes and shapes. Several of them may be found separated from each other, perhaps embedded in cysts, which are dilated follicles, or, if many of them are present, caus- ing atrophy of prostatic substance, until the prostate resembles a sack full of small stones, which may be felt rubbing against each other on pressure ^f/- r€rfi»/!, giving an emphysematous-like crackling (Adams). In bad cases, prostatic calculi tend to unite, projecting into the urethra and forming curiously-distorted, branched masses, dipping down into the substance of the prostate, and extendingforward into the canal of the urethra, and backward perhaps into the bladder. Such masses have been found four or five inches long. One, removed by T. Herbert Bar- ker, is referred to by Thompson as being composed of nine portions, weighing, collectively, three ounces, four drachms, and one grain. Prostatic stones are exceedingly hard, and have a polished surface. They may be brilliantly white, resembling porcelain, or of a fawn or pale-brown color. They are composed mainly of phosphate of lime, with a small admixture (derived from the urine) of the triple (ammonio- magnesian) phosphate. They very rarely give trouble during life, but NEUfiALGIA OF THE PROSTATIC UKETHRA. 217 when, of large size they may give rise to all the symptoms of prostatic ob- struction, in an aggravated form, leading, in the same manner, to chronic cystitis, hypertrophy, and sacculation of the bladder. When these calculi project into the urethra, a metallic instrument, introduced into the blad- der, may be felt to grate upon them in passing. Treatment. — The natural mode of elimination of these masses is by the formation of abscess. They may ulcerate out through the rectum, or perinseura, or into the urethra, or even into the bladder. Stone in the bladdernot uncommonly coexists with them. When they become large enough to give rise to distressing symptoms, an attempt may be made to remove them with the long urethral forceps (Brodie), but the best method is to cut down through the perinseum in the median line, and extract every thing of a calculous nature which can be found. If any portion be left it becomes at once a nucleus for further incrustation. During such an operation the bladder should always be searched for stone. In esceptional oases where prostatic stones can be felt in the substance of the prostate through the rectum, an incision may be made through the walls of the latter, and their removal thus effected. Certain concretions found in the dilated veins around an old prostate and known as phlebolites, must not be confounded with prostatic cal- culi. They are not infrequently detected after death, and are small white or colored smooth bodies, perhaps as large as a pea, such as are formed in dilated veins elsewhere. The calcareous remains of old abscesses which have been absorbed, and which in rare instances are found in the prostate, must not be confounded with calculi. Finally, a true urinary calculus may become lodged in the prostatic sinus when small, and continue to grow there by deposits of urinary salts, causing absorption of prostatic tissue, and finallj' becoming embedded in that organ (Meckel, Adams). Such stones may grow backward into the bladder (prostato-vesical calculi, Vidal), or true stone in the bladder, becoming attached near the neck of the latter, may grow forward into the prostatic urethra (vesico-prostatic calculus). NBUEALGIA OP THE PROSTATIC TJEBTHEA. This is a disease rarely recognized as such. It is confounded with inflammatory congestion and other morbid conditions of the bladder. It has been described by authors, with especial accuracy by Civiale,' under the general head of nervous affections of the neck of the bladder. Civiale, however, states that the cause is often unknown, and in his cases frequently omits to state the age of the patient and the condition of his sexual relations and requirements. It is to bring this fact into prominent notice that the affection is mentioned under the head of prostatic diseases. It would involve needless repetition to describe it here. Its mainly ' " Maladies du Col de la Vessie et de la Prostate." 218 DISEASES OF THE BLADDER. prominent symptom is frequent (perhaps painful) desire to urinate, with no lesion ; in other -words, simple irritability of the bladder. Its descrip- tion will be found under the title " Neuralgia of the Vesical Neck" (p. 234). As wiR be there laid down, the sexual function is most often at fault in its causation, and not only the neck of the bladder, but the pros- tatic and membranous urethra, and even the whole canal at times, is ui- volved, sensitive, irritable, congested, prone to contract, while hypochon- driacal despondency an d perverted intellectual function hold an important place in the picture of the disease. The connection of this affection with sexual causes has never been insisted upon, and yet this cause is, perhaps of all, the most prominent. It will be fully considered under the head of etiology of irritability of the bladder. Syphilis of the Peostatb. — Although it is possible for syphilis to cause its peculiar deposit in the prostate, yet it rarely, if ever, does so. There is certainly no syphilitic condition of the prostate which can be diagnosticated except by analogy. CHAPTER XII. DISEASES OF THE BLADDER. Anatomy. — Anomalies and Deformities, Exstrophy. — Hernia of Bladder. — Hypertrophy. — Atrophy. — Wounds. — Kupture of the Bladder. — Foreign Bodies.— Eetention of tjrine. — Incontinence : in Chil- dren, in Adults. — Tenesmus. — Chorea. — Hasmaturia. — ^Neuralgia of the Vesical Neck. — Cause. — Symptoms. — Diagnosis. — Treatment. AifATOKT. — The bladder is a muscular sac lying, in the male, between the rectum and pubes when empty, and distending, when full, into an oval bag occupying more or less of the hypogastrium. Its position is fixed below by the urethra, but mainly by the pelvic fascia, which, after having lined the cavity of the true pelvis, is reflected upward and lost on the bladder and rectum (as pubo-prostatic and inferior vesical liga- ments) and the recto-vesical fascia which binds the prostate and neck of the bladder to the rectum. Above and on the sides the peritonaeum covers the bladder, but is attached loosely, especially at the base, so as to offer no obstacle to any change in shape or position of the viscus. A knowl- edge of the reflections of the peritonasum upon the bladder is essential to a correct understanding of the methods of relieving retention by puncture. "When the bladder is empty, it lies contracted behind the pubes ; the peritonseum leaves the abdominal walls at the symphysis and passes at once to the bladder, over which it is spread, and then reflected upon the rectum from the base of the bladder, so that, when the latter is absolutely contracted upon itself, that portion of its base lying between ANATOMY OF THE BLADDEK. 219 the seminal vesicles is also covered by peritona3um, and there is, properly speaking, no direct relation between the bladder and rectum. Very different, however, is the condition when the visous is distended. Then, as its cavity fills up, the peritonaeum is carried with it. The recto-vesical cul-de-sac of the peritonaeum is deepened and all that portion of the base of the bladder situated between the seminal vesicles lies directly in contact with the rectum. When the bladder is greatly distended, its base becomes thus uncovered for a distance, roughly estimated, of two inches behind the posterior margin of the prostate. In the same way the distended bladder carries up the peritonseum in front, so that a dis- tance of one to two inches, or even more, above the symphysis becomes bare of peritonseum in extreme retention. Hence the election of these two uncovered spots for puncture. The medium capacity of the adult bladder is eight ounces, subject to extensive variations from habit or disease. The bladder may become so contracted as to contain only a few drachms, or again capable of hold- ing, without rupture, the better part of a gallon. The muscular coat of the bladder is composed of a set of external fibres which run mainly longitudinally, some of them being continued up the urachus, and an internal set whose general direction is circular. These latter, greatly reSnforced in number, encircle the neck of the blad- and internal orifice of the urethra, and pass under the general name of sphincter of the bladder. Certain fibres, running across the base of the trigonum Lieutaudii, serve to pull upon and open the mouths of the ureters. The mucous membrane of the bladder is of a pale salmon color, re- markably insensitive in health, covered by a stratified pavement epithe- lium, and lying in folds when the bladder is contracted. The glands are not numerous, except on the trigone and near the neck. Their office is to secrete lubricating mucus. They are exceedingly small, and com- posed of simple clusters of follicles. The coats of the bladder are united by connective tissue which is everywhere loose, except at the trigone. The vesical arteries come from the hypogastric. The veins termi- nate in a thick plexus about the prostate and sides of the base of the bladder, emptying finally into the hypogastric veins. The lymphatics lead to the hypogastric ganglia. The nerves, partly sympathetic and partly spinal, come from the hypogastric plexus. The neck of the bladder is that portion surrounded by the sphincter and base of the prostate, limited anteriorly by the ridge, more or less prominent in the adult, which maps out the posterior limit of the pros- tatic sinus. The trigone (of Lieutaud) is a triangular space lying between the neck of the bladder and the orifices of the ureters. The muscular coat is here transverse, thick, adherent to the mucous membrane. Its poste- 220 DISEASES OF THE BLABDEK. rior margin is limited by a more or less prominent ridge running be- tween the mouths of the ureters. The ridge can be followed along by the prominence made by the ureters as they penetrate obliquely the muscular coats of the bladder. The " bas-fond " of the bladder exists only after middle life, and is that part of the base of the organ lying behind the posterior ridge of the trigone. When the bladder is distended in later life, this portion lies on a lower leiel than the trigone. The urachus is the remains of the allantoid prolongation. It often remains open for a short distance above the vertex of the bladder and sometimes continues pervious throughout, so that, in adult life, the urine still passes by the navel, but this is exceedingly rare. The bladder in the fostus, and in early life, is an abdominal organ, situated mainly above the pubes. As the pelvis enlarges it settles down behind the symphysis, and only rises into the abdomen when distended. The mucous membrane of the healthy bladder is less capable of absorp- tion than any other. When deprived of its epithelium, absorption goes on as from other nude surfaces. A-Kr mwAT.rR fi AITD DEFORMITrES OF THE BLADDER. The bladder is almost invariably unique. Large saccuH have some- times been described as supernumerary bladders, and they may indeed reach a size double or triple that of the bladder itself. They may always be recognized by being destitute of muscular covering. They are her- niae of the mucous coat through the meshes of the muscular tunic. Molinetti' describes a woman who had five kidneys, five bladders, and six ureters. Partial partitions extending into the bladder have been observed. Blasius' relates a case of perfect segmentation of the blad- der by a partition, one lu-eter opening on each sidC: Podrazki' refers to several cases by different authors. The bladder is sometimes abnor- mally small, occasionally wanting, in which case the ureters may open directly into the urethra or into the rectum, or into a general cloaca, there being at the same time arrest in the development of other portions of the genital apparatus. Besides the above, there is one deformity, ex- strophy, the occurrence of which is sufficiently common to demand a special description. ExsTEOPHT OF THE Blabdee. — ^This deformity is found in both sexes, but much more frequently in the male.' In the female it is of less im- portance, as it may be more easily concealed, and does not prevent the performance of the sexual act. Cases of pregnancy and successful de- ' Quoted by Pitha. ' " Die Krankheiten des Penis und der Harnblase," p. 61, Erlangen, 1871. ' ilr. Earle (volume L, London Medical and Surgical Journal) alludes to sixty-eiglit reported case?, of which sixty ivere male. Isidore Geoffrey St.-Hilaire (" Histoire ge- n^rale et particuli^re des Anomalies de rOrganisation ehez I'Homme et les Animaux," Paris, 1825) estimates that one-fourth of the cases are female EXSTROPHY. 221 livery at term are recorded. The subject will be considered here, how- ever, only in relation to the male. The deformity is an arrest of development in the median line, anal- ogous to hare-lip, and is found in diiferent degrees. In a type case the lower part of the front wall of the abdomen and the front wall of the bladder are absent. The pubic bones are more or less widely separated from each other, their ends being united by a strong band of fibrous tissue. The posterior wall of the bladder, pressed out by the intestines, forms a mottled, red, tomato-like tumor, occupying the position of the symphysis pubis. Inguinal hernia of one or both sides is not uncom- monly present, either partial or extending down into the scrotum, which is usually normal, containing the testicles. The penis is more or less rudimentary, and affected by complete epispadias. The ureters are some- times greatly dilated, forming, as it were, rudimentary bladders. A good illustrative case is figured by Sir Astley Cooper.' The above description applies to a type case. There may be varia- tions in the absence of hernias, a normal union of the pubic bones, the amount of the protrusion, etc. Ordinarily in the adult the mass reaches the size of the palm. With complete extrophy there is also always complete epispadias. A condition analogous to extrophy may exist where the bony union of the pelvis is lacking, but the anterior walls of the abdomen and bladder are perfect. Here there is a sort of hernia of the bladder forward. In such cases there is always some anomalous condition of the external organs of generation. In exstrophy of the bladder, the patient's condition is miserable indeed. The thickened inflamed mucous membrane covering the protruded pos- terior wall of the everted bladder is constantly covered by decomposing " stringy mucus " of alkaline reaction, similar to what is found in vesi- cal catarrh. From the orifices of the ureters, which can be readily seen by pressing back the protruded mass, there constantly distills a limpid, acid, healthy urine. This at once becomes alkalinized by contact with the inflamed mucous surface of the bladder, and goes into rapid decomposi- tion, wetting the patient's linen and keeping him constantly surrounded by an atmosphere of ammoniacal, fetid gases, making him disgusting to himself and intolerable to his friends. The integument of the abdomen and thighs becomes excoriated and inflamed. The friction of garments in walking only serves to aggravate the existing difficulties, and the suf- ferer is in a condition truly pitiable. By pressing back the inflamed bladder a small prostate is exposed, lying at the angle of the penis and the vesical tumor, and upon it the vera montanum and ejaculatory ducts may be plainly seen. These patients have erotic fancies and seminal emissions ; but they are inca- pable of full erection or of perfect sexual intercourse. Patients with exstrophy of the bladder have been useful to science ' Volume i., Edinburgh Medical and Surgical Journal. 222 DISEASES OF THE BLADDER. in facilitating experiments upon the rapidity of the appearance in the urine of substances taken into the stomach. Thus it has been found that asparagus affects the urine ia eight and a half, turpentine in four and a half minutes, etc. (salts much more quickly). Furthermore, they give positive evidence of the fact that the secretions forming on the sur- face of an inflamed bladder are alkaline, and that the urine coming down healthily acid from the kidneys is at once alkalinized on reaching the bladder and promptly decomposed. Hence the rule to give alkalies to correct alkaline urine where such alkalinity is due to bladder inflammar tion, since by this means the urine is rendered less acid and less irrL fating as it comes from the kidney. Treatment. — Attempts made to destroy the vesical mucous membrane by cauterization and leave cicatricial tissue in its place have proved unsuc- cessful. Plastic operations have been performed with sufficient success to justify like attempts where the patient is willing to assume the risk of a fatal termination to an operation undertaken to relieve a deformity which does not threaten life. Usually several operations are necessary to reduce the aperture to a small size ; but, even when the flaps sloughi the subsequent contraction of the cicatrix is said to improve the local condition. If an operation is to be performed, each case forms a study by itself. Usually a large abdominal flap is dissected up from above the tumor and turned down over it, epithelium inward. The raw external surface of this flap is covered by one or more side-flaps or by integument taken from the thigh ; such flap or flaps are secured in place over the abdominal flap by bringing the raw surfaces into contact, and fixing the whole by sutures. Some sloughing is to be anticipated, and subsequent operations have to be devised to meet the requirements of special cases. The most that can be done is to inclose the bladder, leaving an opening below, through which the mine flows unrestrained, as it is impossible to reproduce a sphincter. Finally, a suitable urinal is adjusted and worn constantly. John Wood ^ reports a case which seems to be an exceedingly good example of what may be effected. A boy seven years old was operated upon four times, and the bladder was closed in — all but a small hole large enough to admit the little finger. The patient was able to retain two ounces of urine, but any cough or other contractile effort would expel it in a jet. The patient died six weeks after the last operation, from ery- sipelas. Ayres, of Brooklyn, Pancoast, of Philadelphia, and many for- eign surgeons, report cases where alleviation of some of the symptoms was effected by operation. The most that can be promised by operative interference is to leave behind a fistula, more or less large, over which a urinal must be constantly worn. The patient's virility is not returned to him, nor is his condition very materially bettered. ' Medical Times and Gazette, 1866, vol. i., p. 115. HERNIA. 223 A less dangerous and equally efficacious mode of treatment seems to be to adapt a suitable urinal to the parts as they are left by Nature, such a one as shall shield them from injury, and keep the patient dry and clean. A urinal of this sort exists, and about a dozen patients in the United States, male and female, have attested its sufficiency for all prac- tical purposes. It was originated by Mr. Earle, of St. Bartholomew's Hospital. It is figured by Vrolick,' and again by McWhinnie.' It con- sists (Fig. 75) of a metallic shield, preferably of silver, sufficiently bulged to contain the protruding vesical wall without coming into con- tact with it. The edge is rounded off so as to make for itself, by pressure, a deep groove around the vesical tumor. From its lower part, which is slightly bellied downward, extends a tube upon which is fitted a long, flat rubber bag, to be worn strapped to the thigh, and to serve as a reservoir for the urine. The bottom of the bag terminates in a metallic screw, which can be removed to allow the urine to drain off. The metallic shield above is held in place by a truss, which serves at the same time to retain any hernial projections in the groin. The in- strument may be kept clean by the use of a weak solution of permanganate of potash. While wearing it the patient is preserved from any friction. All the urine is collected as it flows, and a considerable degree of comfort is obtained, while, with a little care, all offensive odor may be avoided, and the patient put in a position to attend to all the ordinary duties of life, without being objec- tionable to those around him. Fig. 75, HERNIA OF THE BLADDER. Dislocation of the bladder in the form of hernia may be congenital (rarely), or come on later in life, especially in old age, from exertion, retention, or violence. Abdominal, inguinal (scrotal, sometimes on both sides), crural, perineal, ischiatic herniee, and cj'stocele through the fora- men ovale (Lentin), have been noted. In women, vaginal and femoral cystocele are most common ; in men, scrotal — that portion of the bladder uncovered by the peritonfeum being found in the hernia. The bladder may alone constitute the hernia, or coexist with a portion of intestine, perhaps being adherent to it. Cystocele has been opened by mistake in operations for strangulated hernia. Pott records two cases. Stagna- ' Plate 604, " Cyclopasdia of Anatomy and Physiology." ^London Medical Gatette, 1850, vol. xlv., p. 360. 224 DISEASES OF THE BLADDER. tion of urine, with inflammation of the bladder and formation of stone, may result from cystocele ; finally the hernia may become (rarely) stran- gulated. The diagnosis is usually easy, especially with a catheter, since the tumor increases when the bladder is full, and ma\' be emptied by press- ure, such pressure causing a flow of izrine through the catheter. Treatment. — Replace the tumor, if possible, and retain it by a truss. If it be irreducible, a suspensory bandage should be worn, and the tumor emptied, by pressure, during urination. If it become strangulated, herniotomy must be performed. A knowledge of the possibility of cystocele is the best safeguard against mistaking it for ordinary hernia. The distinction becomes more diflBcult if the retained portion of the blad- der is much thickened by chronic inflammation, or contains stone. HYPERTEOPBTT OF THE BLADDEE. Hypertrophy of the bladder as a spontaneous affection does not exist. It is exceedingly common in connection with any morbid condition which prevents the free outflow of urine (hypertrophy of the prostate, stricture, tumors), with stone, or in connection with cystitis from any cause (hernia of the bladder, etc.). The different forms of hypertrophy (concentric, eccentric, with sacculi) are described as part of the dis- ease, in connection with the morbid conditions occasioning them. Civi- ale speaks of a partial hypertrophy of the bladder, affecting chiefly its anterior wall, depending upon chronic inflammation or tubercular infil- tration — evidently not simple hypertrophy. ATROPHY OP THE BLADDEE. In rare cases in reduced, soft-fibred, debilitated individuals the bladder is sometimes found weak and thin, apparently atrophied in all its coats, and liable to rupture. Civiale gives the caution of avoiding pressure- on the bladder-walls during catheterization in weak subjects, for fear of perforation. Bonnet, Hauf, and Hunter,' give examples of sudden rupture of the bladder in young persons from this cause. Ate- nied bladders, and those whose nervous supply is cut off by spinal or brain disease, undergo more or less fatty atrophy. ■WOUNDS OP THE BLADDEE. Wounds of the bladder are not common, since the position of the organ protects it from ordinary accidents, inclosed as it is, when in a state of relaxation, by the bony pelvis. Excepting the violence done by instruments in lithotomy, possibly in lithotrity, or during other opera- tions, the bladder is but little liable to injury except dimng distention. ' Quoted by Pitha. RUPTURE. 225 It may be perforated by a fragment of bone in fracture of the pelvis. Rising above the symphysis pubis it becomes exposed to incised, punc- tured, and gunshot-wounds. Wounds of the bladder are exceedingly dangerous to life, without being necessarily fatal. Bullets and frag- ments of shell have entered the bladder without producing fatal conse- quences,' and there formed nuclei for calculus — as have also portions of bone. Treatment of injuries of the bladder is that of symptoms and indi- cations — arresting hemorrhage, and making a free outlet for urine as well as providing an escape for any extravasated fluid. No matter where the perforation may be, if infiltration is going on, it is always better to set the bladder at rest by a free perineal incision, as in lateral lithotomy, so as to prevent the visous from filling up. Rest, supportive treatment, and the combating of peritonitis, if it arise, by the early and free use of opium, constitute the outline of treatment. This course is preferable to the practice of tying a catheter in the bladder, which could not fail to prove an additional source of danger. ETTPTURE OP THE BLADDEK. A bladder, when over-distended by urine, may become ruptured by external violence, and this especially if it be atrophied or thinned by disease, ulceration or otherwise ; or the accident may occasionally hap? pen if the bladder were previously weakened in any part by the accu- mulation of urine alone, as in case of stricture. Usually, under such circumstances, the immediate cause has been muscular contraction. The most frequent cause of rupture of the bladder, as commonly met with in practice, is a fall, the bladder being distended. Imperforate urethra is an efficient cause in the foetus. Among traumatisms, where the vis- cus is not weakened by previous ulceration, falls, blows, and crushing injuries, with or without fracture of the pelvis, or even appreciable in- jury to the soft parts, may be mentioned. The most common position of the rupture is in the posterior wall of the organ, the fissure- usually including the peritoneal coat Other portions of the bladder--w;alls oc- casionally suffer. The symptoms are sudden occurrence of intense pain in the abdo- men, with urgent desire to pass water, while attempts to urinate are usually, but not always, ineffective." Ordinarily the patient is unable to walk from the first. Collapse soon follows. Death may occur in this stage, or the patient reacts and passes into a state of acute peritonitis, or suffers from symptoms of peritonitis with those of infiltration. If he survive the acuteness of this attack, the symptoms merge into those of ' I hare recorded in the New York Journal of Medicine, May, 1865, the case of an adult whose bladder was perforated when distended, by a bullet, during the New York riots, in July, 1863 (the gentleman being a looker-on), terminalting in complete recovery. — Van Buken. ' Erskine Mason, " Rupture of Urinary Bladder," K.'Y. Med. Journal, August, 1872, 15 226 DISEASES OF THE BLADDER. local peritonitis, constant and often ineiFectual desire to urinate being still a prominent symptom. The catheter passes generally without difficulty, and clear urine may be drawn, or urine tinged with blood. Whenever a diagnosis of rup- tured bladder can be made, a very guarded prognosis must be given, as a vast majority of the cases terminate fatally. Of seventy-eight cases collated by Stephen Smith,' there were but five recoveries. The prognosis is naturally more grave where the extravasated urine has entered the peritoneal cavity, than where it has only escaped into the cellular tissue of the pelvis. Treatment. — It is unwise to temporize by the introduction of catheters. Sound surgery calls for an opening at once in a dependent part of the organ, so that no accumulation of in-ine whatever can take place. The lateral operation for stone must be performed, the neck of the bladder being incised and stretched so that the urine will drain off without accumulating. If fluctuation can be felt in Douglas's cul- de-sac, the latter should be punctmred with a trocar and the fluid evacuated. The advantages of this method of treatment, introduced by Dr. Walker, of Boston, are ably discussed by Mason, in the case referred to. In only two reported cases has this operation been tried thus far — both were successful : in one, Walker's, the rent was in the anterior bladder-wall, complicated by fracture of the pelvis ; the other, Mason's, was complicated by general peritonitis. The unsparing use of opiates to keep down peritonitis, and meet- ing any svmptomatic indications which may arise, constitute the re- maining treatment. POBEIQN BODIES TS THE BIiASBEB. Besides the foreign bodies which find their way into the bladder through wounds, or come down the ureters (renal calculi), a host of substances have been encountered in the bladder, introduced through the urethra. All unimaginable articles, such as pins, beads, stones, pieces of straw, heads of rye, heads of wheat, portions of glass, tubing, pipe-stems, lead and slate pencils, portions of chalk, wax, etc., have been found in the male bladder, introduced there through the urethra under the influence of morbid erotic fancies. The budding sexual instinct of a boy yearns for satisfaction, but finds none; is thoughtlessly stimulated by the youth himself, by impure thoughts or books, often kindled by those who are older. An uneasy feeling of a desire to do something leads a timid boy to masturbation, and tempts him to play all sorts of pranks with his sexual apparatus. In this way, substances, of every conceivable description which the orifice of the urethra wiU admit, are introduced into the canal and again extracted, ' New York Journal of Medicine, 1861. FOREIGN BODIES. 227 until, on some unlucky occasion, the object slips beyond the grasp and remains fixed in the deep urethra, or the bladder. The patient's shame will often prevent him from seeking relief; a small smooth foreign body in a healthy bladder may create no disturbance at &st, and so the patient goes on, supposing that every thing has arranged itself, until, in after-years, perhaps long after he has forgotten his boyish folly, he gets bladder-symptoms, is cut for stone, and the latter is found to have formed upon a nucleus introduced from without. Not infrequently, however, a foreign body comes legitimately, as it vrere, into the bladder ; dermoid cysts containing bones, teeth, and hair, may discharge into its cavity. The broken end of a metallic, or, more commonly, a gum-elastic catheter, may constitute the foreign body, usually in cases where the individual is obliged to have frequent re- course to a catheter for the purpose of emptying his bladder. A catheter is most apt to break at the eye. The old-fashioned gutta-percha bougie is particularly dangerous, on account of its liability to become brittle when old. Such bougies should not be used. Again, substances of all sorts, bone, seeds, etc., may enter the bladder through ulceration into the rectum, while splinters, bullets, and bone, may be lodged there during injuries of the bladder. Treatment. — If the foreign body be a portion of catheter or bou- gie, the patient will usually hasten to tell his troubles and demand relief. If, however, it is some other foreign body, he will probably seek aid for the cystitis it may have occasioned, but will steadfastly deny the knowledge of any cause, often indeed after the foreign body has been detected, or even extracted. When the nature of the sub- stance in the bladder has been learned, an attempt should be made to extract it, to prevent it from becoming a nucleus for stone. If there be much cystitis present, rest in bed, with demulcents and some anodyne, for several days before the operation, would be advisable. Any thing which will go into the urethra would come out of it, if it could be correctly seized, with its points turned backward, and be drawn upon in a correct line ; consequently, an attempt should be made to reach all long bodies (pencils), and all small bodies, by using a small lithotrite, or other forceps designed for this special purpose, of which there are several varieties kept by instrument-makers. If the object be seized in a faulty diameter, it may be released and caught again. This rule applies to portions of metallic catheters as well. It is exceedingly diificult to catch them correctly ; soft catheters, however, are very easy to extract ; they become doubled up, and may be withdrawn, however caught. The difficulty in seizing a portion of soft catheter is, that it cannot be felt on account of giving no click or grating against a metallic forceps; consequently, in the search for such a foreign body, the blades of the lithotrite have to be shut occasionally over different parts of the blad- der-surface, and the offending body is pretty sure to be found, finally, 228 DISEASES OF THE BLADDER. between its jaws. Care must be exercised, of course, not to catch a fold of the bladder. Two substances which may be introduced into the bladder demand a special notice — wax and glass. The former becomes so soft at the tem- perature of the body that it not only cannot be felt, but, if seized, can only be taken away piecemeal, while some portion is pretty sure to re- main behind. As to glass, or other brittle substance, the danger of injuring the bladder by splintering the foreign body in attempts at ex- traction with forceps renders all such efforts, as a rule, unadvisable. Consequently, for all foreign bodies of wax or glass, and for all such as cannot be extracted after patient, gentle effort with the lithotrite or for- ceps, the median operation for stone should be performed, and this as early as possible, before the foreign body has had time to become incrusted with urinary salts. If, for any reason, it should be advisable to postpone the operation, it would be wise to wash out the bladder daily with a view of retarding calculous deposit upon the nucleus. Dr. Doug- las, of Rondout, N. Y., in cutting a patient to extract a piece of glass, fearing that pressure with his forceps might splinter it in the bladder during extraction, devised the ingenious expedient of covering the blades of his forceps with soft molasses candy, knowing that if any of this sub- stance was left in the bladder it would melt and pass away. The device was fully successful. RETENTION OF tTRINE. In retention the bladder fills up, and the urine is not or cannot be passed. It must be clearly separated in the mind from suppression, where no urine comes down from the kidneys. This distinction can always be at once established by percussing the hypogastrium. The causes of retention are varied : Voluntary retention, often repeated and long kept up, may result in positive inability to empty the bladder ; all varieties of urethral obstruction — stricture, enlarged prostate, inflamma- tion or acute congestion of the prostate, even spasm of the cut-off muscles — are capable of producing retention. Finally, true vesical pa- ralysis will give rise to it, unless the cut-off and sphincter muscles are paralyzed at the same time, when there' will be incontinence. Another cause of retention is found in the blunted sensibility of the bladder, which exists in certain high febrile conditions (typhus, small-pox), in coma, in some syphilitic and inflammatory brain-diseases, and in shock from injuries. Symptoms. — In suppression (p. 352) there is always resonance over the pubes ; in retention always flatness. The bladder may be often seen and felt, filling up the hypogastrium, perhaps reaching the navel. Pressure upon it usually causes a desire to urinate. Fluctuation may be made out between a finger in the rectum and the hand upon the hypogastric tumor. The bladder will not burst from retention of urine. INCONTINENCE OF URINE. 229 unless it be previously ulcerated or subjected to mechanical violence when full (a fall or blow) ; after it has been over-distended for a time, a certain amount of dribbling will take place through almost any ob- struction. From the effect of violence, or if the urethra be ulcerated or sensibly weakened behind a stricture, extravasation of urine may occur through the urethral walls. The treatment has been already considered in relation to stricture and prostatic disease. In ail other conditions — atony, paralysis, fever, etc. — a soft catheter of medium size should be passed every eight hours, and the bladder kept syringed out with water once or twice daily. When there is no urethral obstruction, a largely-distended bladder may so pull upon and distort the fixed curve of the urethra that an obstruc- tion to catheterism exists just within the triangular ligament. The dis- tended bladder rising out of the pelvis frequently produces a sharp angle in the urethra at that point. Hence, in case a soft instrument should be arrested here, a metallic catheter of accurate curve should be substituted, and managed with extreme gentleness, so as to avoid perforating the floor of the urethra. In cases of retention the aspirator will always afford speedy relief. Cazenave, of Bordeaux,' states that retention may always be relieved by introducing a piece of ice, about the size of a chestnut, into the rectum, repeating the same, if necessary', every two hours. INCONTINENCE OF TJIIINE. Incontinence, like retention, is a symptom, and not a disease. In incontinence a portion or all of the urine dribbles away, or is passed involuntarily. Besides the true, there are two very common forms of false incontinence — the one nocturnal, occurring in children ; the other in adults (stagnation, with overflow), where, after retention for some time, the excess of urine dribbles away. It may be stated as a rule, to which there are few exceptions, that an involuntary flow of urine in the adult indicates retention and not incontinence. NocTTJENAL Incontinence in Childken. — This disagreeable affec- tion often depends upon mismanagement : children not being awakened at sufficiently short intervals to empty their bladders, and acquiring the habit of passing urine without being waked thereby. In other children, again, the malady is sufficiently marked to constitute a disease. In these cases the urine escapes during the unconsciousness of sleep, but not at other times. Such children are not necessarily weak, nervous, or choreic, nor do they belong to any particular constitution or diathesis. Treatment consists in paying attention to the child's general hj'giene, awakening it to pass water late at night and early in the morning, using moral suasion, and avoiding the use of fluids toward evening. Besides these means, absolute benefit may be expected from belladonna, com- ' Journal de MSdecine et de Chirurgie, May, ISYl. 230 DISEASES OF THE BLADEER. mencing at a small dose, perhaps one-tenth of a grain of the extract, if the child is very young, and increasing gradually until some of the poi- sonous effects of the drug are noticed. Several other means inay be mentioned which are often effective — blistering the perinseum, the use of actual cautery, touching it several times about the anus. Recently the use of chloral hydrat. has been advocated, the idea being to make the child sleep more profoundly. Another means which has appeared in the medical journals, and has been employed, it is said, with success in breaking up the habit, is sealing the prepuce at night with a drop of collodion. Mechanical appliances, encircling the penis or pressing upon the perinasum, have the disadvantage of tending to beget a habit of handling the parts. IifCONnxEXCE rsr Adui,ts. — Stagnation with overflow or false in- continence has been already considered. True incontinence depends upon — 1. Unsymmetrical development of the prostate, where, after the collection of a little in-ine, the rest trickles away, there being no disten- tion of the bladder. 2. Concentric hypertrophy of the bladder, where the viscus cannot distend, and all urine above a few drachms must flow at once away. 3. Paralysis of the " cut-off" and the sphincter muscles of the bladder with or without paralysis of the detrusor urinse. The treatment of these conditions is detailed elsewhere. It is advisable that the patient should wear a urinaL VESICAL TElTESmUS. Cramp of the bladder is simply an uncontrollable tenesmus occurring in the course of several inflammatory diseases. Where there is no in- flammatory condition present, it may be classed along with neuralgia of the vesical neck, in which condition it is often exceedingly severe. CHOREA OE THE BLAJJDEE. This affection is rare, and seems to occur only in children. It usually coincides with other choreic symptoms. The following cases give a pict- ure of the disease : Case XXTT . , aged six, a weakly, lymphatic boy, of rheumatic antecedents, growing fast, with a moderate appetite and large head, is brought by his mother, with the complaint that he wets his pantaloons while at play. He sometimes soils the bed at night, but not invariably. The boy knows when he wets his clothes, and runs to tell his mother. He invariably declares that he " cannot help it." He is an obedient, gentle little fellow, old enough to be ashamed of hunself, and seems really desirous of holding his water, but, as he remarks, he " cannot do it." An attempt was made to correct the habit by having the boy called in at stated intervals from his play, for the purpose of emptying his bladder, but the involuntary, spasmodic escape of urine still occurred occa- sionally in spite of the fact that the bladder was not allowed to fill up. This boy had no CHOEEA. 231 other choreic symptoms, except in the muscles of his right eye Ordinarily, his eyes were straight, but, when tired, or excited, or angry, or frightened, his right eye would be drawn outward — sometimes outward and upward, the axis of the other eye being straight. This strabismus would come and go rapidly, varying according to the voluntary move- ments of eye. Moral suasion and belladonna were equally ineffective in relievin"- the vesical symptoms in this case, but tonic and general hygienic treatment always bettered the patient, until, in the course of two or three years, his bladder returned to a full possession of its normal functions, and his strabismus entirely disappeared. During this periodi from different causes he would occasionally get run down in general health, lose flesh and appetite, and then his involuntary spasmodic emissions of urine day and night, and his tendency to intermitting strabismus, would return. The urine was always normal. In this case there was evidently a spasmodic contraction of the detrusor urinse of the choreic sort, over which the patient had no control. There was no stone nor inflammatory state of the bladder, nor any kidney- disease. He was never seen in the act of making water involuntarilv, so that it is impossible to state whether the stream flowed in jets or con- tinuously. Case XXIII. , aged fourteen, has always been a nervous boy. He is exceed- ingly sensitive in disposition, very bashful, easily excited, or brought to tears — general health fairly good. He has been under treatment for some time past, but without benefit. He is troubled with frequent desire to urinate, in paroxysms — the paroxysms seeming to be the culmination of excessive nervous fidgetiness. They occur especially when the boy is annoyed about any thing, and are almost always accompanied by a sensation of chilli- ness. He frequently wets the bed when asleep, and, when awake, the desire to urinate comes on so suddenly and so strongly that he often soils his clothing. With this he has a strong tendency to twitch the head and shoulders, as in chorea. He was put upon iron, quinine, and arsenic, with general hygienic directions about food, exercise, and fresh air. In two months he reported improvement. His treatment was continued, and he was ordered gymnastic exercise. Nothing further was heard from him. Case XXIV.^ , aged eight, is a fat, healthy, lymphatic boy ; one of a large family of children, of whom nearly every male has distinct chorea, either generalized or affecting special muscles. Some of the older children have outgrown the tendency. The patient is troubled occasionally with slight general choreic twitchings, when from any cause his appetite is low, or his general health poor. Under such circumstances he has frequent paroxysms of intermitting, uncontrollable contraction of the bladder, forcing hdm to frequent micturition and attempts at emptying the bladder evtry few moments Sometimes the call comes so suddenly that he wets his clothing, and he also is unfortu- nate at night. "When the boy is enjoying good general health, neither h is general chorea nor his frequent calls to urinate disturb him. He improves under arsenic, quinine, or any general tonic or country air. These cases, to which might be added several others, make out a distinct choreic condition for the bladder. It seems to be a rare affec- tion, but this may be owing to the fact that it has not been looked for. It occurs, like most other choreic afi'ections, in early life, and in con- junction with other symptoms of local or general chorea, more or less strongly marked. Treatment. — Correction of any faulty condition of life by improved hygiene ; iron, arsenic, quinine, cod-liver oil, and other tonics in the way of drugs, with electricity, constitute the treatment, and will probably triumph over any case. Local measures are not needed. 232 DISEASES OF THE BLADDER. Hsematuria is a symptom and not a disease, but it very often pre- sents itself as the most prominent objective characteristic of a morbid condition. Often its cause is evident, sometimes so obscure that deatli alone reveals it. Hcematuria is tlie passing of blood witb the urine. The blood may be free or in clots. There may be so little that it is only discovered by microscopic examination, by which means the amber bi-concave disks are easUy detected ; there may be enough to give the urine a peculiar, hazy, smoky hue, which is very characteristic of blood, even when there is no pink or red shade in the specimen ; finally, it may be so abundant as to make the urine look like pure blood, or, if blood have been retained for a considerable time within the bladder, the urine may be col- ored almost black by it. • The blood usually comes from the urethra, the bladder, or the kidneys, and it is often of the utmost importance to decide from which of these three sources it is derived. There are but few distinguishing marks. If the bleeding is from the fore part of the urethra, some of it will reach the meatus between the acts of micturition ; if behind a narrow stricture, or posterior to the membranous urethra, it will not. Blood eifused into the urethra clots there, and assumes the shape of a leech, or of a tape or thread. Such clots are apt to come out with the first gush of urine, although, if there be a tight stricture, they may not be able to squeeze through until the stream is running at full force, and consequently would not appear until the middle or near the end of the flow. Blood from the seminal vesicles will be clotted and mingled with the yellow bodies found there, and with spermatozoa. Blood from the prostatic sinus is pretty sure to be clotted, perhaps in strings and threads mingled among flakes of pus-corpuscles. When blood comes from this region, the spermatic fluid in sexual intercourse is very apt to be bloody. Blood from the neck of the bladder may or may not be clotted. Often a few irregular clots will come first ; then smoky urine will flow, and, finally, as the bladder expels its last drojis, the prostate and vesical neck being squeezed, a little highlj'-colored urine, or fluid resembling pure blood, will be voided. Blood flowing from any part of the bladder, and sometimes from the prostatic sinus as well, if it flows rapidly into an empty bladder, is pretty sure to clot in mass, and to dissolve afterward. If, however, it flows very slowly, or into a bladder partly filled with urine, it may not clot at all, but remain freely suspended in the urine, retaining its natural red color ; or, after a few hours, becoming brown or black. Blood may clot in the pelvis of the kidneys, but coming down from the kidneys does so usually in a fluid state, either as red or black blood ; fibrinous clots may, however, pass the ureters with symptoms of kidney-colic. HJEMATUEIA. 233 Blood from the kidneys has no special physical character by which it can be distinguished from blood coming from the bladder, except in those cases where blood-casts of the uriniferous tubules are found. These are pathognomonic. The quantity of blood flowing from a can cerous kidney varies very greatly, sometimes disappearing for weeks, and then recurring violently. Bayer ' says that, from a comparative examination extending over a length of time, of all the urine passed by patients with calculous pyelitis or cancer on the kidney, he noticed several times [pliisieiirs fois) that the urine voided three hours after eating was more than ordinarily loaded with blood. When the blood comes from the kidneys, there is often pain or heaviness of the lumbar region of one or both sides. Blood may flow from the ureter if a calculus be retained there. Rayer has noted several such cases, in two of which there were also exuberant granulations in the ureter, which bled. The origin of blood in the urine may in some cases be cleared up by a clever expedient resorted to by Thompson, for the differential diagnosis of pus from the bladder or kidneys in obscure cases. A soft catheter is gently introduced just within the bladder-neck, the urine drawn ofi", and the cavity washed out very gentlj^with tepid water. If the water can- not be made to flow away clean, the inference is that the blood com.es from the cavity of the bladder. If it will flow away clean then the catheter is corked for a few moments, the patient being at rest, and the first drachm of urine which collects may be drawn off and examined. The bladder is now again washed out, and, if after a single washing the second flow of injection be clear, while the drachm of urine was bloody, the inference is again complete that the blood comes from one or the other kidney. Bloody urine is always albuminous. Ihe causes of hoematuria are very numerous. Among the most prominent may be mentioned all traumatisms of any character of the kidney, ureter, bladder, or urethra, all acute inflammations of any portion of the urinary tract, or of the seminal vesicles, from acute nephritis to gonorrhoea and urethral chancre, certain forms of pyelitis ; all chronic inflammations of these same regions, especially if there be ulceration; overdoses of turpentine when the blood comes from the kidney, or can- tharides when it comes from the bladder; stricture (Case XX.), (kidney stone, bladder, or urethral), strongulus of kidney, abscess, cancer, or other tumor of the kidney or urinary tracts ; varicose condition of veins near the bladder-neck, villous tumor of bladder ; finally may be mentioned spontaneous, so-called essential, hsemorrhage, sometimes recurring peri- odically once a month, like feminine menstruation," the hremorrhagio diathesis, critical haemorrhage in certain febrile or other diseases (typhoid, variola). These discharges may come from any portion of the ' " Maladies dea Eems," Paris, vol. iii., 1841, p. 33a * Eayer, op. cit., p. 333. •234 DISEASES OF THE BLADDER. urinary mucous membrane. Paroxysmal tsematuria, due to malaria, cold, exposure, etc., has been described by Harley,' Roberts," and others. Hiematuria is endemic in some localities. South America, Isle of France, etc. (due to the parasite Silharzia hmmatoMa). Treatment. — The successful treatment of hsematuria depends upon discovering a cause which may be removed (Case XX.). In any case, however, alkaline diluents are serviceable by rendering the urine less irritating. Case XXV. — A healthy young gentleman during the heat of summer, while perspiring violently, was suddenly seized with symptoms of renal calculus, followed by profuse haematuria. This contiuued to an alarming extent, sufficient, in a short time, to reduce the patient to a condition of great emaciation and anjemia. He was now put upon large doses of citrate of potash, and his hsematuria gradually disappeared. No calculus was passed. During the tropical heats of a New York summer such cases are of not very uncommon occurrence. The different haemostatics are usually of no service, but tliey may be tried, and occasionally with advantage. Lead and opium (aa gr. j-ij), three or four times daily ; ergot (fluid extract 3 j-ij), or subcuta- neously (gr. v of ergotine) ; aromatic sulphuric acid, 3 fi-j doses; tincture of matico, 3 j- 1 C doses ; alum, sesquiohloride, subsulphate, and other preparations of iron, tannin, gallic acid, creosote, Oak-Orchard mineral water, Rockbridge Alum mineral spring, etc. Rest on the back is often necessary above aU things, and in this posi- tion ice may be applied with advantage to the hypogastrium, perinseum, and in the rectum. Lallemand employed nitrate of silver in the blad- der, and iron and alum solutions have been injected with more or less benefit. It is necessary to repeat here one caution already given in an- other section : If the bladder becomes filled up with a large clot of blood, let it alone ; no harm will come of it. It will dissolve and come away; any attempt to pump it out through a catheter, or break it up, or dissolve it, if successful, will only allow the blood to re-collect, and is fraught with the danger (for the patient) of exciting inflammation by violence. The best treatment is opium, to control desire to urinate, rest, and diluents. NEUBALaiA OF THE VESICAIj NECK. This most common affection of the bladder has received its clearest exposition from Civiale, who has devoted nearly a hundred pages to it in his " Traite des Maladies des Organes genito-urinaires," Paris, 1858. Phillips ° treats of it as " contracture du col de la vessie," a title first given the disease by Caudmont, another Parisian surgeon, whose views ' Med. Chir. Trans., 1865. ' " Urinary and Renal Diseases," second American edition, p. 151. » " Traits des Maladies des Voles urinau-es," Paris, 1860. NEURALGIA OF THE NECK. 235 are given in English by Dr. Slade,' of Boston. Gross ^ gives a case under the title of neuralgia of the bladder, using the term neuralgia in its English sense, to which the idea of pain is attached. The French expression " nevralgie " does not neossarily include the idea of pain, but signifies simply a nervous disorder — functional, not organic. The anatomical seat of the disease is the prostatic sinus around the seminal ducts as well as, and indeed more strictly than, the neck of the bladder. The nervous element of hyperesthesia of the deep urethra and vesical neck bears a large share in producing the symptoms of nearly all blad- der-diseases. Neuralgia in its pure form has very clear outlines, but the part it plays, when engrafted upon other bladder and urethral dis- eases, throws confusion into their diagnosis and chronicity into their type. The causes of neuralgia of the vesical neck are numerous, but none holds the same prominence as does the perversion of the sexual instinct and appetite, its over-stimulation by excess, or, more often, its imperfect satisfaction — in short, irregular or ungratified sexual desire. The action of these causes is to congest and keep in a more or less constant con- dition of irritation the prostatic sinus in the neighborhood of the semi- nal ducts. This congestion extends readily in both directions, involving the cut-off muscles in front and creeping backward into the neck of the bladder through the inner orifice of the urethra. Rarely, if ever, does this affection occur in its typical form (simple irritability of the bladder, without inflammatory lesion) — rarely does it so occur where the sexual element is not at fault. It attacks men j'oung and old, married and single, but the great majority of cases will be found in young bache- lors, recently-widowed gentlemen, and old bachelors. Where the youth of the patient or the married state would seem to throw a sexual cause out of possibility, almost invariably there will be found, by close ques- tioning, on the one hand masturbation or the encouragement of budding erotic fancies by impure thoughts and associations ; on the other, excess, infidelity, or imperfect and unsatisfactory sexual relations. So close is the connection between an unnatural sexual condition and an unhealthy state of the neck of the bladder, that it needs but little practical obser- vation of cases to convince one that these influences alone are to blame for the origin of some and for the long continuance of many other mor- bid vesical conditions. Second to this sexual cause in producing neuralgia of the vesical neck comes the arthritic or gouty diathesis, that general blood condition attended by acidity and concentration of the secretions, local conges- tions so often of the tegumentary structures, with neuralgic and irritable habit. Finally comes a long line of causes including every thing capable of inflicting a structural change upon the tissues of the neck of the blad ' Boston Medico! and Surgical Journal, July, 1856. * "Diseases of the Urinary Organs." 236 DISEASES OF THE BLADDER. der or in its neighborhood (stricture, abscess, large prostate, inflamma- tions, stone, worms, inflamed hffimorrhoids, fissure of rectum, etc.); and though these in themselves are not necessarily complicated by a neural- gia of the vesical neck, yet they keep up congestion there and often are thus complicated, where the urine is irritating, the constitution arthritic, or especially the sexual appetite at the same time perverted or ungrati- fied. The nervous hypochondria, with despondency, the excited and suspicious tendencies so marked and remarkable in nearly all men at any time of life in connection with functional or organic trouble in the genito-urinary tracts, are only explicable by recognizing that Xature has implanted in man a sexual want which controls many actions of his life, impels him to continue his species and cries out in distress whenever it is trifled with, ungratified, or over-stimulated, or whenever its existence seems to be menaced. A man wiU feel more depressed at seeing a little excess of phosphate in his urine which he thinks, in spite of all proof to the contrary, indicates a local " weakness," than he wiU at loss of memory or mental incapacity which he can recognize himself and be fully conscious of. There are few men who would not rather lose a leg or an eye, than a testicle ; while functional or organic disease of the bladder, testicles, or penis, causes more mental inquietude and distress to its possessor than does a cavity in a lung. Why should this be, except that Nature has endowed man with an instinct of terror at the idea of losing his sexual capacity, and has established a law for the regular and judicious performance of the sexual act, which he must obey or else suffer in some way the penaltj- ? This suffering may not be evinced by symp- toms in the organs of generation themselves, and probably wiU not be unless through excitement of these organs by abuse or irregular use, or unless through their stimulation by erotic fancies, the patient attract the morbid nervous tendency to a local explosion. A man perfectly pure in thought and deed would not suffer from vesical neuralgia, unless, of course, some physical lesion of the parts should first occur to excite local congestion. Old maids and priests suffer from sexual distress as much as young and old bachelors and widowers, but they very rarely give any local signs of trouble. Their symptoms may be scattered over all the organs, and may impair any or all of the functions. Symptoms. — ^Pure neuralgia of the vesical neck is synonymous with the condition vaguely known as irritability of the bladder. This affection is totally denied by some authors, who aflirm that a lesion exists in aU cases, and that it is simply a confession of ignorance to talk of pure irritability. The charge cannot be justly made. A cause for irritability can always be discovered, where there is no appreciable lesion, by studying the sexual wants and relations of the individual. It is expedient, however, to drop the term irritability of the bladder as meaning a disease, and to retain it in the signification only in which it has been adopted in this country — as indicative of that symptom, common to nearly all NEURALGIA OF THE NECK. 237 bladder affections, frequent desire to urinate, where the cause lies in the bladder — hence not in diabetes or hysteria. This at once reduces irrita- bility from a disease to a symptom, and the term may be used in or- dinary description as synonymous with "frequent desire to urinate." Irritability may be found in connection with inflammatory affections caused directly by the inflammation or in the same affections kept up and aggravated by neuralgia of the vesical neck. The symptoms of a pure case are as follows : Frequent desire to urinate, the attack coming on sometimes suddenly, sometimes gradually, without appreciable cause, or perhaps commencing in an inflammatory condition of the parts (gonorrhoea), but not subsiding with the latter. This desire to empty the bladder may or may not be attended by a slight burning pain in the act. In severe cases there is powerful tenesmus (cramp). The relief after urination is usually not perfect, and the desire soon returns. There is often a certain slowness in the act, the bladder contracting without force, and the stream being small, or, on the other hand, the bladder may contract spasmodically, when the call comes, throwing out the urine with great force. Again, there may be spasmodic contraction of the cut-off muscles leading to inability to urinate, or hesitation in the act. There are some prominent peculiarities about these calls to urinate. They rarely disturb the patient at night. Once asleep, he rests quietly, but, if from anxiety or other causes he is restless and wakeful, he is obliged to empty his bladder frequently, by night as well as by day. When under the stimulation of liquor, the urine can sometimes be held for a number of hours. When pleasantly occupied, or deeply interested in any thing, as at the theatre, in agreeable company, or engaged at some earnest work, the bladder is often but little if at all troublesome. On rainy, damp, or cold days, the calls to urinate are more frequent, perhaps once an hour. The same occurs during idleness, and especially during mental worry or disquietude. The spirits are usually depressed, the patient anxious, perhaps hjrpochondriacal. The urine is usually clear, rarely shows any purulent deposit (unless the affection has lasted for months or j'ears), but often contains an excess of amorphous phosphates. This deposit sometimes alternates from week to week with a deposit of urates. Sometimes both ingredients exist in excess. Crystals of oxalate of lime are not uncommonly present. There is no soreness over the pubes, though pressure there will sometimes call forth a desire to urinate. In the rectum there is often a slight sensation of heat and uneasiness. There is frequently a dull, dragging, uncomfortable feeling in the perinseum — but pressure there is not painful. Erections may be frequent or absent — ^the latter to such an extent that the patient may believe himself impotent. There may be abnormal feelings of heat and ten- derness about the scrotum and testes. Added to these there may be all sorts of functional disturbances of the bowels, often constipation, with 238 DISEASES OF THE BLADDER. feelings of lassitude, and general weakness. Spasmodic stricture of the urethra may come on as an accompaniment of this condition, while great irritability of the cut-ofif muscles exists as a rule. Nocturnal emissions are not infrequent. On exploring the urethra with a full-sized blunt steel sound in these cases, it is customary to find the whole canal sensitive and irritable. The muscular fibres contract about the instrument, and oppose its prog- ress. At the membranous urethra, the cut-off muscles contract spas- modically, often sufficiently to bar the progress of the sound entirely, and give the idea of organic stricture. As the instrument advances, the cut-off muscles may be felt to quiver in slight partial contractions, while the patient complains greatly of pain. When the beak of the sound enters the prostatic sinus, the patient is very apt to feel faint. He may indeed go into syncope, or have an attack of nausea ; or, perhaps, a sexual orgasm may be induced, in which case the prostate and cut-off muscles contract violently upon' the sound, causing the patient consid- erable pain. As the sound passes the neck of the bladder, either the natural feeling of a desire to urinate will not be perceived or (usually) the sensation will be highly exaggerated and painful. Sometimes spasm of the bladder wiU be induced and the instrument will be forced out, or a jet of urine may gush out along the urethra outside of the in- strument. On withdrawing the sound, a little blood will often be found upon the beak, but the patient as a rule feels relieved, and will often experience for hours thereafter an ease and local comfort such as he has been a stranger to for months, perhaps for years ; his interval of urination being decidedly lengthened, although the smarting at the next urinary act will be greater than before. The above general outline of symp- to-ms will include most cases of pure neuralgia of the vesical neck, where there is no lesion, and has been no serious antecedent disease. As for the symptoms of a nervous element complicating the differ- ent structural diseases of the genito-urinary tract, a detaU is impossible. Suffice it to say the symptoms drag out, the disease tends to run a chronic course, attended by morbid excitability of the prostatic urethra, and an irritability of the neck of the bladder which is out of proportion to the lesions existing. This irritability is not constant, it is worse one day, better another, and subject to variations which no physical condi- tions can account for. Where such prolongation of the symptoms and an excitable state exist in connection with organic disease of the parts — but out of proportion to them — a profound study of the case ivill often bring out some sexual distress which is finding this means of expression. Pure and simple neuralgia, if continued long enough, may finally lead to a mild cystitis around the neck of the bladder — especially if the patient give way to his frequent calls to urinate, and strain to void the last drops of urine, thereby mechanically bruising the coagested NEURALGIA OP THE NECK. 239 vesical neck and exciting it to inflame ; just as too frequent stools pro- duce an analogous condition of the lower end of the rectum. After such inflammation has been kindled and true cystitis exists, the neural- gic element persists with it as a rule. The historjf of the advent of the attack, the excessive sensitiveness and irritability of the cut-off muscles, and a diagnosis by exclusion, will rarely fail to detect neuralgia of the vesical neck, as the acting cause of cystitis where it is so. Such cystitis may be prolonged for years and finally end in death, as in Gross's case, believed by that eminent surgeon to be of malarial origin. These cases require more careful study than perhaps any other affection of the urinary organs, and are in many instances mistaken for and treated as organic disease. Diagnosis. — The diagnosis of neuralgia of the vesical neck is easy when considering the sensibility of the urethra as above narrated, the insensibility of the bladder-walls when touched with the point of the sound, and the great fact that the urine of pure neuralgia contains no sensible deposit of pus, while that of cystitis always does. Where the two conditions coexist, the points noted above will help to clear up the diagnosis, and establish the neuralgic element, if it exist. The treatment is simple, and, if it can be carried out, usually brill- iantly effective. An alkali, if necessary, general hygiene, and atten- tion to the sexual element — by marriage, if possible, by continence, if there is excess ; by purity of thought and deed in any case — will place the patient in a curable condition. A mineral acid with possibly a lit- tle strychnine — if the urine be neutral or phosphatic ; an avoidance of alcoholic beverages, and a cessation of the use of tobacco, may be re- quired, with, possibly, change of residence, occupation, or habits that keep up an irritable condition of mind. With these general means nothing is so potent locally, in a pure case, as the use of a moderately- sized conical steel sound, well warmed and oiled, and introduced with the utmost gentleness. The time for reintroduction will depend upon the duration of the effect of a single use of the instrument. If there is prostatitis or cystitis, the instrument will aggravate the local condi- tion; if neuralgia, its gentle use will always be followed by comfort, and the relief will last a variable time. In old subjects it is sometimes necessary at first to reintroduce the instrument every day ; in younger people every second, third, or fourth day, until a cure is effected. The action of the instrument seems to be to blunt the morbid sensibility of the parts by pressure, to improve the circulation by temporarily squeez- ing out the blood, and by putting the irritated muscles lightly upon the stretch. No internal medication can be relied upon in this com- plaint. If the symptoms rise high and approach those of cystitis, a small amount of anodyne by the rectum may be serviceable for a time. When a neuralgic condition of the vesical neck complicates and pro- longs or aggravates an existing organic disease, even here the gentle 240 DISEASES OF THE BLADDEE. use of the steel sound is often followed by marked benefit, although it may temporarily seem to aggravate some of the symptoms. In these cases the sexual element must be attended to in some way, while the best effects are often produced by a cessation from business cares, trav- eling a few weeks in the country, or a course of baths at some watering- place — the character of the water being a matter of small importance. CHAPTEE Xin. DISEASES OF TEE BLADDEE. Acute Cystitis. — Gonorrhoea! Cystitis.— Diagnostic Table of Cystitis of the Neck and Prostatitis— Pathologi- cal Lesions in Cjstitis.— Treatment— Chronic Catarrh of the Bladder.— Atony of the Bladder.— Paral- ysis, Heterologous Deposits, and Tumors, in the Bladder-Walls. TN-PT.AT^nrATTox of the bladder, according to the anatomical portion of its walls involved, is known as — Cvstitis mucosa — catarrh of the bladder. Interstitial cystitis. Peri-oystitis ; epi-cystitis. These varieties, however, do not aemand detailed and separate de- scriptions, since they follow one upon the other as grades of intensity of the same morbid process. Thus, it may be said that no form of blad- der-inflammation can exist alone, except that affecting the mucous coat. Epi-cystitis may do so, but only as a peritonitis involving the outside covering of the viscus. Vastly the greater proportion of morbid causes acting to produce bladder-inflammation in the male exert their influence directly upon its mucous membrane, and consequently the modality assumed by the inflammation is that of catarrh of the free (mucous) sur- face. If, now, from long continuance or great severity of the catarrhal inflammation (formation of ulcers and sloughing), the morbid action should extend deeper and involve the connective tissue of the walls of the bladder, the cystitis at once becomes interstitial, possibly eventuat- ing in abscess. During all this time the catarrhal cystitis keeps up, the interstitial variety being only an extension of the latter. Abscess may form in the bladder-walls, and break externally, without communication with its cavity. Peri-cystitis is the formation of matter in the connective tissue around and outside of the bladder. This may result from an extension of interstitial cystitis, or may, and usually does, depend upon infiltration of urine, or external violence. The diagnosis presents no difficulties. The affection occurs after great mechanical violence to or in the region of the bladder, from infiltration or as a result of long-continued intei> CYSTITIS. 241 Btitial cystitis. In peri-cystitis a point of suppuration will be found sooner or later outside of the bladder. During interstitial cystitis the bladder gradually contracts down, un- dergoing concentric hypertrophy ; its walls thicken enormously, possibly reaching the thickness of an inch. Abscess may form in them ; its cav- ity becomes nearly obliterated, perhaps down to half an ounce ; inconti- nence ensues ; the mass, like a hard, smooth, wooden ball, may be felt in the hypogastrium, or from the rectum, of a size varying with the duration of the disease. It may be as large as a man's first. It is not necessarily very sensitive to pressure, and is smooth and of even hardness on its surface. This condition of bladder-disease is not curable. Its walls cannot be redilated. Palliation is the treatment. Inflammation of the bladder is not found as an idiopathic essential disease ; that is, it does not occur except through the intervention of some cause acting locally. Thus, the effect of cold, so active in produ- cing catarrhal inflammation of certain mucous membranes (conjunctival, Schneiderian, gastric, intestinal), is powerless to excite inflammation in a healthy bladder, however active it may be in kindling an existing coiv gestion, or chronic inflammation, into an acute state. The apparent exception to this rule, found with certain acute diseases, and with paral- ysis from spinal or brain lesions, is explained by recognizing the local effect of over-distention, or of acid or retained (decomposing) urine (Case XXVI.) . Gonorrhoeal cystitis is a complication, not an essen- tial disease. In cheesy tubercle and cancer, as well as in diphtheria, there must be a local deposit in the bladder-walls before cystitis comes on. The nearest approach to an essential cystitis, if it may be so called, is found in that form produced by an overdose of cantharides. This sub- stance has the power of directly congesting the vessels of the neck of the bladder and prostate — and such a cystitis could hardly be called idiopathic. From the foregoing it is evident that acute cystitis does not occur spontaneously, and is an exceedingly rare affection, except as an exacer- bation of already-existing chronic disease, or from traumatic causes, me- chanical or chemical (irritating urine). Chronic cystitis, on the other hand, is very common, so much so that there are few diseases of the urinary passages of which it does not form a part. Chronic cystitis, moreover (unlike many other chronic inflammations), rarely commences as an acute disease, but is chronic from the first, becoming afterward acute, from time to time, by the action of provoking causes. Chronic cystitis, therefore, would naturally demand consideration first, but, for convenience of description, the artificial order is adopted. ACUTE CYSTITIS. The causes of acute cystitis are fourfold : 1. Traumatic, mechanical, or chemical. 16 242 DISEASES OF THE BLADDEE. 2. Extension of inflammation (gonorrhoea, inflammation of prostate, neighboring abscess). 3. Exacerbation of existing chronic inflammation. 4. Specific action of drugs (cantharides). 1. Traumatic Causes. — Any thing capable of doing mechanical vio- lence to the bladder-walls, especially to its mucous membrane near the neck, may occasion acute cystitis. The rough use of instruments, as in crushing stone ; wounds of the bladder-walls by mechanical objects, or fracture of pelvis ; the presence of stone ; pressure of a neighboring tumor. In the last two cases some chronic cystitis always precedes its acute manifestation : mechanical distention from retention caused by stricture, acute febrile disease, coma, or paralysis, acting in conjunction with altered urine ; chemical violence, irritating injections, very acid and concentrated urine — all these act as traumatic causes. 2. Extension of Inflammation. — As in gonorrhoeal cystitis, prostatic inflammation, neighboring abscess. Here, also, chronic inflammation, perhaps of short duration, appears first. 3. jExacerbation of existing chronic inflammation from the effect of cold, acid urine, rough treatment by instruments, spontaneous increase of symptoms depending on neuralgia of the vesical neck, a diphtheritic patch of membrane, etc. 4. Cantharides, terebinthinates, etc., acting specifically. Symptom,s. — The symptoms of acute cystitis are the same, whether the affection be primary or engrafted upon an already-altered state of the local circulation. The calls to urinate are frequent and imperative, by night and day. The feeling of relief after micturition is absent. The act is accompanied by smarting pain, with tenesmus. Pain of a heavy, burning character is felt in the perinseum, and above the pubes, radiating thence, perhaps, to the end of the penis, to the loins and back, or down the thighs. The urine contains pus in greater or less quanti- ties, at first evenly distributed through the fluid, then voided as stringy mucus (whence the name catarrh). Portions of bladder-wall may slough from the intensity of the inflammation, in which case the urine contains shreds of sloughy tissue, gases, etc., and has a gangrenous odor. The reaction of the urine, at first acid or neutral, becomes alkaline. Triple and amorphous phosphates are found deposited in excess. Blood appears in the urine in greater or less quantities, perhaps pure and liquid, or in clots. There is rarely a chUl, but fever may run high, with all its ac- companying symptoms, dry tongue, great restlessness, jactitation — hic- cough, if gangrene be present. Mental inquietude, apprehension, anx- iety and distress, are prominent features of acute cystitis, and are never entirely absent.' ' It may be observed that cystitis, when acute, is a much more grave disease than when in the chronic form, especially if it extends from the neck so as to involve the body of the bladder. Toward the end, in a ease which is to terminate fatally, constant but unavailing efforts at urination are a prominent feature. GONORKHCEAL CifcTlTIS. 243 Acute cystitis, from whatever cause, presents the above general group of symptoms, A few words of special detail are necessary re- garding the gonorrhoeal form. GoKOKEHCEAL Cystitis. — This affection comes on during the exist- ence of gonorrhoea, or urethritis, or even of a gleet — if the gleet de- pend upon the stricture — by direct continuation of the inflammation backward upon the mucous membrane. The inflammation is confined to the region of the neck, and does not attack the body of the bladder. It never appears until after the first week of a gonorrhoea, rarely till after the third week, when the urethral inflammation has reached the lower portions of the canal. It is more frequently seen in practice as a re- sult of simple extension of inflammation later in the course of^ the dis- ease. Often, however, a second or provoking cause has been in action, and without its assistance the complication of gonorrhoeal cystitis might have been escaped. These provoking causes are any thing which will irritate the urethra ; the use of alcoholic beverages, sexual intercourse, abortive treatment of gonorrhoea, catheterism, jolting, violent or even sometimes moderate exercise, where the urine is acid, and the patient nervous and excitable. Any of these causes may light up a mild cystitis of the neck in any patient with urethritis. Symptoms. — The symptoms of gonorrhoeal cystitis vary from a hardly appreciable irritability — with congestion — up to the very highest grade these symptoms (of irritability) can assume, with a tenesmus so constant as to amount to actual incontinence, the patient voiding a few drops of blood or milky fluid every few minutes. The tenesmus is par- ticularly painful, although the mere passage of urine is often attended by great pain. The pus, or blood, flows most abundantly at the end of the stream. A noteworthy feature of gonorrhoeal cystitis is the absence of general phenomena. Fever is sometimes inappreciable, and rarely runs high. Anxiety, malaise, and nervous distress, are, however, dis- proportionately prominent. Constipation is habitual. The urethral discharge becomes greatly lessened, or even disappears on the advent of the bladder-symptoms ; as the latter disappear, however, the former returns. The habitual duration of the malady, suitably treated, is four or five days for mild cases, a fortnight for the more severe. As a rule, no functional disturbance is left behind by this affection, nor does it predispose to any more serious lesion of the bladder's neck or vicinity. The only affection with which gonorrhoeal or other acute cystitis of the neck is liable to be confounded is prostatitis. The two may be not infrequently combined, but, when separate, the distinction is easy. The following comparative table, from Fournier,' shows the characteristic differences : ." " Diet, de M«d. et de Chir." 24:4: DISEASES OF THE BLADDER. Cysiitw of tTie-Neek. ProsiatUis. 1. Charaoteristio yesical tenesmus, fre- 1. Much less vesical tenesmus. Eectal quent uneoutToUable calls to urinate. tenesmus more marked. 2. Micturition particularly painful dur- 2. Nothing- similar, ing the passage of the last drops of urine, when there is a convulsiTe contraction. 3. At the end of micturition excretion 3. Nothing similar. Urine normaL of a thick fluid — a mixture of pus and blood — often a flow of pure blood. 4. Simple perineal sensibility ; pains ir- 4. Perineal pains deep, very violent, in- radiating toward the anus much less vio- creased by movements, by defecation, etc. lent than in prostatitis. 5. Prostate normal. 5. Eectal exploration reveals a prostatic tumor — hard, very painfiil, etc. 6. No retention of urine. 6. Dysnria, retention of urine. 7. Slight or no general symptoms. 1. General symptoms well marked ; fe- ver, anorexia, etc. That form of cystitis produced by cantharides is really a strangury. Great congestion of the vessels of the bladder's neck exists mth con- stant tenesmus. It is rare to meet cases of this kind at the present day. Older authors refer to them produced by the administration of " love-potions " by " witches." Constant priapismus accompanies the tenesmus, and the result in the worst cases may be sloughing of the penis, and death. The pathological changes produced by acute cystitis upon the blad- der-walls and its membrane are, briefly, capillary injection of the mucous surface, changing the pale, salmon-tint into a brilliant crimson, the color being perhaps uniform, perhaps in patches, with a more or less punctate appearance. There may be ecchymotic spots, purple-colored patches mixed with the red. The mucous membrane is softened and swoUen. These changes usually commence at the neck and often remain limited to this locality, but may extend over the whole internal surface of the bladder. The glandular foUicles near the neck become involved, en- larged, and surrounded by a red areola. In certain high grades of inflammation, the membrane may be ulcerated, or patches of false mem- brane encountered. This croupous character has been especially ob- served in the cystitis caused by cantharides. True patches of diphthe- ritic exudation have been observed secondarily in the bladder. There may be sloughs of the mucous membrane, or of more or less of the thickness of bladder-walls, or interstitial thickening, with or without abscess (interstitial cystitis), or abscess around the bladder, in which case there will probably be more or less peritonitis. With these evidences of acute cystitis may be mingled the marks of older chronic inflammation ; such as a thickened, condensed, tough structure of the mucous membrane and bladdei>walls, colored in purple and red or of a bluish-gray, slate-colored tint; trabeculization, saccula- CHRONIC CYSTITIS. 245 tion, ulceration, perhaps pus in or around the bladder-walls ; possible gangrenous patches; the mucous membrane may be incrusted with urinary salts, etc. Treatment. — The treatment of acute cystitis from any cause-=— gon- orrhoea as well — is always the same. It rests firmly, as already indicated for prostatitis (p. 308), upon the tripod of rest in bed, with elevation of pelvis ; alkaline diluents ; enough anodyne to relieve pain and tenesmus. To these may be added local application of heat. If there be any remov- able cause (presence of a catheter tied into the bladder), it should be taken away. If the cause be stone or a foreign body, no attempt should be made to remove it until the intensity of the inflammation has been quieted by the means above alluded to. If cantharides, turpentine, or cubebs, is being taken by the patient, it should be discontinued during the acute stage of the affection, to be resumed in the subacute stage. Copaiba sometimes works wonderfully well in quieting acute symptoms, but it cannot be relied upon. Asparagus should not be eaten by a pa- tient with acute cystitis ; common salt, strong coffee, and lemon-juice, should be also avoided. There is no occasion for any local or general ab- straction of blood, but the medicines and measures detailed at pages 302- 303 should be studiously enforced. If the cystitis be a strangury from cantharides, plenty of opium — or camphor in emulsion — and a very free use of diluents, must be relied upon. In all cases repeated use of a full hot bath has a soothing effect — or of the hip-bath. The rectum should be kept free by copious warm enemata, and opiates should be given by ' the rectum and not the mouth. Absolute rest, with the hips raised, and alkaline diluents, alone suffice in mild cases. If abscess form in or around the walls of the bladder, an opening should be made externally through the hypogastrium, rectum, or perinseum, at the earliest possible moment, to prevent perforation of the mucous membrane, and the pos- sible danger of infiltration. The key to the treatment of peri-cystitis is to open abscess wher- ever it tends to point, making the opening carefully and very early. CHRONIC CATABBH OP THE BliABBEB. Of all the affections to which the bladder is subject, chronic catarrh holds the first rank in regard to frequency. It never occurs as an idio- pathic affection, but is invariably a secondary result arising from other morbid conditions of the urinary passages. Once started, it does not tend to get well spontaneously, but to become slowly and steadily worse. Fortunately, its causes are well knovra, and most of them easy of dem- onstration. Many of these can be removed, and vnth them the chronic inflammation which they keep up. Some cases are incurable on account of permanent structural alterations in the bladder-walls, or where the cause cannot be reached. All, however, may be benefited by careful 246 DISEASES OF THE BLADDER. and judicious management, and there are few abnormal conditions of the body whose amelioration is attended by more satisfaction on the part of the surgeon, or more gratitude on that of the sufferer. Causes. — Almost all the organic diseases of the urinary passages are attended, during some part of their course, by more or less chronic catarrh of the bladder ; so much so, that a study of the altered condition of the bladder forms a part of the picture of the disease, and has to be con- sidered with it. Hence most of the varieties of chronic catarrh are dis- posed of elsewhere under the heads of other diseases. For their study the reader is referred to the proper section (stone, stricture, prostatic disease). All causes of chronic vesical catarrh may be arranged under two grand heads : 1. Mechanioal, mcludhig obstructive prostatic and urethral diseases, stone, morbid growths in the bladder or rectum, or around the bladder, hernia of the bladder, extrophy, retention of urine, sudden taking off of the pressure of accumulated urine from an habitually over-distended bladder, neuralgia of the vesical neck. 3. Chemical. Very acid urine (rarely), frequently decomposing, alka- line urine, from the liberated ammonia ; urine containing pus, from pye- litis ; atony, paresis of the muscular coats and true paralysis, inasmuch as they invariably tend to produce decomposition of the mine by stag- nation. Many, in fact most cases of chronic cystitis, result from the com- bined action of both mechanical and chemical causes. In obstructive disease from stricture, or large prostate, added to the mechanical stretching, the chemical action of the decomposing tuine is always at work. The same may be said of retention. Eetention alone, in a healthy bladder, will not necessarily cause cystitis, although it may do so from the mere mechanical violence done by stretching. The constant sUght violence due to voluntary retention pushed beyond a normal Umit, and often repeated, wUl eventuate in cystitis. The same holds good of the sudden but extreme retention occurring in coma, shock, the acute fevers, etc., if it be not relieved. In these conditions of unconsciousness, or delirium, the well-informed physician is always on the lookout for the state of the bladder, frequently palpating and percussing the hypo- gastrium to see that aU goes well. It is very gratifying, in these cases, to observe the instantaneous relief which maybe afforded by inserting a soft catheter, and emptying the over-distended bladder. Even if Over- flow has come on, the regular use of the catheter, preventing prolonged over-distention, may avert the impending cystitis and atony. Yet, in practice, not a few cases of cystitis will be found, to take their origin in retention during fever, or unconsciousness, not promptly recognized. On the other hand very acid, or even slightly decomposing urine, would not excite inflammation in a bladder unless its circulation and tone were already impaired, as by atony, paralysis, etc. Finally, one other causative CHRONIC CYSTITIS. 247 factor of cystitis deserves a word ; namely, extension of chronic inflam- mation backward from a urethra or prostate already chronically in- flamed. Of the two sets of causes the mechanical not far more frequently, the chemical usually coming in to assist them in their work. Chronic cystitis, from mechanical causes, is disposed of elsewhere (stricture, hypertrophied prostate, inflammatory, tubercular, cancerous or other prostatic disease, cystitis from stone). Traumatic violence in the bladder, as elsewhere, is attended by inflammation. Morbid growths in or around and pressing upon the bladder, cause chronic cystitis by obstruction to free escape of urine, by calling an extra amount of blood to the part, and by the mechanical bruising which the bladder-walls sustain against them. Again, the tumors themselves may inflame, or their discharges cause decomposition of the urine, thus exciting chronic catarrh. In hernia of the bladder there is mechanical obstruction to circulation, with distention, and de- composing urine. In extrophy there are friction with clothing, exposure to the air, and mechanical obstruction to circulation. A bladder gradu- ally accustomed to habitual over-distention may give its owner no ap- preciable annoyance, but the mechanical stretching here has modified and weakened the cireulation of the part, and produced atony, and when all the tension is suddenly let up^ and the bladder allowed to col- lapse, the blood is very apt to rush suddenly into and over-distend the weakened vessels, and result in a condition of inflammation, the type of which, however, at first, is more often acute than chronic — and grave at all times. In long-continued neuralgia of the vesical neck, the mechanical, act- ing cause is the constant and continued bruising of the bladder-neck, by often-repeated, perhaps violent and spasmodic contractions in micturi- tion. Added to this sufficient cause is a second one, namely, an ex- tension of congestion backward from the engorged membrane of the prostatic sinus. The chemical causes conducing to cystitis have been alluded to in con- nection with over-distention of the organ (stricture, enlarged prostate). Very acid urine rarely causes cystitis, being more apt to produce urethral inflammation ; acting, however, upon an already-congested bladder, it always tends to heighten the grade of the congestion or inflammatory process. Decomposing urine will sooner or later light up cystitis, on ac- count of the irritating properties of the ammonia which it evolves, and in atony or paralysis there would be no cystitis without the action of this cause (Case XXVI.). The irritating properties of pus alone are sufficient to occasion symptoms of cystitis, as when the pus is derived from the kidneys in pyelitis. Attention is especially called to this fact, because it is often overlooked. The patient complains of frequent pain- ful micturition, and the urine is loaded with pus. The seat of disease r|.J.s DISEASES OF THE BLADDER. is located in the bladder, and tMs organ is tormented by the use of in- struments, or worried by useless stimulating injections — the true source of the pus (pyelitis) being overlooked. Symptoms of Chronic Cystitis. — The symptoms of chronic cystitis resemble those of the acute form, in a degree proportionate to the grade of the inflammatory process. There may be only a little increased frequency of urination, with slight cloudiness of the fluid, as seen in the history of enlarged prostate ; or the calls may be very frequent, and the pains excessive, varied, and constant, as in the acute disease. In fact, chronic cystitis is liable at any time to be Kghted up into an acute state by the continued action of its own cause, or by the supervention of others (effect of cold, violent exercise, abuse of alcohol, acid urine). The urine of chronic cystitis always contains pus, either freely suspend- ed through the fluid, or, more often, in gouts and clots of stringy muco- pus, more or less mingled with crystals of triple phosphates and with blood. Pus which is passed in the liquid state may become converted into " stringy mucus," while standing, by the alkaline decomposition of the urine, or the process may be imitated artificially in a test-tube, by adding ammonia or liquor potassee to urine containing free pus. The latter immediately becomes translucent, coherent, and is indeed the substance commonly called " stringy mucus." The special symptoms attending chronic cystitis are enumerated un- der the heads of the causes occasioning them, and need not be repeated here. Treatment. — Chronic cystitis being an affection always entertained by some other morbid process, its treatment consists in the removal of the cause. Some of these causes are removable, others are not. In the latter case the treatment is palliative, and addressed to symptoms. After the removal of the cause the chronic cystitis will get well in early life, or at any age, imless there has been organic, permanent change induced in the bladder-walls (hypertrophy, sacculation). For these lat- ter cases, or where the cause cannot be removed, the palliative treat- ment is as follows: For acute exacerbations, the same as for acute cystitis, based on the tripod attitude, alkali, anodyne ; for the forma- tion of abscess in or around the bladder-walls, besides the above, an early and carefully-made opening ; for the continuous chronic state the treatment consists in keeping the lu-ine, as it comes from the kidneys, slightly alkaline, washing out the cavity of the bladder with warm water, then with medicated injections (p. 197), if an instrument can be mtroduced ; and in the use of a small amount of anodyne in suppository it night, when the pain is great. The balsam of copaiba, cubebs, tui^ pentine, and the infusions of buchu, triticum repens, uva-ursi, flaxseed, etc., may also be sometimes of use. The value of counter-irritation oyer the hypogastrium must always be kept in view. These means, aided by as much rest as is consistent with health, change of air, and ATONY. 2i9 hygienic details in regard to food, etc., will efifect all the relief that can be afforded. Where there is an element of neuralgia of the vesical neck in the case, it must be suitably treated (p. 339). The peculiarity of chronic cystitis, dependiog, as it always does, upon some other morbid condition, renders its special description unsatisfactory, and begets a ne- cessity for constant reference to the other affections which underlie it. Cystotomy for Chronio Cystitis.— Dr. Robert Battey, of Georgia, reports' a case of cystotomy performed as a last resource upon a patient with chronic cystitis, with the effect of aifording much immediate relief, and prolonging life (he believes) for eighteen months. Dr. IngaUs, of Chicago,' states that Dr. Powell performed this opera- tion in 1866, and thereafter with good general effect, the wound being allowed to heal as after the operation for stone. In many cases it is only temporarily of service. It might be finally resorted to after the failure of other means, but with doubtful prospects of any permanent good effect ; sometimes there is no relief, and often the trouble returns at once with the healing of the wound. ATOmr OF THE BLADDER. Atony of the bladder is, as the name implies, simply a lack of tone in the organ. It is muscular paresis, and it is to be widely distinguished from paralysis, an affection of central and not of local origin, with which disease it is commonly confounded. Truly, a stretched muscle which wiU not contract is paralyzed ; but, to avoid confusion, the term atony must be retained, paralysis only being applied where there is nerve- lesion. Every bladder suffers in a mild degree from what may be called physiological atony as the individual grows older. A healthy boy can throw a stream from his bladder to a much greater distance than he can when he becomes an adult, even taking into consideration the increased size of the prostate and enlarged calibre of the urethra, and the same remark holds true of adult life, when compared with healthy old age. The bladder being accustomed to a constant, slight distention, loses its expulsive power measurably with advancing age. Besides this mild condition of atony, however, there is a pathological form due to over-stretching of the muscular coats, either gradual and continued, or sudden and extreme (retention), or to constant congestion, as with hypertrophied prostate. Any one may observe the phenomenon of atony in his own person. If the urine be voluntarily retained for some hours after the bladder is full and the natural desire felt, it is noticeable, when an opportunity presents itself, and an attempt is made at passing water, that it is necessary to wait some time, perhaps several minutes, before the stream begins to flow. When it comes, it com- mences very gradually, and without force, getting stronger as the flow ' Medical Companion, June, 1869. ' Medical Record, December, 18'?2. 250 DISEASES OF THE BLaDDEK. continues; finally, the last drops dribble slowly away. This is the mildest pathological degree of atony, and is caused by a paresis of the over-stretched detrusor urinse. In men of sedentary habits, or those engrossed by absorbing occupations (students, actors), where the calls of nature are habitually disregarded, this slight degree of atony, often reproduced, may finally lead to a permanent lack of the expulsive power. Sometimes actual retention may come on, starting in voluntary retention, the bladder having lost its tone so far as to refuse to contract when an opportunity offers. Passing water habitually in the recum- bent position, while lying in bed, is believed to be an occasional cause of atony. Predisposing circumstances are general weakness and laxity of the body. In some cases there seems to be a normal predisposition to this condition, while in others fatty atrophy may induce it. The form of atony occurring with hypertrophied prostate does not necessarily depend upon mechanical overstretching. It is due to the constant congestion of the hypertrophied muscular coats of the bladder, kept up by the obstacle to the return-flow of venous blood from the bladder-walls, formed by the size of the prostate. With this cause, a certain degree of continual distention of the bladder-walls often goes hand in hand, and, where there has been retention, this circumstance takes its place as the most prominent cause. Often, atony, from overstretching, owes its origin to retention of urine occurring in the course of acute disease (typhoid, variola), or temporary loss of sensibility (coma, concussion, compression) not rec- ognized and relieved ; or, most frequently, to retention complicating stricture in the young, enlarged prostate in the old. Nervous influence has no necessary connection with atony. The injury is mechanical ; the overstretched detrusor urinse loses its power, and is unable to expel the urine. Symptoms. — The symptoms of this affection have been considered under the heads of its most constant causes, stricture and prostatic hypertrophy. To recapitulate for all cases: in complete atony, the expulsive power of the bladder being lost, the viscus fills up, and we have the condition named by Civiale " stagnation with overflow." The excess of urine, after the bladder has held all that it can, as a passive sac, flows over, upon some muscular effort of the patient (sneezing, violent coughing, laughter), or trickles passively away. In many of these cases of stagnation with overflow, the bladder is patient, and holds, perhaps, two or three pints constantly, without giving its owner any considerable uneasiness. TThat little excess collects over this amount occasions the normal desire to urinate. This is effected by voluntary contraction of the diaphragm and abdominal muscles, and perhaps an ounce or more of fluid is ejected in a dribbling stream. This brings relief for an hour, when the effort is repeated, with a like result. Such patients are apt to complain that their bladder is so smal] ATONY. 251 that it will only contain a few drops of urine, after the collection of which they are obliged to empty it, which they believe they do. Par- ticularly are these frequent calls pressing, if, as is very apt to be the case, there is some cystitis along with the atony. AH the signs of an over-distended bladder are present with complete atony. The crucial test is the introduction of a catheter. As soon as the eye of the instrument reaches urine, the flow through the tube com- mences. It does not spurt out as from a normal bladder, but drops down nearly perpendicularly from the end of the instrument. A cough or a long breath will make it flow faster, as will also, very materially, pressure of the hand over the hypogastrium. Operations on the bladder seem sometimes to induce atony (perineal section, lithotrity). Treatment. — The object of treatment of atony is to attempt to restore contractile power to a muscle which has been overstretched. The first indication is, obviously, to keep the muscle from any further violence, by catheterization performed three or four times daily. In the young we may always hope for a cure ; in middle age for amelioration ; but in old age with enlarged prostate the injured muscle rarely recovers its tone — nor, indeed, is it very desirable that it should do so. Besides keeping the bladder from being again distended, we have a very effective means of hastening the return of the contractile power by the employment of cold injections into its cavity. If there be much cystitis with the atony, the cold should be used sparingly, but otherwise the bladder should be filled at each sitting with several successive injections, commencing at the first sitting with water of 90° Fahr., after this has flowed out, following with water at 85° Fahr., and a third time at the same temperature — never more than four ounces of fluid being thrown in at one injection. The water may be retained from one to two minutes, and then be allowed to drain off. This process may be repeated daily, starting at a temperature 5° Fahr. lower at each sitting and pro- ceeding as directed above. Water may be injected as low as 40° Fahr., but it should be allowed to run out again immediately. It acts as a local douche, and is powerful for good in youth and middle life. This treatment may be continued for months, and it will yield good results if any such are possible. The cold douche applied to the hypogastrium, sacrum, and perin^eum, is a good adjuvant to the injections. Local appli- cations of electricity may also be employed, an insulated electrode being carried into the bladder, and the current passed directly through its walls to the other electrode in the rectum, or to a moistened electrode over the hypogastrium. No internal medication is of any service, unless possibly a mild alkali to keep the urine from exciting cystitis, or perhaps a little cantharides, strychnine, or ergot, for its specific effect. Tonics and general hygiene may be necessary in special cases. 252 DISEASES o:b the bladder. PAKAIiYSIS OF THE BLADDER. As atony is common, so is true paralysis of the bladder uncommon. It occurs only in connection witli nerve-lesion, or rarely as a functional nervous affection (reflex urinary paralysis, Brown-S^quard). The causes of paralysis of the bladder are brain-disease attended by hemiplegia (rare), partial paralysis from reflected peripheral nervous irritation act ing through the spine (exceedingly unfrequent), any disease or affection of the spinal cord (inflammatory, apoplectic, syphilitic, cancerous, from pressure. Pott's disease, fracture of spine, tumor), especially if such spinal disease be attended by paraplegia, partial or complete. This latter set of causes, which may be summed up in the one word para- plegia, is by far the most active and efficient. Vesical paralysis may come on gradually, as sometimes in Pott's disease and in certain syphilitic paraplegia, or (most commonly) suddenly. In the former case the bladder discharges its contents from day to day more feebly, the change taking place perhaps so gradually that the patient does not notice it. Soon some of the urine is retained, only an excess over a certain fixed quantity being voided. This residuum goes through the changes of stagnating m-ine, and by decomposing lights up cystitis, the more readily on account of the weakened state of the bladder-walls due to impaired innervation. The patient now notices that his urine smells badly, is more or less muddy, perhaps full of thick, ropy mucus, and that he has frequent calls to urinate. Perhaps the paralysis may go no further, but the cystitis will continue to be steadily progressive unless arrested by appropriate treatment. On the other hand, the paralysis may go on to become complete, when retention will at once appear. Very rarely there is paralysis of all the muscles and true incontinence results; but this is so exceptional that it may be said not to occui^ Most commonly, as the paraplegia comes on suddenly, so also does the vesical paralysis, and a bladder, at a given moment perfectly healthy, becomes at once incapable of contraction. Retention ensues, the urine over-distends the bladder and then overflows, dribbling away. The bladder becomes inflamed by the decomposing retained urine, pus, stringy mucus, earthy phosphates, vibriones, triple-phosphate crystals abound. The weakened bladder-walls may ulcerate extensively, or be- come incrusted with earthy salts, or stone may form. It is in some such deplorable condition as this that the bladder usually first receives surgical notice and attention, whereas the whole list of symptoms might have been avoided (except the loss of contractile power) by the applica- tion of the proper means at the proper time. Treatment. — When a patient, from any cause, becomes wholly or partly paraplegic, his bladder should not be allowed to become distended. The catheter should be passed soon after the accident, and reintroduced three or four times daily, always with great care, on account of the PARALYSIS. 253 insensibility of the parts, and the danger of lighting up cys'titis mechan- ically. At the same time the bladder should be thoroughly washed out with warm water, once or twice after each introduction of the catheter. Colder water may be used later, but this remedy, so useful in atony, has little power over true paralysis of the bladder ; on the contrary, it may do harm. "Warm water is used simply for purposes of cleanliness, to take away the ferment, mucus, and to prevent cystitis. This can be done, probably, in every case that is properly managed. The following case illustrates the point : Case XXTI. — ^A gentleman of forty-five had an apoplectic effiision into the spinal cord, which -was followed by immediate paraplegia and total paralysis of the bladder. The catheter was passed within six hours after the attack, and subsequently three times daily. Tar-water was used as an injection into the bladder. The tIscus was kept clean, and was never allowed to become over-distended. Two years afterward his condition was as follows : There was total paralysis of the gastrocnemii and solei, with wasting of the calf, and some wasting and lack of power in the other muscles of the leg and thigh. The bladder was paralyzed, so that no drop of urine could be passed without the catheter, and the stream flowed perpendicularly from the end of the instrument. The rectal sphinc- ter was paralyzed, so that the bowel protruded, unless retained by a pad. Yet there was no cystitis. The urine had a specific gravity of 1020, was acid and clear when passed, and continued acid after standing thirty-six hours. There was no excess of mucus, and no pus except a few little clusters of pus-corpuscles visible to the eye, and evidently com- ing from the urethra, caused by the constant use of the catheter. The patient had no frequency of desire to pass water. AU this was two years after the oceurrence of the paraplegia, a period evidently long enough to establish cystitis, if it were a necessary consequence of the paralysis. Here the prompt passage of the catheter, and its subsequent use, which prevented stagnation, together with the injections to keep the bladder clean — for the tar-water was no better than simple water — averted catarrh of the bladder. Where the patient is not seen until stagnation and overflow have oc- curred, it is more diflScult to keep down the inflammatory outbreak, but the sooner it is attempted the more chance is there of success. After catarrh of the bladder has become thoroughly established, the treatment becomes mainly palliative, but even here much can be done by the sys- tematic, regular use of the catheter, with thorough washing of the blad- der, first with warm water, and then with borax, or other mildly stimu- lating injection, as directed in cases of catarrh, with atony and enlarged prostate (p. 198). Chronic cystitis being, as has been shown, a secondary disease, the main reliance of treatment, in any case, consists, after the removal of the cause, in the surgical measures already enumerated, injections into the bladder, medicated or otherwise, position, and external counter-irritation. The terebinthinate and stimulating diuretic drugs habitually employed, though of service in certain selected cases, are of far inferior importance. The value of these drugs is secondary, and is greatly overrated by the profession ; they do more good as diluents than by any specific virtue, and, being generally combined with anodynes, the reputation which they 254 DISEASES OF THE BLADDER. enjoy is really more often due to virtues of these latter than to any spe- cial power of their own in controlling vesical sj'mptoms. HETEBOLOGrOTTS DEPOSITS AND TUIVEORS IN THE BLADDEE-WALLS. The bladder is rarely the seat of any foreign growth, yet certain deposits and tumors are found here. These are (a) cheesy tubercle, (5) fibrous growths, (c) cysts, (d) cancer, (e) villous tumor. These different new formations cause symptoms more or less severe according to their situation and size. Thus, by pressure on a ureter, they may lead to distention of that canal and of the pelvis of the kidney, with (possibly) final rupture of one or the other, or atrophy of the se- creting portion of the kidney. Again, the growth may be near the neck of the bladder, presenting an obstacle to the escape of urine, which may even lead to complete retention ; whUe, on the other hand, if it springs from the fundus away from the sensitive portions around the neck, it not only does not oppose any obstruction to the free outflow of urine, but, in exceptional cases, may give rise to little if any cystitis. Some of these tumors, again, become engorged with blood from motion or other cause, and then all the symptoms are aggravated. TVhen a free flow of blood takes place, the symptoms remit and the patient feels better. The above remarks apply to the whole category of foreign growths taken together, and to no particular class. (a.) Cheest Tctberclb. — Tubercle of the bladder does not occur as an isolated affection. It is not very often encountered in connection with pulmonary tuberculosis, but comes on more frequently with tuber- cular ulcerations of the intestines, and is especially common with similar disease of the kidney or prostate, or even with advanced tuberculariza- tion of the testicle, cord, and epididymis. The glands and follicles, usually, near the neck of the bladder and orifices of the ureters first suffer. Groups of little whitish elevations, surroimded by a red areola, may be seen at first, and these, going on to increase, coalesce and break down into cheesy degeneration and ulceration, sometimes leading to perforation of the bladder. The diagnosis is mainly made by exclusion. The bladder-symptoms are simply those of chronic cystitis, more or less severe according to the situation of the deposit. There is rarely much blood in the urine. The exploring sound may sometimes detect the ragged ulcerations and appreciate the thickening of the bladder-walls. Beyond this, explora- tion is usually negative ; no tumor is felt either by the sound in the blad- der, or by rectal or hypogastric palpation; while the debris of tissue found in the urine has no distinctive characters. The diagnosis usually rests upon the general condition of the patient, and the state of the whole genito-urinary apparatus. Advanced phthisical disease elsevrhere, of the lungs, intestines, etc., but particularly of the epididymis, with a TUMOKS— CYSTS— CANCEK. 255 ridgy, knobbed feel of the seminal vesicle and vas deferens of the same side, especially if there is evidence of prostatic trouble, and above all, any suspicion of tubercular pyelitis — any of these concurring symptoms makes the diagnosis probable, while all of them would make it certain. The disease occurs most frequently in youth and early adult life. They are always serious, generally desperate. Treatment. — The treatment is the same as for phthisis elsewhere — proper warmth, fatty food, fresh air, outrdoor life, tonics, etc. Locally, anodyne suppositories, if pain be great, rest, alkaline diluents ; finally, syringing the bladder with warm water occasionallj', unless the introduc- tion of the instrument produces too great pain. These patients rarely recover. (5.) FiBEOtrs TuMOES. — These tumors are not common, but occa- sionally one or more of them are found in the bladder, where they give rise to trouble mechanically, being perfectly benign in character, com- posed of connective-tissue elements, growing in and from the submu- cous connective tissue. They appear first as slight elevations. These enlarge and grow into the cavity of the bladder, sometimes becoming pediculated. They are to be distinguished from the irregular polypoid overgrowths from the posterior urethral orifice of the prostate, and from supernumerary prostatic tumors. Symptoms. — Careful sounding with a Thompson's searcher, or, per- haps better, a lithotrite, may detect the position, size, and perhaps the number of the tumors. The recent method of exploration introduced by Simon, of Heidelberg, namely, by a hand introduced into the rectum whUe the patient is ansesthetized, might be tried in obscure cases. The rarity of blood in the urine distinguishes them from villous growths. The amount of cystitis is usually not so great as in tubercle, while the oachexia and occasional profuse bleeding of cancer are wanting. Chil- dren and young adults are most liable to be affected. Treatm,ent is palliative — alkaline laxatives, anodyne suppositories if necessary, warm washing of the bladder, use of catheter, etc. (c.) Ctsts are rare in or around the bladder, but occasionally they are found. They sometimes contain bone, teeth, muscle, and hair, which occasionally find their way by ulceration into the bladder, and constitute nuclei for stone, or give rise to pilimiction.' Hydatid as well as simple cysts have been encountered. A striking case of cyst of the bladder is reported by Listen." The diagnosis was made with the aid of a catheter, which was being passed for retention. The instrument struck against a soft, movable mass at the neck of the bladder. Listen decided to perform epicystotomy at once, and removed a large cyst very like the bladder in volume, form, and appearance. (d) Castcbe is rare in the bladder, but stiU it is more common than benign forms of tumor, or other foreign growths not inflammatory. It ' " Memoire de la Soc. de Biologie," 1850, Kayer. « Medical Times, August, 1862. 256 DISEASES OF THE BLADDER. may originate in the bladder, but more often is an extension of disease from the prostate or bowel. When occupying the bladder it may grow from any portion of the walls, but usually springs from near the neck or orifices of the ureters. Different varieties of cancerous growth have been encountered. The encephaloid (soft) cancer is by far the most common. Scirrhous and the epithelial are less frequently observed ; col- loid cancer has been seen. The cancerous nodules develop imder the mucous membrane in the walls of the bladder, and often grow to the formation of a considerable tiunor. Encephaloid, especially, may grow out in a fungous manner, until it fills the whole cavity of the bladder. Cancerous growths go through the same phases here as elsewhere, finally ulcerating and destroying life by loss of blood or cachexia, or wearing out the patient by extreme pain. The symptoms vary but little from those of other tumors. There may be the same mechanical obstruction to the escape of urine, due to the position of the growth, and calling for the use of the catheter, the same cystitis, more or less intense, according to the position and size of the tumor and the extent of ulceration ; but in several particulars the symptoms of cancer in the bladder are special, and the diagnosis more easy than for other tumors. The pain is more severe, is referred to the back, loins, and thighs, as well as to the pubic and perineal region ; en- larged glands may sometimes be felt along the brim of the pelvis. The bleeding is usually intermittent in character ; at first there may be long intervals of months between the paroxysms. The blood flows suddenly and profusely, in clots and fluid, attended by great pain. After each bleeding the severity of the symptoms lessens. Between the attacks there is more or less oozing, sometimes enough to keep the urine con- stantly red ; sometimes, during the earlier months of the disease, only to be detected by the microscope. The introduction of a catheter is very apt to occasion haemorrhage, and should be avoided as much as possible. Sometimes slu-eds of tissue, projecting from the borders of an ulcerated, cancerous nodule, will be caught in the eye of the catheter, and be pulled away. The microscopic examination of such shreds maj sometimes throw light upon the nature of the tumor. In the middle and later stages of the disease the cancerous cachexia may be marked, and the bleeding more constant and profuse, while the intervals between the paroxysms will be shorter. Finally, in scirrhus, the hardness can be felt by the finger in the rectum, and in the common form of cancerous disease, medullary, the size which the mass attains renders it nearly always easy of detection long before it has advanced far enough to be fatal. This growth has been mistaken for enlarged prostate. Its gen- eral size, shape, and position, may be studied out with the searcher, while the finger in the rectum will sometimes recognize a peculiar, soft, semi-elastic tumor behind the prostate, and be able to appreciate press- ure made upon the tumor above the pubis. Cancer, here as elsewhere, VILLOUS GROWTH. 257 IS a fatal disorder. The treatment is purely symptomatic and palliative, keeping up strength by all known tonic and hygienic means, and using the same sedative and local treatment as for other tumors of the blad- der, employing special means as they are required by special cases. Opium ranks first in usefulness. («.) Villous Geowth. — There is a peculiar growth encountered in the adult bladder, known as villous tumor. It occurs less frequently than cancer, but perhaps more frequently than fibrous or cystic tumors. It has been considered malignant, but can lay claim to the title on no score except that it often kills. It is a soft, pulpy body, growing to the size of a nut, constituted by innumerable villi, which branch off in every direction, are attached to the submucous connective tissue of the blad- der, are identical in structure with the villi of the healthy chorion, and are exceedingly vascular. Several tumors may coexist in a single blad- der, or a portion of bladder-surface may be found velvety, from being covered by small villous processes similar to those on the tumor.' The most usual site for these tumors is the base of the trigone, between the orifices of the ureters. There is nothing cancerous about their structure. Tlieir cause is unknown. They never lead to secondary cancerous de- posits elsewhere. They do not spontaneously ulcerate. The lymphatic glands are not implicated. There is no characteristic cachexia. When they kill, death seems due purely to loss of blood and exhaustion from pain. The symptoms of villous growth are like those of other vesical tumors, except that they are less often obstructive, and that the urine has blood in it almost constantly. No tumor can be felt, as the mass is too soft to be recognized either by the finger in the rectum or the searcher in the bladder. Sounding almost invariably aggravates the symptoms, and gives rise to a fuller supply of fresh blood. Shreds of the tissue sometimes come away with the urine, and may show char- acteristic appearances under the microscope. The structure of the growth is simply an enormously wide, thin-walled vessel, curved on itself to form a loop, and covered by three or four layers of cylindrical epithelium, seemingly placed directly upon it.' The suffering is often intense, and vesical tenesmus very marked. The treatment is mainly palliative — opium suppositories, internal hfemostatics (?) and mild astringent solutions (acetate of lead, nitrate of silver, tannin) injected carefully and tentatively into the bladder. These, with hygiene and rest, are all the relief that art at present afibrds. In desperate cases an attempt might be made to open the bladder and remove the tumor, cauterizing its base. The diiEculties attending such an operation do not need description to be realized. In favorable cases pediculated tumors of this sort have been successfully removed, and have not returned.' ' "Lectures on Pathological Anatomy at Guy's Hospital," 185V and 1858, Samuel Wilkes, 1869, London. « Kindfleisch, "Pathological Histology." ^ Ibid. 17 258 STONE IN THE BLADDEK. CHAPTEE Xiy. STONE IN TEE BLADDER. Materials of whicli Calculi are formed. — Causes of Stone, internal and external. — ^Number. — Size. — Shape. — "V^eight. — ^Degree of Hardness. — ^Possible Consequences of Stone, including: Symptoms, Pathology, and Modes of Death. — Symptoms considered in relation to Diagnosis and Selection of Mode of Core, — Sounding. — Circumstances prejudicial to a Choice of Lithotrity, The presence of a foreign body in the bladder is recognized by common consent as the cause of the most painful suffering to which humanity is liable. The foreign body in the great majority of cases is generated entirely within the urinary passages, most frequently in the kidneys ; sometimes it is introduced from without, as when such sub- stances as slate-pencUs and hair-pins have been inserted into the urethra, under the influence of morbid erotic impulse, or a bullet, a portion of shell, or fragment of bone, has found its way into the bladder by gunshot- wound. In either case the result is a concretion of stony hardness resulting from the more or less rapid deposit or crystallization of the salts of the urine upon a nucleus, forming what is known, in common language, as stone in the bladder. In ninety per cent, of cases of stone the nucleus has been most probably an aggregation of crystals of m-io acid, which, happening originally in the kidney, has passed, with or with- out attendant symptoms of renal colic, into the bladder, and failed to escape by the urethra. Of the remaining ten per cent, of nuclei, ex- traneous substances constitute, perhaps, the largest proportion, then blood-clots, or other organic products, such as a mixture like mortar, of altered, ropy pus, with a precipitate of urinary phosphates, or an aggre gation of crystals of oxalate of lime from the kidney. As to the subsequent growth of the calculus, there is endless varia- tion, both as to its rate of rapidity and the nature of the materials which serve for its increase. These materials, derived from the saline constituents of the urine, combined wdth an uncertain amount of animal matter — the secretions from the vesical mucous membrane, pus, or blood — are deposited around the nucleus in concentric layers of varying thickness. As the chemical constitution of the urine is liable to con- stant change, the additions to the bulk of the calculus are correspond- ingly uncertain. Calculi consisting entirely of oxalate of lime, which are rare, are slowest of growth; next those composed of pure lithio acid ; while stones of mixed character, in which the concentric layers are formed, according to the constitution of the urine prevailing at the time of deposit, of lithic acid or oxalate of lime, the amorphous urates COMPOSITION. 259 phosphate of lime, or the triple phosphate of ammonia and magnesia, are very common, and of more rapid but uncertain growth. Calculi composed mainly or entirely of the phosphates grow most rapidly and attain the largest size. The phosphatic salts, always present and held feebly in solution in the urine by an excess of phosphoric acid, are liable to be constantly and largely precipitated in the bladder whenever any considerable por- tion of its lining membrane is the seat of suppurative inflammation. The soda of the liquor puris takes the acid away from these superphos- phates, and the residual phosphates are thrown down at once, mostly in the form of an amorphous insoluble powder. Moreover, urine thus de- prived of its normal acidity undergoes more promptly putrefactive fer- mentation, and the ammonia, always generated during this process, effects its peculiar reaction upon pus, when present, converting it into an adhesive, ropy, mucoid substance, a characteristic ingredient in the urine of so-called catarrh of the bladder, to which, indeed, that form of cystitis owes its name. Here we have at once two most important factors in the formation of vesical calculus. The remarkable insolubility of lithic acid,' and of the neutral phos- phates as well, are noteworthy facts in connection with the etiology of stone. The iirates would rarely precipitate or crystallize at the tempera- ture of the body, without a nucleus to invite them. The phosphates, by the aid of mucoid pus, do so more frequently ; the large number of phosphatic calculi often found in the suppurating bladders of old people would seem to establish this fact. Whatever favors the generation of uric acid in the organism would seem, therefore, to serve in some degree as a cause of calculous disease. Gout and rheumatism, undoubtedly, do this. According to Prout, lithic acid is the essence of gout ; '' and gouty subjects are notoriously liable to gravel and calculous affections in all their forms. The occurrence of stone in the bladder, in successive gen- erations in the same family, is thus explained. A tendency to excess of lithic acid belongs also to early life ; it is one of the recognized peculiar- ities of infancy. Cases of congenital stone in the bladder are on record. The frequency of calculous disease in children is thus explained. In Thompson's table of 1,837 cases of lateral lithotomj', 473, or more than a quarter of the whole, were children under five years of age.' At the other end of life, obstructive disease, generally from enlarged prostate, is a frequent cause of stone in the bladder. The conditions are highly favor- able to the formation of stone in a patient suffering from enlargement of the prostate ; the change in shape which the bladder takes on, the catarrhal inflammation of its lining membrane, which almost inevitably sooner or later supervenes, together with the inability to completely evacuate its contents, whether from the obstruction at its outlet, or loss ' From the Greek TdSos, a stone. ^ Prout on " Stomach and Kenal Diseases." ^ Thompson's " Practical Lithotomy and Lithotrity." 260 STONE ry THE BLADDER. of contractile power, or both combined, all favor this result. These circumstances would seem to explain why vesical calculus is more fre- quently encountered at the two extremes of life. In Civiale's table of 5,376 cases of stone in the bladder, 2,314, ornearly one-half, were under the age of puberty — ^the largest number at any one year of life being 321 at five ; while, of the remainder, the next highest number, 18i, occurs at the age of sixty.' Inflammations affecting any portion of the mucous membrane lining the urinary passages would seem to favor the formation of calculous deposit. Stricture of the urethra, for this reason, and also from its obstructive influence, is a recognized cause of stone.' The influence of mineral ingredients in water habitually employed for drinking and cooking, is generally supposed to cause calculous disease ; but of this there is no adequate proot In certain regions of our country stone is very infrequent, as in Xevr England ; " while in Ohio, Kentucky, Tennessee, Xorth Carolina, and Alabama, the disease is not uncommon. It is certainly very rare in the negro.* Without reference to race, the same unexplained tendency to calculous disease exists in certain local- ities in Europe, as in Norfolk, in England, "WOrtemberg, and Moscow ; while in Denmark it would seem to be less frequent. There are no chem- ical or meteorological facts yet determined by science concerning either water, soil, or climate, which would justify an attempt to explain these discrepancies. Disease of the brain or spinal cord, paralyzing the lower extremities and bladder, favors the formation of stone. Here inflamma- tion of the bladder, from stagnation and decomposition of the urine, is the immediate exciting cause. To what extent the coexistent diminution of nerve-power aids in the process is not so clear. There is little doubt but that the free use of animal food and malt liquor, coincidently with excessive fatigue and profuse sweating, is likely to cause a concentrated quality of urine prone to crystallize readily, especially in a healthy child, or in an adult of gouty habit ; and it is not improbable that in a coin- cidence of favorable conditions of this kind many cases of stone take their origin. Civiale expresses the opinion that calculous disease in children not unfrequently dates from such sudden crj-stallization. Foreign bodies introduced into the bladder, from without, become incrusted with the salts of the urine in an incredibly short space of time. A catheter left in the bladder will show deposit on its surface on removal at the end of forty-eight hours, and the incrusted material consists almost entirely of phosphatic salts. Stones which take their origin in this man- ner alwa3-s increase rapidly in size, and they have been met with at all periods of life, except, perhaps, in very early childhood. The late war in this country furnished several examples of bullets, fragments of bomb- shells, etc., which had penetrated the bladder and become nuclei of ' "Traite de rAffection calculeuae," Paris, 183S, p. 646. * I have lithotomized two adults irho were the subjects of stricture. — Yas Bcren. ' Morland, " Diseases of the Urinary Organs," Boston, 1858, p. 387. • Gross on " Diseases of the Urinary Organs," Philadelphia, p. 343. NUMBER, SIZE, SHAPE. 261 stones. Pins, fragments of fish-bones, chicken-bones, and other articles swallowed as food or by accident, liave found their way, by ulceration from the intestines into the bladder, where they have given origin to cal- cuU. Even foetal bones have ulcerated into the bladder from the uterus, and pieces of wood and bone have been forced into the bladder as the result of accident ; and, finally, through recto-vesical fistulse, fruit-seeds, and other hard materials mingled with the contents of the bowel, have become nuclei of vesical incrustation. The most frequent cause of the presence of extraneous substances in the bladder is to be found, unfortu- nately, in the unnatural gratification of the sexual desire. It may be safely assumed that every material substance that could possibly enter the human urethra has been used forthis purpose, and a certain propor- tion of articles so used have found their way into the bladder. ' The short, direct, and capacious urethra of the female, which, by affording to nuclei formed in the body so ready an escape, renders stone in the bladder a rare disease in women, serves precisely an opposite purpose under these circumstances, so that in this class of cases the proportion of females is much larger, evidently because a foreign body can slip through the female urethra and be lost in the bladder much more readily than through the longer and more tortuous passage of the male. Hence, while in the aggregate we meet in practice but one case of vesical calculus in women to twenty in men, it may be confidently asserted that the proportion of cases, in which a calculus has formed on a foreign body introduced from without, is larger in women. There are several other forms of vesical calculus composed of materials existing only exceptionally in the urine, or in quantities so minute as to very rarely form concretions, such as cystine, xanthine, uric oxide, silicic acid, and carbonate of lime, for the study of which we must refer to works devoted specially to the chemistry of the urine.'' Number, Shape, and Size, Weight, aot) Degree op Haedness. — Vesical calculi are usually solitary, of a compressed ovoidal shape, and in size varying from that of a large pea — just too large to escape by the urethra — to a magnitude limited only by the capacity of the bladder. ' I removed a phosphatio calculus of large size, from a man of sixty-seven, at Bellevue Hospital, in 184Y, which had formed upon a head of wheat-straw ; and some years later I operated upon a boy of seventeen, at the New York Hospital, in the centre of whose calculus was found a piece of a slate-pencil, an inch and a half in length, which he confessed to have introduced into his urethra some years before, at school. Within the same year my colleague, the late Dr. John Watson, removed from a young man, at the same hospital, a phosphatio calculus of a shape so curiously elongated as to suggest an unusual nucleus. On section it was found to contain a piece of an ordinary lead-pencil, several inches in length. I have in my possession a phosphatio calculus, sent to me by my friend Dr. Tay- lor, of Memphis, Tenn., removed from a woman, in which the calculous matter is deposited around a fragment of allhoa-root, four inches in length, and converted into a brush at one end — an instrument used by a certain class of women for brushing the teeth with snuff — a practice not uncommon in some localities. — Tan Bttken. * Neubauer and Vogel, " A Guide to the Qualitative and Quantitative Analysis of the Prine" (New Sydenham Society), London, 1863, and Thudichum, " Patl-ology of the Urine." 262 STONE IN THE BLADDER. In weight and density they vary according to their chemical composition, the weight of a calculus conveying no accurate idea of its volume. The mulberry calculus, consisting of oxalate of lime, so called because the inequalities of its external surface sometimes resemble those of the fruit from vrhich it is named, is the heaviest in proportion to its volume, the hardest, and most dense in structure; next in order of hardness and density is the calculus of pure uric acid ; then the composite calculi, composed mainly of urates ; finally, the lightest of all, and also the most friable, the phosphatic. The hardest stones are more apt to be solitary, and they are generally the smallest in size. These considera- tions are of practicafValue as bearing on the avaUabUity of the crushing operation, for there are some calculi of oxalate of lime, and even occasionally one of pure lithic acid, so dense and hard as to resist the strength and povrer of the best-constructed lithotrite. Mulberry calculi, nevertheless, vary in hardness, and Civiale reports several cases in which he crushed large calculi of this sort at one operation.' The length of time during which a patient may have suffered from symptoms of stone affbrds no positive evidence as to its size, nor is the reverse of this assertion true; for, as already stated, mulberry calculi and those of lithic acid grow slowly, and seem even to remain stationary for long periods, while those of compound character, and specially phosphatic calculi, gain size more steadily and rapidly. The last two varieties include the large majority of vesical calculi as encountered in practice; the stone, consisting of pure lithic acid, is met with perhaps once in eight or nine cases, while the mulberry calculus not once in twenty. In con- sidering the size and hardness of vesical calculi, it is to be borne in mind that they are always lighter, harder, and even somewhat smaller after removal from the body, and thorough desiccation, than when saturated with mrine in the bladder. A calculus may be friable externally, while its nucleus may prove to be exceedingly dense and hard. For example : a patient may have carried a calculus of pure uric acid, or oxalate of lime, in his bladder for months, growing very slowly, and causing so little irritation as to scarcely trouble the transparency of his urine. Suddenly, from cold or other causes, the vesical irritation is increased ; pus is formed ; the phosphates are precipitated, and the calculus begins to grow rapidly from accretion of the more friable phosphatic salts. In crushing a calculus of this kind its fragments would naturally give evidence of diiferent degrees of hardness. As to multiple calculi, while a solitary stone is the rule, two may possibly be encountered in every six or eight cases as they occur in practice, and a larger number with increasing rarity. They are certainly ' Loc. cii., p. 193. Sir Henry Thompson also reports four calculi of oxalate of lime in 184 cases of stone treated by lithotrity, British Medical Journal, ,Tune, 1871, p. 671, and iTanctiich has recorded many others. Sechster Sammelbericht v. tt. 50 Talleu v. Blasensteinzertriimmerung, Wien, 1873. MULTIPLE CALCULI. 263 more common in advanced life, but there are no known conditions upon which their presence may be predicated. Plurality of calculi would seem to result from the somewhat rapid and successive generation of renal nuclei and their transmission to the bladder, from the spontaneous fracture of calculi in the bladder, which occurs more frequently than is generally supposed; and from the influence of the bladder's contrac- tions upon a soft magma, composed of earthy phosphates and altered mucoid pus, which is more or less constantly present in cases of chronic cystitis from prostatic or other obstruction.' When their number is small they influence each other's shape, and grow to be many-sided rather than round or ovoid, the obvious result of mutual contact or friction, giving rise to flattened sides or facets. When a stone presenting this unusual form is removed by lithotomy, it suggests at once the probability of the presence of others in the blad- der. If very numerous, on the contrary, and apparently just in pro- portion to their number, they tend to revert to the roimded form. When a calculus varies from the common ovoid by unusual elonga- tion in shape, it is suggestive of the presence of an exceptional nu- cleus — something introduced through the urethra. In calculi of this character the mass is ordinarily friable, being composed entirely of phos- phates. At the same time this friability does not always justify the employment of lithotrity as a remedy, for the nucleus may be a substance which cannot be crushed, as in some of the instances already mentioned, and notably in the case of Henry Thompson, where a stick of sealing- wax was found in the centre of the mass, a substance which at the tem- perature of the body is quite soft.^ Vesical calculi present great variety as to roughness of surface. Sometimes as smooth as a well-worn pebble, they are generally rough, from crystalline deposits, and these asperities are in some cases exceed- ingly prominent and sharp. In very rare cases calculi assume fantastic shapes without any obvious cause. Occasionally the stone becomes fixed at the neck of the bladder, and from this situation it sends forward a prolongation into the prostatic urethra b^' which its shape is moulded. In regard to the size of urinary calculi, very little more of practical value can be said here that does not come more properly under the heads of diagnosis, and selection of mode of cure. Surgical works on this " The influence of this latter cause of multiple calculi -n-as happily illustrated in a ease recently brought under my notice by Dr. Blake, of this city, of an old lady of eighty, who had suffered for a long time with procidentia of the uterus, in which the bladder was also involved. On repeated occasions, after retention of urine caused by their ac- cumulation, she had discharged quantities of minute shot-hke phosphatic calculi through the urethra, and after death the bladder contained hundreds of these little rounded masses, avera^ng about the size of No. 6 shot. — Van Buken. ^ In a case reported by Dr. L Porter, Jr., of Massachusetts, a phosphatic stone three and a half inches in length by one and three-quarters inch in width, and weighing three and a half ounces, was taken from a male after death. It was found to have been formed upon a stem of the Archunc/elica purpurta, two and a quarter inches in length.— .Boston Medical and Surgicaljournal, March 4, 1858. 2Q4: STOXE IX THE BLADDER. subject teem -svith rare and curious cases of calculi, of great size and weight, the largest of which will be found to have been taken from dead bodies, and the next in size pretty uniformly to have brought about fatal results by their removal during life. It will always be necessary to refer to old authors for extravagant examples of this kind, for, in proportion as the means of relief which surgery can offer become more safe and sure, they will occur more rarely. Possible CoxsEQUEycEs of Stojte, ixcluding STiiPTOMS ajsd Pathology. — Uneasy sensations, referable to the neck of the bladder, desire to pass water recurring with unusual frequency — both due to the strange impression upon the nerves of the organ, and generally ascribed to what is called " irritability" — are the first evidences of the presence of a foreign body in the bladder. When small and movable, as it usually is, the foreign body is liable to be carried by the flow of urine to the outlet of the bladder, and thus to cause sudden stoppage of the stream, accompanied by a twinge of sharp pain shooting along the course of the urethra, and felt most acutely at its outlet. The muscles at the neck of the bladder are thrown into spasmodic contractions by the presence of the foreign substance, and grasp it closely ; if its surface is rough, the contact brings blood from the sensitive and vascular membrane, and this, when the spasm relaxes, is voided with increased difficulty with the next urine that flows. The neck of the bladder is its most sensitive part, and the recurrence of this rough contact sooner or later begets permanently exaggerated sensibility, together with increased vascularity — ^in other words, inflammation. Inflammation, under these circum- stances, always begins at the neck of the bladder, and indeed may be for a long time confined to this locality ; but it tends, sooner or later, to invade the body of the organ ; and thus, as the stone grows in size, after a longer or shorter period of simple irritation, cystitis is established — brought about by prolonged repetition of mechanical violence, both from contact of the stone, and from the bruising by spasmodically excited muscles in the act of voiding urine, which is repeated with unnatural frequency and effort. Inflammation of the bladder from the presence of stone is alwaj^s gradual in its approach, and chronic in its character. The healthy bladder is patient under violence, and slow to take on true inflammation, so that cystitis is chronic from the first ; and, though liable to acute paroxysmal exacerbations, is essentially chronic in its manifes- tations throughout. During the first weeks or months of the stone's presence in the bladder, while as yet there is no cystitis, but irritation only, the urine remains clear and bright, showing only a slight increase of mucus, or of epithelial debris, and occasionally a little blood. The blood is more likely to be present after rough or violent exercise, or a jolting ride. But, after the beginning of cystitis, pus-corpuscles will always be found, generally in sufficient quantity to render the urine tur- bid to the eye, and always recognizable by the aid of a microscope. SYMPTOMS. 265 Meanwhile the muscular coat of the bladder is taking on gradual hyper- trophy from increased use, and its interlacing fibres begin to stand out in relief; while the irritated organ, intolerant of distention, discharges its contents at still shorter intervals, and thus a tendency to habitual contraction is established. The constant presence of pus in the urine occasions more rapid increase in the size of the stone from phosphatic precipitation, and the lining membrane of the bladder, now entirely in- volved in chronic inflammation, loses its normal tint of salmon pink, and becomes deep red, granular, or perhaps even villous, with occasional ecchymosis, and sometimes patches of yellowish surface-exudation. Most of the exudation, however, takes place in the sub-mucous web of connective tissue around the enlarged follicles, adding materially to the thickness of the bladder-walls. It is a noticeable feature in the behavior of the bladder under irri- tation, that it has its periods of excitement and quiescence without any obvious cause, the inflammatory phenomena manifesting themselves by paroxysms rather than by steady progress, and thus justifying the old expression, " a fit of the stone." The varying conditions of the sexual organs — so closely associated with the bladder— may throw some light on this peculiarity, as may also the degree of nervous impressibility of the sufferer by irritating causes. Be this as it may, it is certain that the period of life between puberty and the sixtieth year, during which the sexual organs are active, is the period during which stone in the bladder is attended by the greatest amount of suffering, and the opera- tions required for its relief by the greatest danger. The time required to bring about the changes in the bladder above described varies greatly. A child may carry a calculus for years, and yet the urine remain bright and free from pus ; in an adult, months may accomplish extensive alterations, but in advanced life, where the urinary organs are especially prone to take on morbid changes, and where, in- deed, these may be already present as consequences of . stricture, or en- larged prostate, it is fair to expect the most serious local results from the formation of stone. Here the advantage of diminished sexual excitability, and increased tolerance, is counterbalanced by the lack of vigor which belongs to age. Preexisting lesions of the obstructive sort in an old man may have already given rise to chronic cystitis, with contraction of the bladder, and thickening of its walls ; or, as occurs not unfrequently from prostatic obstruction, the bladder may have given up the struggle to overcome the obstacle, and may have fallen into atony, with loss of contractile power and indefinite expansibility. The pain and suffering in the first of these two conditions are infinitely the greater, for the spasmodic contraction of the hypertrophied muscular walls of the bladder tends to grind the dis- eased mucous membrane against the newly-formed stone, often to force the stone into painful contact with the more sensitive neck, and thus 266 STONE IX THE BIADDER. add to the existiug obstruction, and increase the difficulty and frequency with which the urine is voided. In the latter condition, the contractile element being absent, the patient is compelled to draw off his urine with a catheter, and is thus free from the constantly-recurring desire to urinate, with its accompanying spasms and tenesmus, and suffers, instead, a milder pain at longer intervals. It is worthy of notice how closeh the muscular element in the bladder is connected with the pain of stone. It is a desideratum to be able to abolish it at wOl. At present we can accomplish this end only temporarily and imperfectly by opium, and (perhaps) in some degree by electricity. In the complicated cases of vesical calculus which we are now con- sidering, other changes in the bladder are liable to take place. Of these some are constant, others only occasional. Of the former, the most important is the local dUatation at its base — a sort of hollow or scoop- ing out, which forms immediately behind the enlarged prostate, called by the French the " bas-fond " of the bladder. This becomes neces- sarily, both in the upright and horizontal positions of the body, the deepest as well as the most dependent portion of the cavity of the blad- der, and it is therefore usually occupied by the stone, when present ; and the stone is thus, in a measure, prevented from contact with the sensi- tive outlet of the bladder. The excavation of the has-fond is often so considerable that an ordinary sound introduced into the bladder cannot be made to strike a calculus lodged here, the convexity of the instni- ment passing above it, and failure in diagnosis has often resulted from this cause. A sound with a short curve, like that of a lithotrite, so that its beak can be reversed in the cavity of the bladder, and swept across its base, is the instrument to be employed whenever the presence of stone is suspected, in conjunction with an enlarged prostate. Calculi may, and often do, form in the little pouches jutting out between the meshes of hypertrophied muscular fibres known as sacculi, and some- times become so large as to be permanently entrapped in their cavities. In the cases, and they are not infrequent, in which the bladder has lost its contractile power, imless the catheter be employed at regular intervals, the bladder is constantly in an overstretched, water-logged condition, relieving itself, irregularly and imperfectly, by spontaneous overflow. Civiale calls this " stagnation." Under these circumstances, and, indeed, whenever the outlet of the bladder is the seat of obstruction, the ureters, subjected also to over-distention, become dilated and tortu- ous ; the inflammation of the mucous membrane of the bladder extends to and gradually involves their altered and weakened walls, and, con- tinuing to extend, finally invades the pelves of the kidneys. The se- creting structure of the kidneys, predisposed to disease by disturbance of functions, now soon participates in the advancing disorder, and func- tional disturbance, of serious import, attended by evidences of uremic poisoning, foreshadows the fatal result which is imminent. This is, proba- SELECTION OF MODE OF CURE. 267 bljr, the most usual course by -which the end of life is reached in vesical calculus not interfered with by art, especially when associated with obstructive disease, i. e., stricture, or enlarged prostate. Ulceration of the chronically inflamed mucous membrane of the bladder occurs in a small proportion of cases. A few instances are on record in which cal- culi have Vforked their way out of the bladder through ulcerations involving all of its coats, and have been ultimately found in the vagina, the perinseum, the umbilicus, and even in the groin. Urinary extrava- sation does not seem to have occurred in these cases, the whole process being apparently conservative, an effort on the part of Nature to get rid of the foreign body. Probably abscess in the thickened walls of the blad- der, opening invcard, first receives the calculus, which travels as the abscess burrows in search of an outlet. These conservative efforts of Nature are alwaj's of great interest to the surgeon, as they not only justify, but suggest the efforts of art in search of modes of cure. When death has occurred from stone, numerous small abscesses are often found in the thickened and altered walls of the bladder, and also in the sub- stance of the kidneys. Multiple abscesses not unfrequently form in the enlarged prostate, and instances are not very rare in which the whole prostate has broken dowm into an abscess. Abscess outside of the blad- der, in the neighborhood of its neck, from peri-cystitis, and pelvic cellu- litis terminating in abscess, are complications of possible occurrence ; and, in children where the peritonaeum covers so much larger a proper tion of the bladder-base than in the adult, both acute and chronic peri tonitis have been encountered, not only caused by stone, but produced by operations for its relief, both with the knife and the lithotrite. Symptoms consedeeed in eelahon to Diagnosis and Selection OF Mode of Cuee. — The symptoms of stone in the bladder are pain, increased frequency of the desire to void lu'ine, diificulty in the act of micturition, occasional presence of blood in the urine. Pain. — As to the pain caused by stone, it is uncertain, variable, and capricious. Sometimes entirely wanting, it is not unfrequently constant and agonizing. In a majority of cases its principal seat is the neck of the bladder, extending along the course of the urethra ; but it often will happen that a patient, when asked to fix the point of his greatest suffering, will indicate the under surface of the glans penis, just behind the frasnum. This explains the tendency of most calculous patients of the male sex to habitually squeeze and rub this part, as this sort of manipulation seems evidently to dull the edge of extreme pain. Unhappily, young subjects are thus prone to acquire the habit of self- abuse. Children with stone habitually pull upon the prepuce, and its unnatural elongation is usually regarded as one of the signs of the dis- ease. The rectum is a common seat of uneasy sensation, if not of acute pain ; this is especially noticeable in prostatic cases, where there is a bas-fond for here the stone lies almost in contact with the walls of the 368 STONE IN THE BLADDER. lower bowel. When the bladder has become inflamed and altered, more or less dull pain is felt above the pubes, radiating to the hips, sacrum, thighs, and perineum. The pain, in vesical calculus, is aggravated by motion, whether active or passive, and it is relieved by quiet and rest; especially by rest on the back with the hips raised. But the greatest pain of stone is usually felt in the act of passing water, and mainly toward the close of the act, when the bladder, empty of urine, grasps the stone with violence, and forces it against the sensitive orifice of the urethra, as if determined to eject it. Often a veritable spasm seems, in this crisis, to seize all the muscular tissues in the neighborhood of the outlet of the bladder. While suflfering from this pain, the child, unre- strained by modesty, and giving full vent to his feelings, will grasp his genitals and dance around the room, howling with anguish. In estimating the value and significance of pain, as a symptom of stone, it must be borne in mind that pain of a similar kind, although less in degree, is also present in cystitis of the neck of the bladder, from any cause, and also in simple nervous irritability of the neck of the bladder from sexual causes — "neuralgia of the vesical neck" — an affection too often ignored. In this latter condition the pain and fre- quency of voiding urine are sometimes greater than in actual inflam- mation. The sensibility to pain, or impressionability of the sufferer, is also to be taken into account, and, above all, the condition, of the genital organs, as to healthy innervation ; for, unsatisfied sexual long- ings, and unnatural practices employed to gratify these longings, be- get a peculiar hyperaesthesia of the genitals, in which the urinary organs largely share. Mhplaced sensations are sometimes caused by the chronic inflam- mation due to stone, or other cause, the more common expressions of pain being absent, as in Brodie's case, where a long-existing neuralgia of the foot was relieved by the discovery and cure of an old stricture of the urethra. Nor, finally, must it be forgotten that stones have been found in the bladder, after death, in persons who had given no evidence of the existence of the disease during life. Increased frequency of desire to void urine is also a symptom of the diseases of the neck of the bladder, just enumerated, as well as of stone, and the pain in the act is also, as a rule, greatest at its close, just as the tender parts are grasped spasmodically by the extending muscles. But in stone this final, spasmodic pain is infinitely more acute, it lasts longer, and seems to be more apt to be mitigated by pressure at the head of the penis. The presence of a little blood ia the urine in conjunction with pain at the close of the act, especially after active exercise, or riding over a rough road, is very significant of stone ; but this conjunction of symp- toms is also occasionally present in other bladder, urethral, and kidney diseases. {See H.^ejla,tueia.) SELECTION OF MODE OP CURE. 269 Perhaps the most characteristic symptom of stone is the sudden ar- rest of the stream of urine while in full S.ow, accompanied by simulta- neous spasmodic contractions of the muscles at the neck of the bladder, with coincident sharp and severe pain. This group of symptoms ivS pro- duced by the falling of a movable body in the bladder, over the orifice of the urethra, so as to close it suddenly as by a ball-valve. In the rare case of a polypus, or of a prostatic tumor growing from within the neck, the tumor in either case being attached by a slender pedicle, the same phenomenon has been known to occur.' It will thus be seen that, of the cardinal symptoms of stone, there is no one that is absolutely pathognomonic of the disease, and that clini- cal study and experience are necessary to the proper estimate of their significance. Study of the patient's habits, history, constitution and hereditary tendencies, will materially aid in forming a judgment as to probabilities. The same symptoms would possess a very different value before puberty, and after the age of forty ; for, in childhood, all the dis- eases mentioned above as likely to be confounded with stone could be at once ex eluded,, and the irritation caused by excessive acidity alone would remain to be considered. In estimating the pathological condition of the urinary passages as affected by the presence of calculus, the microscopical and chemical ex- amination of the urine must not be neglected. The existence of true inflammation can always, by this means, be distinguished from simple irritation by recognizing the presence of pus-globules in any quantity; and the character of these globules would seem to furnish some evidence as to whether they are the result of mere surface irritation, or of deeper and more serious lesions of tissue." Pus in the urine may come from the secreting structure of the kidney, as when it assumes the form of tubular casts ; from the pelvis of the kidney ; from the ureters, blad- der, or urethra ; and, except in the case of casts, its source is to be dis- tinguished mainly by the coexisting evidences of local lesions. In pus ' Willis deposited in the Museum of the Royal College of Surgeons, London, a blad- der taken from a man of sixty-seven, dead of cancer of the kidney, in which there "was " a small polypoid body growing from its inner surface, directly over the orifice of the urethra, and covered by a shell or crust of the triple phosphate. . . . He had long suffered from occasional attacks of retention of urine and symptoms of stone. . . . Retention of urine was the urgent symptom of the case." It was always relieved by the introduction of a small flexible bougie, alongside of which the urine would escape. The bougie evi- dently pushed away the ball-valve, and was substituted for the catheter, as it answered the same purpose, with less irritation. — " Urinary Diseases and their Treatment," by Robert Willis, M. D., London, 18&8, p. 284. ^ " Quite normal pus-corpuscles of a perfectly circular outline, which, after treatment with acetic acid, exhibit the characteristic nucleus, composed mostly of two or three nucleoli, admit of the conclusion that the disease giving rise to their formation is of a mild form — a simple catarrh of the mucous membrane. But when the pus-corpuscles are irregular in form and outline, and on treatment with acetic acid show an irregular nucleus, or an indistinct granular mass in their interior, or when such corpuscles are mixed with irregular dihris, not particularly defined, then purulent destruction is evident, and the integrity of the organ where this formation takes place is in great danger, or lost altogether. Such pus would be the product of ulceration and tuberculosis." — Vocel, quoted by Thudichum, "Pathology of the Urine," London, 1858, p. 239. 270 STONE IN THE BLADDER. from the pelves of the kidneys the globules are free and not collected in masses, and the whole deposit is heavy, sinking rapidly to the bottom of the vessel, and often presenting to the naked eye a peculiar greasy appearance. Pain on pressure over the site of the kidney, or the pres- ence of any imusual swelling or tumor in this locality will aid in recog- nizing pyelitis, which is almost invariably accompanied by more or less hectic and emaciation. Pus from the urethra is apt to assume the shape of floating thread-like filaments visible to the naked eye. These are washed from the surface of the urethra by the passing urine, roUed over and over, and thus spun into threads. Moreover, pus from the bladder can always be distinguished from that furnished by the urethra by col- lecting the urine which passes first and contains the washings of the urethra in a separate vessel, and comparing it with that which comes afterward. A very common error in practice is to mistake the gelatinous mucoid material which results from the reaction in the bladder of ammonia upon pus for true mucus, and thus fail to recognize the existence of cystitis, perhaps already well established and extensive. The student of urinary diseases who will take the trouble to agitate in a test-tube a drachm of pure pus derived from any source with an equal quantity of aqua ammonisB, and observe the result, wUl hardly fall into this error. True mucus, which is always present in healthy urine, coUecting in a floating cloud of variable density as the urine cools, is furnished by the mucous follicles, which everywhere line the urinary passages. That fur- nished by the urethra is notably increased by erotic excitement. Mucus from the urinary passages proper is liable to be temporarily increased by greater density or more irritating quality of the tnine ; thus, the morn- ing urine will always show a larger cloud of mucus. The presence of a foreign body in the bladder notably increases the amount of mucus in the urine. Pure mucus is always translucent, and its diagnosis may be established by the number of epithelial cells embedded in its substance. The mucus-corpuscle cannot be distinguished, singly, from the pus-cor- puscle, and perhaps neither of them from a young epithelial cell; but, in mass, the difficulty ceases. The amount of mucus present in urine is rarely sufficiently large to lead to its being mistaken for gelatinoid pus. When there is any doubt, the habitual presence, in any considerable quantity, of pus-globules wUl readily settle the question in favor of the latter ; gelatinous pus in any quantity, moreover, is never found, except when the urine is alkaline. It is generally associated, therefore, with the earthy phosphates ; and, when the prismatic crystals of the triple phosphate of ammonia and magnesia are found embedded in it, the presence of ammonia, arising most probably from decomposition of urea, may be safely assumed. Finally, in cases where mucoid pus is largely present, the daily washing out of the bladder with tepid water will often restore the normal acidity of the urine, by removing the ammonia and SOUNDING. 271 other irritating causes, and, simultaneously -with this change, the mucoid pus will disappear, to be replaced by a deposit of ordinary pus, usually diminished in quantity by the soothing influence of the fomentation. Attention to these facts will tend, in obscure cases, to facilitate the diagnosis of stone. The presence of the symptoms of vesical calculus which have been detailed, or of any of them, when their cause cannot be clearly made out after mature consideration, justifies a formal explora- tion of the interior of the bladder, by means of a sound. Such further examination, it should rather be said, becomes a duty ; for the paramount importance to the patient of the early discovery of a stone in his blad- der, in view simply of the comparative safety with which he can be relieved of a small stone before its presence has caused morbid change in the bladder, renders an early resort to the only certain test of its pres- ence, an imperative obligation upon his surgeon. Sounding. — The operation of sounding a patient for stone requires a light hand and gentle manipulation. It should not be resorted to dur- ing a " fit of the stone ; " nor, if there be any suspicion of cancer of the bladder, without great circumspection, for severe haemorrhage and aggravation of symptoms have followed in such event. Previous prep- aration is advisable in persons who suffer much, by rest, diluents, alkalies, if indicated, or possibly anodynes. In all serious cases a period of comparative quiescence of the symptoms should be chosen for the operation. An anaesthetic is required for adults, only exception- ally ; for children it is desirable in the large majority of cases ; and, as a matter of complaisance, perhaps, for women. The instrument should be of metal, with a short curve, like that of a lithotrite, and slightly Fig. 76. bulbous at its beak. The " searcher " of Sir Henry Thompson (Fig. 76), the best sound in use at present, is capable of serving a double purpose ; for it is hollow like a catheter, with an eye near its beak, and a metal plug fitted to its open end, so that the urine in the bladder can be drawn off, if in excess, or warm water injected, if necessary, during the opera- \ yiE^L.,.T.-^--7f-' — -^- — - ^ ' —-,■.■■ -^- - _^»^^^^_yi 0TT9 &. fCEYNDERS Fig. 77. tion. Mercier's " sonde coudde " has a different curve, and although not a catheter, is an excellent searcher (Fig. 77). The patient should lie on his back, with his hips slightly raised, on a firm bed or lounge, so placed that the operator may act from his right side, for the sound is 272 STONE IN THE BLADDER. preferably introduced from this side, in order that the operator shall be ia position to use his right hand most advantageously, and without changing sides Avhen the sound shall have entered the bladder. The manipulation employed in introducing the sound is the same, with trifling modification, as that required for the lithotrite (Chapter XVI.). When in the bladder, the sound is to be pushed gently onward, until the posterior wall of the bladder is reached, when, withdrawing it slightly, its beak is to be turned carefully, first to one side, and then to the other, until the lateral wall or floor of the bladder is touched, by rotating its shaft between the thumb and finger ; then it is withdrawn an inch — more or less — and the same manoeuvre repeated ; this is done again and again, if necessary, until the concavity of the sound comes in contact with the neck of the bladder, when it is withdrawn entirely. For a patient under middle age, this mode of examining with the sound would be adequate to the discovery of a calculus, if present, in a large majority of cases. Nevertheless, it is a safe rule of practice, never to decide the question after a first examination in which the result has been negative, but to ask for a second or even a third opportunity for search, before giving a positive opinion ; and not to lose sight of the great advantages to be derived from ether or chloroform.' But, in a male patient over the age of forty, there is always a possibility that the bladder may have under- gone a change in shape at its base — such as has been already described as forming- a pouch behind the enlarged prostate — and here another manoeuvre of great practical value is to be added to the operation. Instead of withdrawing the sound entirely, when its concavity has reached the neck of the bladder, as first directed, its beak is to be again carried forward to the centre of the bladder, and, the handle of the instrument being well depressed between the thighs, its beak is to Ije rotated by a complete half- turn of the shaft, so as to assume a reversed position and touch the floor of the bladder ; keeping the handle of the sound sufficiently depressed to render its beak readily movable, this is now to be gently swept from side to side, as when it occupied the first position, and it will pretty certainly strike a calculus, if any be present, in a pouched bas-fond behind an enlarged prostate. The beak of the ' Early in 1847 a boy of two and a half years was brought to me, with a history of great suffering, as from stone, since shortly after birth, but, although examined half a dozen times, none had been discovered. The little fellow struggled violently, and he was necessarily held by main force. As soon as the sound entered it, his bladder was seized by spasm and its contents forcibly discharged, and simultaneously the contents of the rectum also. The sonncl was so firmly grasped by the empty bladder that its beak could not be moved without force, and with great increase of outcry. Under these circum- stances I bethought me of the new remedy which I had seen used a short time before by Morton, upon a patient of the late Valentine Mott, and brought it to bear upon my re fractory patient. The result — with which we are now so familiar from daily use — was then novel, and it was wonderfully satisfactory. A small movable stone was struck by the sound almost as soon as it entered the relaxed and insensible bladder. A week later it was removed by the lateral operation, under ether, and a prompt recovery followed. The patient subsequently served creditably during the late war. I believe this to have been the first case of lithotomy with ansesthesia. — yAH Boken. CHOICE OF METHOD OF CURE. 273 sound is then to be carried again to the centre of the bladder, \yith its handle still depressed, and restored to its first position by a half-rotation of the shaft of the instrument, and then carefully withdrawn. The whole operation should never exceed three minutes. When performed with due gentleness, it should cause but little pain, unless the patient is unusually sensitive, or the bladder in a state of acute inflammation. In the latter case, if delay be not admissible, the propriety of anaesthesia should be considered; for the condition of painlessness affords the operator undeniable advantages in attaining his object, although, with an unpractised hand, it possibly increases his liability to do harm. It is desirable that there should be from three to six ounces of urine in the bladder when the sound is used, or, in other words, that the patient shall have retained his water from an hour and a half to three hours. If too full, a small stone is more likely to escape recognition ; if the bladder contains less than three ounces, the sound is less easily manageable without rough contact with its walls. It happens some- times, on the first contact of the beak of the sound with the walls of a sensitive bladder, that the organ is thrown into a state of spasm, and the urine forced out through the urethra, alongside of the shaft of the sound. When this accident occurs, it is better to defer the opera- tion ; or administer an ansesthetic, and, reintroducing the sound, inject through it four ounces of blood-warm water, and then proceed with the exploration. If a calculus be struck shortly after the sound has entered the blad- der, the operator has then a chance of forming at once some idea also of the condition of its walls, and of the size, roughness, and degree of hardness of the stone ; for the sharp click of a hard stone is not diffi- cult to distinguish from the muffled sensation received from a soft one, . and, if the beak of the sound in contact with the stone is made to glide alongside of it by slow advance or withdrawal, a pretty accurate idea of its size, and of the degree of roughness of its surface, may be acquired. After the operation of sounding, it is safer that the patient should have warmth applied to the hypogastrium and to the feet, and that he should keep his bed, at least for the remainder of the day ; in short, he should be treated as after the use of the lithotrite. Choice of Method of Gure. — When the presence of a stone in the bladder has been demonstrated, the questions at once present them- selves : Can the patient be cured by the crushing operation ? must he submit to lithotomy ? or, is it more judicious to employ no surgical operation in the case, but simply to palliate symptoms by such medical treatment as may relieve from pain, and prolong life ? It may be safely assumed, in general terms, that a cure by operation may be undertaken in any case of stone in which the patient is not of extreme age, where the stone is not of unusual magnitude, and where the patient is free from evidence of any organic disease by which life is 18 274 STOITE IN THE BLADDEB. likely to be terminated within a limited period not very far distant. But we are compelled by the requirements of practice to reduce these questions to a narrower limit. Cases are constantly presenting them- selves in which the patient's age is not extreme, and his general health sufficiently vigorous, but his stone so large that it can be removed only with the aid of the knife — ^by an operation the mortality of which modern science has not been able greatly to reduce. Here the judg- ment of the surgeon is to be guided by the following considerations : the degree of the patient's sufferings ; the probable amount of relief to be expected from palliative measures, and the temper and circumstances of the patient, as measuring his probable capacity to properly care for himself, and command the comforts of an invalid. In the case of an old man able to command all the comforts of life, with a large stone, suf- fering only moderately, and able still further to lessen existing suffering by skillful care, it would be obviously the part of wisdom and himianity to hesitate in advising an operation. The simple fact that an operation can be done is no reason why it should be done in the face of very serious risk to life ; and it is hardly necessary to say that the temptation to perform a capital operation, even at his urgent request, shoiild never weigh for a moment against the best interests of the patient who places his life in our hands. The considerations which influenced Frankhn and D'Alembert to decline lithotomy at the hands of Desault, at Paris, in 1T84, still hold good, for the mortality of this operation has not dimin- ished since the days of Cheselden. Having determined, then, that it is proper, in certain cases, to decline an operation for stone, what course should be adopted after an examination has ascertained the presence in the bladder of a movable calculus of moderate dimensions ? The amount of inconvenience caused by the operation of sounding should be observed, as indicating, in a general way, the condition of the bladder, and the measure of the patient's tolerance ; and further exploration shoiQd be deferred until all increased trouble that may have been caused by it shall have subsided. Meanwhile the patient's history and present general condition should be carefully studied, and the vital organs subjected to physical explora- tion. Especial attention should be devoted to the kidneys and bladder, both by physical exploration, externally from the abdomen, the loins, and rectum, to detect tenderness on pressure, or tumor, and also by careful and repeated microscopical and chemical examinations of the urine. Much information wiU thus be obtained as to the condition of the bladder, the constitution of the urine, and an accurate idea of the size and state of the prostate. When the proper interval has elapsed a full-sized sound or bougie is to be introduced through the urethra for the purpose of testing the temper and capacity of this canal, and to detect the existence of stricture, if present. If the patient be sensitive, this may be repeated several times, at proper intervals, as it CHOICE OF METHOD OF CUKE. 275 erves to diminish abnormal irritability of the urethra, often present rom habitual contact of altered urine ; to educate the passage, as it rere, to tolerance of instruments ; to familiarize the patient to his sur- geon ; and to lessen the nervous dread, which always exists in some legree, of his manipulations. If the urethra has been proved to be lealthy, and of normal capacity ; if the patient can retain his urine rom one and a half to two hours, and is in fair general condition, the Qtroduction of a lithotrite may be undertaken. Its object is to seize and Qeasure the exact size of the stone ; to ascertain, while the stone is in he grasp of the lithotrite, if there be any other stones present in the blad- ler (for it is only by this manoeuvre that the presence of other calculi can le certainly demonstrated) ; to recognize any abnormal condition of the aternal surface of the bladder, such as undue prominence of its muscu- ir fasciculi, or possibly the existence of saoculi ; and to determine with lore accuracy the degree of tolerance of the organ, in view of the fea- ibility of Uthotrity. An instrument of moderate size, and with per- 3ctly smooth blades, should be selected for this operation, and it should le introduced, and managed, while in the bladder, in the manner here- fter described. The lithotrite should not be kept in the bladder jnger than three minutes. If this exploration is satisfactorily aocom- lished, if the stone does not measure more than one and a half to two iches in diameter, is solitary, and the bladder has proved tolerant of lie presence of the instrument, and of the whole proceeding, it may e safely concluded that the case is a proper one for the crushing peration. Thus far the patient has been assumed to present conditions entirely ivorable to lithotrity, viz., good general health, a tolerant bladder, a rethra of normal capacity, and a moderately soft stone, not more than a inch in diameter. But cases of this kind constitute but a small per- sntage of the aggregate encountered in practice. It is necessary that le surgeon should have an accurate perception of all the conditions lat justify this mode of cure ; and that he should be ready to reject, •ithout hesitation, those cases which do not properly come within its 3ope. The choice of a mode of cure in a given case is not a matter to e decided by personal preference, or by partisan feeling — it must be etermined entirely in the patient's interest, and after careful study of le case, especially in reference to the following points, which include le conditions usually presented, favorable or otherwise, to the crushing peration : the period of life ; general or local disease, especially of blad- 3r and urethra ; degree of tolerance of instrumental manipulation ; size id quality of the calculus. A few words will be necessary on each of these points : The age of the patient will determine the mode of cure in about one- ilf of the cases which present themselves in general practice ; for the ost reliable statistics teach that " one-half the entire number occurs be- 276 STOXE IN THE BLADDER. fore the thirteentli year is completed." ' Now the limited proportions of the male urethra before puberty, the excessive sensibUity of the child's bladder, and the want of docility and self-control at this time of life are all unfavorable to lithotrity ; while it is just in this class of cases that the cutting operation has attained its greatest success — a mortality va- rying from one in eleven to one in twenty -eight, the mean mortality of the whole period of life, below the age of fourteen, being about one in fifteen. As a rule, then,' to which exceptions are rare, lithotomy is the preferable method of cure for male children under the age of fourteen. The exceptions are, when the stone has been discovered just after its formation, while still very small, so that one or two operations with a slender lithotrite will certainly remove it. In these operations an anaesthetic would be required. In the future progTess of lithotrity these exceptions may become more numerous. In case of general disease, involving vital organs and threatening life, the performance of any surgical operation, with the object of removing a stone from the bladder, must necessarily be regarded as an ex'ceptional proceeding, warranted only by the certainty of being able to remove immediate danger to life, or to relieve extreme pain, not otherwise relievable, with the prospect of prolonging life for a limited period. Where anj' operation is determined upon, under these circumstances, it would, probably, be more judicious to take the chances of securing relief at once, by lithotomy. An exception, here, would be a case in which there was great tolerance of the bladder, such as generally ac- companies atony of that organ — a condition in which the practised lith- otritist could do pretty much as he pleased. Jiy local disease of the urinary organs is understood, practically, stricture of the urethra, enlargement of the prostate, intense or persist- ent cystitis, and organic alteration of the kidneys. The existence of confirmed organic stricture at one or more points of the urethra, is a serious impediment to lithotrity. A fully distensible canal, with healthy walls, is an indispensable requisite for the easy introduction of the instruments employed in crushing calculus, as well as for the ready escape of the detritus resulting from the operation. The question may be asked. Cannot the stricture be cured, and the pa- tient afterward be subjected to lithotrity ? ITie answer is, to restore the walls of a striutured urethra to their original suppleness, distensi- bility, and smoothness of surface, is a remote and rather uncertain possi- bility, if indeed it be a possibility ; and the arrest of fragments at any point in the urethra where a stricture has once existed, is an accident always liable to occur. Yet there are instances on record in which this impediment has been overcome with more or less success ; and a surgeon of tact and experience may, in a case entirely favorable in other re- spects, successfully compromise with this disadvantage when existing in ' Thompson, " Practical Lithotomy and Lithotrity." CHOICE OF METHOD OP CURE. 211 i moderate degree.' In old cases of stricture, where stone has formed n the bladder, cystitis, of more or less intensity, is necessarily present ; md here a resort to the knife is imperative — for an additional reason ilso, that, by a modification of median lithotomy, the stricture may be Dossibly treated successfully by external incision at the same time that ;he calculus is removed from the bladder. Case 5XVII. — In 1869, a gentleman with an old and obstinate stricture, complicated vith chronic cystitis, came to New York for relief. It was with difiSculty that the smallest jougies could be introduced into the bladder. From the constantly-recurring exacerba- ;ions of intense pain in micturition, and the occasional presence of phosphatic sand in the irine, the suspicion arose that a stone had formed in the bladder. As the stricture was lot amenable to treatment by dilatation, in consequence of the presence of false passages md extreme sensibility of the urethra, a very small whalebone bougie was introduced to lerve as a guide, and, on this, diTision of the stricture was effected by perineal section ; md the incision afterward prolonged to the neck of the bladder, whence were removed ;wo phosphatic calculi of moderate size, which had been promptly discovered after divis- on of the stricture. The patient made a good recovery, and learned to introduce for limself a full-sized steel sound, No. lY. It vcould have been impossible to treat such a case by lithotrity. Enlargement of the prostate is not an objection to lithotrity so long- is it offers no obstacle to the ready passage of the necessary instruments nto the bladder. Nor is the condition of atony, or impaired contrac- ;ility of the bladder, so common a complication of the enlarged prostate, ;o be regarded as an unfavorable circumstance. On the contrary, it is n cases of this kind that the trained lithotritist is sometimes able to nanage successfully the largest calculi removable by the crushing op- sration. Chronic cystitis of a very intense and persistent character, without itricture or any obvious cause save the presence of the stone, is a valid )bjection against lithotrity. While the bladder is acutely intolerant )f its contents, sufficient urine cannot accumulate within its cavity to ifford an area in which the lithotrite can be safely manoeuvred. Apart rom the danger of still further increasing the intensity of the inflamma- ;ion by interference, the simple attempt to introduce the instrument into ;he bladder is liable to bring on acute spasmodic contractions, by which ts contents are forcibly ejected. Means must be employed, therefore, to ower the grade of the inflammation, to improve the quality of the urine, md to diminish the frequency of the calls to urinate, before the feasi- )ility of lithotrity can be determined ; and, if this improvement cannot )e accomplished after a reasonable trial, the crushing operation must be ibandoned. There is a wide margin here for skill and tact, in the em- )loyment of medical treatment to improve the condition of the bladder. iVhen a degree of tolerance has been attained in which the intervals letween the calls has reached an hour and a half, the contents of the (ladder equaling about three ounces, and the improvement is progres- ' Walter J. Coulaon, F. R. C. S., op. cit, p. 52, et seq., has cases illustrative of this oint. 278 STONE IN THE BLADDER. sive, then the use of instruments, in the gentlest manner, may be tried. Cases are on recoia in which, where the calculus has been small, and the patient otherwise healthy, the fact having been clearly established that the cystitis was being kept up solely by the stone's presence in the bladder, ansesthesia has been employed, and the calculus removed suc- cessfully at one operation. This is an exceptional application of Kthot- rity, justifiable only in the hands of a master of the art. Long-continued obstructive disease of the urinary organs, either fi-om urethral stricture or enlarged prostate, is often complicated, not only by chronic cystitis, but by deeper lesions, involving vital organs ; dilated and tortuous ureters, evidences of chronic pyelitis of low grade, with atrophy and other profound alterations of the kidneys. During life, however, the existence of these serious complications cannot be made out with any absolute degree of certainty ; habitual tenderness on deep pressure over the kidneys, tendency to chill on slight provocation, increased frequency of pulse toward evening, nausea and capricious appetite, with feeble digestion, and similar evidences of faOing health, which cannot be otherwise adequately explained, are symptoms from which the existence of these lesions may be inferred. Any operation undertaken upon a person in this condition is liable to be followed by rapidly-fatal symptoms, due most probably to uraemia. The form of renal degeneration known commonly as Bright's disease, a malady entirely different in its pathological signification from that sequence of morbid changes due to urinary obstruction which has just been described, seems, in fact, to be rather rarely associated with calculus disease. It often occurs in connection with cardiac lesion, and is readily recognizable by unmistakable symptoms, of which the most characteristic are the presence of albumen in the urine, and of casts of the uriniferous tubes in its sediment. When present, it constitutes a grave objection to operative interference of any kind. TVhat we require to know especially concerning the stone, in the next place, is its size and degree of hardness; or, if there be more than one, their aggregate volume, so that the amoimt of debris which would result from their crushing might be estimated with some approach to accuracy ; and this knowledge, already attained in some degree by ex- ploration with the lithotrite, is to be used conjointly with what has been learned as to the condition and degree of tolerance of the bladder ; for the surgeon would be justified in attacking a much larger phosphatic calculus in the tolerant or atonized bladder of an old man, than one of uric acid of smaller size in the more irritable bladder of a younger subject. Again, a calculus of uric acid breaks into wedge-shaped fragments, with acute angles ; and the mulberry calculus, from its extreme hardness, yields but few, and consequently large fragments, with very sharp edges ; the result of a crushing in either case would involve more risk of sub- sequent inflammation than the less irritating and more pulverulent CHOICE OF METHOD OF CURE. 279 etritus of a phosphatic stone. It becomes obvious, therefore, that in xing a rule which shall determine the choice between the crushing and itting operations, as based upon the size of the stone, a standard must e adopted which shall vary with its quality. It is safe to say that all iones under an inch in diameter may be crushed ; but it would not be idicious to conclude that all stones beyond this size must of necessity e reserved for lithotomy. Here is room for the exercise of sound judg- lent, and to this end an accurate diagnosis must be made as to the ature of the calculus, as well as to the condition of the bladder. For lis purpose, careful microscopic study of the patient's urine, and inquiry 3 to when it first became turbid, and what changes it has undergone, 'ill give much assistance. The habitual presence in the urinary sedi- lent of the octahedral crystals of oxalate of lime, the prisms of the triple hosphate, of the common and varied crystals of uric acid, or of the urulent sediment of the amorphous urates, would add much certainly ) the diagnosis of the probable nature of the calculus ; while a close ad searching inquiry into the history of the patient, his antecedents, is earlier symptoms, and their different phases as the malady pro- ressed, the possible occurrence of previous attacks of renal colic, and le habits of the patient, as influencing them, with a review of his in- erited or acquired constitutional peculiarities, could hardly fail to elicit aluable information. The probability of a central nucleus of uric acid, from its extreme equency, is very great ; but the possibility of finding a nucleus in the lape of a foreign substance which had got into the bladder from with- ut, such as a fragment of bone, or wood, which it would be impossible ) crush, is not to be forgotten.' ' In the collection of calculi in the Museum of the Eoyal College of Surgeons of Lon- m, according to the catalogue, out of 649 calculi, 212 are composed of uric acid alone; id, in 65 others, it forms the nucleus. Urates are given as constituting the entire cal- ili in 14, and the nucleus of 187 out of the 649 ; 13 are composed entirely of oxalate of ne ; it forms the nucleus in 62. In a successful case of lithotomy, which occurred in this city during the late war, ider the care of Drs. Livingston and Markoe, a quadrangular fragment of bone was und in the centre of the calculus. It had been broken off by a bullet, which had passed impletely through the bladder, leaving the piece of bone to become the nucleus of a one. The size of this fragment was too great to permit its withdrawal through the 'ethra in the jaws of a lithotrite, and its consistence too solid and resisting to allow of ita iing crushed. 280 LITHOTRITT. CHAPTEE XY. LITEOTBITT. Preparatory Treatment. — Instruments required for the Operation, -witli tlie Manceuyres employed in using tiiem. — Impaction of fragments in tlie Urethra, with Methods of removing the same, LiTHOTEiTT (AtOof , « stoue ; and reipu^ to break) is the name by which custom seems to have decided that the crushing operation shall be known. While it was yet a new enterprise, without an established position among the operations of surgery, many other designations were applied to it which have since passed out of use. Modern surgery has fully recognized the process by which it is proposed to reduce a stone in the bladder to powder, or, at least, to fragments so minute as to allow their free escape with the urine, and thus to remove it as thoroughly as by the knife — as the operation of lithotrity. It is only now, since its wide and successful employment by educated surgeons in all parts of the world, that lithotrity has been fully recognized as the mode by which a stone can be removed from the bladder, in proper cases, with the least risk to life. It has taken position, not as a rival of lithotomy, but as a new and additional resource by which the modern surgeon can cure stone in the bladder in a large proportion of cases, without incurring the well-recognized risks of the cutting operation. This process of curing stone was first successfully accomplished by •Civiale, of Paris, who operated before a committee of the French Academy appointed to report on the merits of the newly-invented op- eration, and cured his patient, in 1824. Before this it had been theo- retically proposed to reduce a stone to fragments in the bladder, by Gruithausen, a Bavarian surgeon, by straight instruments, in 1813, with the purpose of subsequently acting upon them by solvents ; and by El- derton, of Scotland, by a contrivance curved like a catheter and contain- ing files, by which it could be ground to powder, in 1814 ; but to Civiale belongs the credit of first practically accomplishing this desirable result, and of effecting an undisputed cure of stone by a new operation. His earlier instruments and operative manoeuvres have undergone great changes. These have been effected mainly by himself, by Amussat, Leroy d'Etiolles, and Heurteleup, on the Continent; and by Brodie, Orampton, Fergusson, and Thompson, in England. Charrigre, of Paris, and Weiss, of London, the well-known surgical-instrument makers, have contributed greatly by their skill to the mechanical perfection of the in> struments employed in the operation. PREPARATORY TREATMENT. 281 At first the instruments by -which lithotrity was effected were inefE- cient, cumbersome, and in many respects defective; the operative manoeu- vres complicated, and unnecessarily severe and prolonged; the cases ill-chosen, and the success of the treatment frequently disputed. In- genious men were attempting and testing new means and methods against an old enemy ; the rivalry among them was not always free from petty and personal jealousies ; nor was the conventional opposition to innovations against established usage devoid of bitterness and bigotry. But, considering the magnitude of the enterprise, the diflficulties which attended its inception and early progress have been overcome with a steadiness and success worthy of the efforts of science in behalf of suf- fering humanity, and the result has added lustre to modern surgery. The efforts of the earlier lithotritists slowly but surely established cer- tain great results, such as the necessity of patient study and diagnosis, with judicious selection of cases, careful preparatory treatment, deliberate and gentle manipulation, and short operations ; and experience, growing steadily wider in its scope, has gradually settled most of the details of the operation, and created rules for the practice of the art which — at the end of half a century — are about as well established as those of any other department of surgery. Peepaeatoet Teeatment, in its bearing upon the successful result of the crushing operation, can hardly be over-estimated as to its im- portance. Sir Benjamin Brodie's experience of 115 cases led him "to the conclusion that lithotrity, if prudently and carefully performed, with a due attention to minute circumstances^ is liable to a smaller objection than almost any other of the capital operations of surgery."' The "at- tention to minute circumstances," emphasized by this honest and able surgeon, is especially applicable to the preliminary management and preparation of the patient for the operation. At least ten days of rest — of freedom from all labor and anxiety at- tending ordinary pursuits — in the apartments to be occupied by the patient, is to be regarded as a necessary preliminary to lithotrity in the least unpromising case. This is essentially important for those who come to a large city from the country, a position in which, for obvious reasons, most patients will find themselves ; and, for those seeking relief in the wards of a hospital, a period of acclimation is even more indis- pensable. The impatience of restraint, and the driving habits which characterize our countrymen, render it necessary to emphasize this point. A false estimate of time and the value of money will often prompt the patient to attempt to hurry his surgeon ; but the enterprise is of too much moment to permit any sordid motive to endanger its favorable termination. In cases of a graver character this preliminary period of rest is still more important, and necessarily of longer duration. ' "Ifotes on Lithotrity," Medico-Chirurgical Transactions, London, 1855, yd. xxxi'iii., p. 169. 282 LITHOTEITT. In a healthy adult with a small calculus we should have to deal most probably with uric acid or its compounds, and here plain and simple diet, with lessened quantities of animal food, and increased allowance of fresh fruits and succulent vegetables, with half a drachm of citrate of potash, thrice daily, in plenty of carbonic-acid water or flaxseed-tea, would be a suitable regimen, calculated to counteract constitutional tendencies, to increase the quantity of the urine, and render its quality more mild and less acrid; and thus to diminish existing irritation of the bladder, and of all the urinary surfaces. Lying on the back, with the hips more or less raised, tends to keep the calculus out of contact with the neck of the badder, and this position has often a marked influ- ence in lengthening the intervals between the calls to urinate — a result which it is especially desirable to favor. Meanwhile instruments are to be employed, at judicious intervals, with the object of completing diag- nosis, and also for the purpose of gradually lessening the sensibility of the urethra to their contact. How often to introduce instruments into the urethra for this purpose is a delicate question ; if the interval be too short there is danger of increasing the irritability we are striving to subdue, and this is an error not uncommonly committed. At first the interval should be longer — from three to five days — if the patient be very sensitive ; the effect should be closely watched, and, if the opera- tion is followed by no perceptible harm, the instrument may be used a day earlier each succeeding time. This is a matter in which tact must take the place of rules. In the majority of cases, perhaps, this desired result will be attained in a few days ; but it is well to know that the most sensitive urethra may be trained to daily harmless contact with the lithotrite, if sufficient tact and patience are brought to the task. In very sensitive patients the soft French olivary bougie, anointed with cerate and then oiled, is to be employed at first ; after this a conical steel sound, gradually increasing its size ; then the metallic sound with a short curve ; and, finally, the lithotrite. For a case of more serious nature — of longer duration, with a larger stone, a bladder yielding more or less pus, and broken health from suf- fering and loss of rest — a longer period of preliminary treatment will be required. As already indicated, the treatment should include all meas- ures likely to improve the general condition of the patient, as well as that of the urinary organs. Unremitting efforts to attain a more com- plete knowledge of the condition of the internal organs will bring to light evidences, probably, of more or less impaired digestion and nutri- tion, which should be met by appropriate dietetic suggestions : cod-liver oil, quinine, iron in some of its forms, are invaluable additions, under these circumstances, to well-selected and easily-digestible food. The patient's habit of body should be studied, and the natural and regular action of the bowels solicited by the simplest means. Active purgatives are to be avoided ; they are liable to irritate the lower bowel, and to PREPAKATORT TREATMENT. 283 render the urine concentrated. Straining at stool is always injurious to a calculous patient ; botli the attitude and the effort tend to bring the stone into painful contact with the neck of the bladder. The mildest laxative, aided in its operation by an enema of warm water, in the hori- zontal position, and the use of a bed-pan, are preferable. While it is desirable to keep the urine copious and diluted, it is to be borne in mind that the too free use of diluents is liable, in some cases, to impair the tone of the stomach, and also to increase the frequency of urination. The condition of the vital organs is to be scrupulously observed, and any evidences of lesion of the ureters and kidneys, noted carefully, as of serious import. Painful sensitiveness of the urethra is often kept up by the habitual contact of purulent and ammoniacal urine ; it is desirable, therefore, in addition to the means employed to improve the general health, as soon as the urethra has proved tolerant of soft instruments, to make use of injections of tepid water into the bladder, pure or medi- cated, as often as they can be employed to advantage. In this class of cases absolute rest is generally advisable ; but some- times, and especially where anodynes have been freely employed, the nervous irritability is greater in proportion than the local inflammatory lesions, and where this condition is suspected it would be well to try the effect of a daily walk in the fresh air — riding being more likely to increase the local pain. Where opium has become necessary from habitual use, it is better to manage it judiciously until after the opera- tion, and then withhold it. The warm bath, or frictions to the skin by band-rubbing, or hair mittens, is often of service. The patient should be distracted as much as possible from mental preoccupation with his sondition, and he should be encouraged as to the future ; there are no local diseases which so uniformly give rise to exaggerated mental de- pression as those of the xu-inary organs. In the large and important class of cases of stone complicated with snlargement of the prostate, it is especially desirable to secure the 3ntire docility of the patient. He is advanced in life ; has already, per- laps, been compelled to learn to relieve himself by the catheter ; may lot, in fact, be able to empty his bladder without the instrument, in jonsequence of atony. He will probably, therefore, have notions of lis own, and be hard to teach. Local explorations for the sake of liagnosis are to be conducted in such cases with extreme care and sircuraspeotion. In case of atony, if the patient is not already famUiar vith the manoeuvre, it will be necessary to teach him to introduce a arge-eyed evacuating catheter, through which to drain off the urine, and vash out the detritus, and this will be a task of little difficulty, for vhere atony exists there is usually great tolerance of the bladder — un- ess, indeed, the case be so far advanced in disease as to preclude all .ttempts at relief. If the atony is only discovered to exist when the )atient first seeks advice, the surgeon will secure his entire confidence. 284 LITHOTRITT. readily and at once — for there is no condition in which more marked relief can be afforded than in this — by instructing the patient how to use the catheter for himself, and afterward employing vesical injections. The nervous impressibility of calculous patients is usually so con- siderable, and the influence of fear, anxiety, and painful anticipation upon the action of the bladder is so marked, that it is good practice, when the patient is .in condition to have his stone crushed, for his surgeon to give him no previous notice of the fact, but to introduce the lithotrite as on previous visits — where it was done for exploration — to seize the stone, if it should lie favorably, and crush it without fiirther ceremony. riG. 7s. Fig. so. TxsTEF3IE^-TS EEQuiEED POE THE OpEEATiox.— The surgeon who would master the art of lithotrity must make himself thoroughly famihar with the construction and qualities of the instruments which have been contrived with the object of reduciag a stone in the bladder to powder. The lithotrite is the perfected result of many trials, and of the correc- INSTEUMENTS EEQUIEED. 285 tion of faults, as found out by experience, in instruments previously in- rented, modified, and thrown aside. Amussat and Key had recently sstablished the fact that straight instruments could be passed through the urethra into the bladder with a certain degree of facility, and for this reason, apparently, the earlier efforts to bring a perforatino-, grind- ing, or triturating power to bear upon the stone were made by Civiale ind his followers, with straight instruments. This surgeon made his first great success with his " litholabe" — a straight instrument — and for Fig. 81. Fm. 82. ;en years no other than straight instruments were used for lithotrity. The " trilabe "—also known as Hunter's forceps (Fig. 78)— is still oc- sasionally employed to catch last fragments, and in case of impaction )f a fragment in the urethra. About the year 1834 the articulated ithotrite of Jacobson (Figs. 79, 80), and tbe curved lithotrite, with jaws 280 LITHOTEITY. to open and shut, devised by "Weiss, of London, began to be substituted for the " trilabe," and Heurteloup so modified this latter invention that percussion, bj means of a hammer applied to the free extremity of its movable or male blade (Fig. 81), could be brought to bear upon the stone. Heurteloup also used a table to which the patient was strapped, so constructed that the position of his whole body, and consequently of the stone in the bladder, could be changed at wiU, thereby placing it in the surgeon's power to bring the stone within the grasp of the jaws of the instrument, without moving the latter. This mode of operating, though eifective in the hands of its inventor, was soon discarded as too cumbersome, and the use of the hammer and percussion has been gradually superseded by lever-power, in the form of the rack an^ pinion, and of the screw. The rack and pinion was first adapted to Weiss's curved instrument by Sir William Fergusson, in 1834 (Fig. 83). By this mechanism a certain jerking impulse may be added to the crushing force which it exercises upon a hard stone, resembKng in some degree that of the percussion-hammer. The lever-power in Fergusson's instru- ment is necessarih' regulated by the diameter of the handle, by means of which the force is applied, and the strength of the operator's hand. It is worthy of remark that the use of the screw, first proposed, in 1824, by Weiss to Sir Benjamin Brodie, was rejected through fear of vio- lence to the walls of the bladder from the explosive force with which fragments of stone were scattered by it, the difference in this respect, between cracking a dry stone in the air and one sodden with moisture in a fluid medium, not having been correctly estimated. This fear has been proved by experience to have little foundation. Yet, although actually employed by Hodgson, in the Birmingham Hospital, in 1825, the screw did not come into general use until ten years later, after the rack and pinion had been proved to be both harmless and efiicient. The greater eflBciency of the screw as a power, and the ease and smoothness of its application by the mechanism now in use, have led to its very general adoption. It is well for the beginner to select a certain form of instrument, and always use it ; he will thus gain the advantage that comes from familiarity. In a recent report from Sir Henry Thompson, of one hundred and eigbty-four consecutive cases of lithotrity, he states that he employed in this wide range of operative experience — which must have embraced all the varieties of calculous disease properly remediable by the crushing operation — but two lithotrites, a stronger instrument for first crushings, and another, with plain blades, for reducing the fragments to powder. These instruments, known by his name (Fig. 83), are at the present time very generally in favor, and with justice, for the perfection of their con- struction leaves little to be desired. French lithotrites (Fig. 84), which have essentially the same construction, with slight differences in detail, INSTRUMENTS REQUIRED. 287 may be possibly superior in finish ; but, where the full power of the crush- ing instrument is wanted, the English steel is more reliable. A less practised operator would probably require also a third lithotrite, with broader, shorter, and entirely smooth, plain blades or jaws for finding last fragments and making explorations and measurements. Formerly, when it was thought desirable to bring away as much as possible of the Fia. 83. Fig. 84. Fro. 85. Fis. 86. detritus of the crushed calculus between its jaws, this style of instru- ment was known as the scoop-lithotrite (Fig. 83). At the present time this is not considered good practice, as it exposes the neck of the bladder and the urethra to risk of injury. In describing a lithotrite, we speak of its " handle," " shaft," and 2SS LITHOTRITT. " beak," or short-curved extremity. The point at which the beak joins the shaft of the instrument is its "angle," and this should be some- what greater than a right angle, but not exceeding 120°, as, be- yond this, power would be sacrificed to facility of introduction. Re- garding the lithotrite as a sort of sliding forceps, we recognize a " female " (Fig. 85) and a " male " blade (Fig. 86.), the former larger, heavier, forming the greater proportion of the instrument at its beak and shaft, which is deeply grooved for the reception of the male blade ; the latter, called by some the sliding-rod, more slender, but carrying the screw at its handle, is intended to move backward and forward in the groove of the female blade, and here the finish should be perfect, in or- der to avoid friction. When the male blade is pushed forward as far as it will go — pushed home — the beak of the lithotrite is closed and solid ; as it is moved backward, or w^ithdrawn, the jaws of the instrument are in the same degree opened. A measuring scale marked on the front of the handle of the lithotrite indicates, with exactness, the extent of this opening. The jaws of a lithotrite vary in strength and structure in accord- ance with the work required of them. For the exertion of the greatest degree of crushing power, as when brought to bear upon a stone of size and hardness, the jaw at the end of the male blade is narrow and fashioned into deep and sharp angu- lar teeth, while its fellow is broad, heavy, and " fe- nestrated" (Fig. 87); that ^^mZNN-lZ~^^ is, furnished with a longi- j-ie ST. tudinal slit, or window, at its centre, through which detritus and fragments are forced, as the jaws are closed, thus preventing clogging, or impaction. These jaws are also of as great length as the necessity of their being worked in the limited cavity of the bladder will permit. Hence the calculus upon which their teeth cannot be firmly fixed may be fairly regarded as beyond the reach of the crushing operation. TMiere less power is required, as in crushing small or soft calculi, or in pulverizing fragments, the jaws of the lithotrite are shorter, and less heavy, and their opposing surfaces are simply roughened (Fig. 86). With this instrument, Sir Henry Thompson tells us, he does nine-tenths of the work. In the so-called " scoop " lithotrite, the extremity of the female blade is excavated into a shallow, spoon-like cavity, and both jaws are short and smooth. In the two latter instruments there is a small opening at the angle of the female blade for the escape of detritus ; and the angle of the male blade, in all of them, is purposely made its point INSTKUMENTS REQUIRED. 289 of least strength, so that if fracture should possibly occur, it must take place at this point, and the resulting fragment be small and easily removable. The " beak " of the lithotrite, in all forms of the instrument, should be perfectly smooth and well rounded externally, the jaws of the female blade being in all cases wider, so as to receive that of the male blade into its cavity ; and the edges of each carefully beveled, so as to offer the least possible chance of catching a fold of mucous membrane between them as they come together. The " male blade " can be readily detached from its fellow, for the purpose of cleaning the instrument. In its handle is lodged the power, an endless screw, vcorked by a wheel which forms a part of it (Fig. 86). The " female blade," in the English instrument, is furnished witli a fluted cylinder at its handle, for convenience of manipulation (Fig. 82). Here we find a button (Fig. 87, Ms), connected with a small cog consisting of a few threads of a female screw movable by applying a thumb to the button, and so constructed that, by this simple movement, it can be thrown into or out of connection with the endless screw in the handle CTIEMANN-CU. Tig. 8T (bis). of the male blade. By this simple and ingenious mechanical con- trivance, a power is held in reserve which may at any moment be brought to bear upon an object grasped between the jaws of the lithotrite. In the original instrument of Weiss, the screw was worked by hand like a gimlet, and, when screwed home, and the stone or frag- ment crushed, it was necessary to unscrew it again by the same slow movement, before its jaws could be opened sufficiently to grasp another fragment. The contrivance at present in use was devised by CharriSre, the ingenious surgical-instrument maker of Paris, and is called by the French the " 6crou brisee." In the French lithotrite the screw-power is thrown in and out of gear by a quarter-turn of a movable disk, attached to the handle of the female blade, and this takes the place of the button-trigger of the English instrument. In studying the instruments employed in lithotrity it must be borne in mind that the object of the operation is to reduce a stone to powder, with the least possible risk to the bladder or urethra. This risk comes from contact of the necessary instruments, and of fragments of stone as they escape. In the construction of the modem lithotrite, the avoidance of injury by contact has been kept scrupulously in view, while preserving 19 290 LITHOTKITT. enough strength to accomplish its purpose. Hence its greater lightness as at present used ; the force of contact is materially diminished. The beveling of the edges of the jaws of the lithotrite, to prevent nipping of the mucous lining of the bladder, the slenderness of its shaft, to obviate friction against the walls of the urethra, and its general smoothness and accuracy of finish, all conduce to this general object. It is obvious that, the greater the power of the instrument, the greater the risk to tlie bladder. For this reason the heavier lithotrite is resorted to only in case of absolute necessity, almost all the work being accomplished by the lighter one. When a stone or fragment is seized by one of these, and its power proves insufficient, the stone will slip from the grasp of the instrument; the comparative smoothness of its jaws favors this result. In the rare cases where too hard a stone is fairly between the dentated jaws of the lithotrite of greatest power, the operator will distinctly recognize the recoil and spring of his instrument as he turns the screw, and he must use his tact and judgment in not urging it too far. Yet, cases in which a lithotrite has broken in the bladder are singularly infrequent, especially so since lithotrity with modern instru- ments has been so generally employed. It will be evident, from what has been said, that the lithotrites of the present day are designed to crush calculi in the bladder, and to reduce their fragments to coarse powder, so that the debris thus produced may readily pass with the urine. Formerly it was a part of the operation to remove the debris after crushing, and scoop-lithotrites, made especially for this purpose, were employed. As experience has increased, it has come to be regarded as a principle essential to the success of the crush- ing operation to avoid ofBciousness in the use of instruments, and to trust as much as possible to the efforts of Nature. Hence the surgeon confines his efforts to thoroughly reducing the calculus to powder, and confidently leaves the result to the expulsive power of the bladder — which experience has shown to be fully adequate to this end. There are cases, however, in which the tolerant condition of the blad- der invites lithotrity, but where the bladder's contractile and expulsive power is defective ; where an obstruction or dam has been formed at its outlet by an enlarged prostate ; or where both of these disabilities coexist. Here, if the patient has abeady learned to pass a catheter for himself, an instrument — flexible, or of silver — of larger calibre and with larger eyes may be substituted for that in ordinary use, and, if suflSciently docile, he may be taught to wash out his bladder with tepid water (p, 196). Otherwise, after the stone has been crushed, the evacuating catheter (Fig. 88) must be employed by the surgeon. This instrument is made, preferably, of polished iron, of as large calibre as the urethra will admit, with a large, oval opening at its convexity, and provided with a jointed stylet (a), terminating in a roughened head — by means of which a fragment, accidentally lodged in the instrument or at its eye, INSTRUMENTS EEQUIKED. 291 may be promptly crushed or forced back into the bladder, if the current of water should prove insufficient to dislodge it. The caoutchouc bag (b) is better than any form of syringe ; it can be used with one hand, by the patient himself, and with less risk of violence to the bladder. There is a certain advantage in teaching a patient to use instru- ments for himself ; where atony exists, this must be done sooner or Fio. sa Fig. 90. later, and the sooner the better. But, if time presses, or the patient be slow in learning, it may be necessary for the surgeon to act, and, m any case, he should lead the way. The evacuating catheter is better introduced while the patient is on his back, and a little tepid water thrown in— a four-ounce bagful, if the bladder will receive it. Then let him get into the upright position and 292 LITHOTRITT. lean a little forward, while as mucli more water is injected as will bring on a slight sensation of distention, or desire to urinate ; at this moment withdraw the catheter a very little, so that its eye is just at the outlet of the bladder, and then disengage the nozzle of the injecting-bag and let the water escape. If gently managed, this manoeuvre can be re- peated several times without too much fatigue to the patient, or to his bladder, and it is the most effectual method of getting rid of the d(iiru of a stone, where the bladder cannot act for itself. There are other modes of accomplishing the object, which may be employed where the patient is unable to assume the upright position, or where it has been thought better to operate under the influence of an ansesthetic. Clover's apparatus (Fig. 89) consists of a large-eyed me- tallic catheter, such as has been described, to the nozzle of which a powerful sucking-bottle of caoutchouc, with a cylindrical reservoir of glass at its neck, is adapted. This has been modified in Paris b}' substituting an exhausting-pump for the caoutchouc bag (Fig. 90). There is some danger, when suction is employed, of drawing the mucous membrane of the bladder into the eye of the catheter. The ordinary enema or self-injecting apparatus of caoutchouc, with a glass reservoir let into the tubing at a short distance from its nozzle, is also of practical utility. Additional tubing can be added, if desired, to any length. The fragments can be seen collecting in the transparent reservoir, while the supernatant fluid is thrown back into the bladder. Before finally withdrawing the evacuating catheter, the patient should be again in the horizontal position, and, the instrument being advanced a little farther into the cavity of the bladder, the pointed stylet should be reintroduced. This precaution is necessary, in order to get rid of a frag- ment possibly impacted in the eye of the catheter, which might cause laceration in withdrawal, as well as to close this large opening, the edges of which would be liable to occasion a similar accident. The double catheters employed for washing out the bladder by a continuous current are not suitable for the present purpose. The channel of exit cannot be made large enough to serve eificiently in the evacuation of debris without increasing the diameter of the instrument beyond a convenient size. The best of them, that of Mercier, of Paris (Fig. 91), has this fault. There are conditions, however, in which such an instrument might render service. The large opening or eye at the beak of the evacuating catheter is made, in some instruments, at either, or on both sides, at its concavity or convexity. In the use of all evacuating catheters it is well to exercise caution as Tig. 91. IMPACTION OF A FEAGMENT IN THE URETHRA. 293 to over-distention of the bladder by the injected fluid, especially in a patient who is insensible. Fluids under pressure transmit force equally in every direction, and in much greater degree than seems probable to one who has not given especial attention to this point. Moreover, it is one of the objections to lithotrity that it leaves the bladder with a ten- dency to atony, and this is a condition readily produced, or aggravated, if alreadj' existing. Whenever it is feasible, the urine passed after the crushing operation has been performed, or the washings of the bladder — if artificial evacu- ation has been effected — should be passed through a strainer, and this should be provided before crushing. A piece of muslin, substituted for the perforated bottom of an ordinary tin colander, and kept in place by a movable ring or band slipped on its projecting bottom rim, makes a very good strainer. Such a contrivance may be placed upon an ordinarj' chamber-vessel, and so used ; or, if the patient passes his urine while in bed, the contents of his urinal should be poured upon the strainer, so that all detritus escaping from the bladder shall be surely collected. IstPACTiON OF A Feagmbnt nvf THE Ueethea. — A fragment of the crushed calculus may lodge in the urethra, and require surgical aid to effect its removal. This accident, formerly not infrequent, and greatly feared, occurs rarely in modern practice. Its frequency in the early his- tory of lithotrity — Leroy d'EtioUes says it is to be expected once in every four cases — was due to the impatient desire to see the immediate effect of the operation, which led to early and unrestrained efforts at voiding urine to get rid of the result of the crushing. The surgeon, also, considered it his duty to bring awaj' as much as possible of the crushed stone between the jaws of his lithotrite, after each operation — a frequent cause of abrasion and laceration of the lining membrane of the urethra, producing, naturally, an irritable condition of the muscular tis- sue surrounding it, and a tendency to spasmodic contraction. Such a condition would greatly favor the arrest and impaction of a sharp angu- lar fragment, or even of a round or smooth one, which, in a healthy ure- thra, would find its way out readily. At the present day, every precau- tion is taken to avoid injury to the urethra, and the patient is not allowed to pass water in the upright position for at least twenty-four hours after an operation of lithotrity. Moreover, the surgeon makes it a point to pulverize the fragments of the stone as thoroughly as possible, and the improved construction of his instruments enables him to do this without fatigue or injury to the bladder. Yet, the accident will occa- sionally happen, and it is well to keep the possibility of its occurrence in view under the following circumstances : when operating upon young and irritable subjects ; whenever uncontrollable spasm of the bladder comes on, as it sometimes does, after a crushing ; and, especially, when stricture, or any lesion of the urethra, has existed. The varying dimensions of the urethral canal explain why impaction 2M LITHOTRITT. of a fragment occurs, almost of necessity, at certain points where it is narrowest, viz. : at its membranous portion just behind the hole in the triangular ligament, where also the presence of the cut-off muscular fibres especially invites the accident; at the middle of the spongy portion, where the urethra, after its enlargement opposite to the bulb, has again gradually diminished in calibre ; and, finally, just within the external meatus. At each of these points the removal of an impacted fragment calls for a different surgical manoeuvre. If lodged in the bladder-side of the opening in the triangular ligament, or in the grasp of the " cut-off'" muscles, it is to be gently pushed back again into the bladder. This Fig. 92. Fig. 93. Fig. 94. has been effected most frequently, perhaps, by the introduction of an ordinary full-sized catheter ; but the following is more perfectly adapted to the purpose, namely, a metallic catheter of the largest size, with an open end, containing a bulbous stylet that fills the open end during IMPACTION OF A FKAGMENT IN THE UEETHKA. 295 fntroduction, and when in contact with the calculus can be withdrawn, so as to leave a cup-like cavity,' with rounded edges, to inclose the fragment more or less completely. Should the fragment prove to be immovable without the use of force, which must always be avoided, the injection through the catheter of water, olive-oil, or flaxseed-tea, as warm as can be borne, will aid the manoeuvre. When a fragment has freed the opening in the triangular ligament, and has lodged at a point in front of it, an attempt to push it back into the bladder is not advisable. Fig. 95. The proper course now is to withdraw it through the meatus. I'or this purpose a variety of instruments have been devised, their number sug- gesting the idea that the proceeding is not devoid of difficulty ; and, in view of the danger of laceration of the urethra, this is not without truth. The best of these instruments is the simple, long, urethral forceps (Figs. 92, 93, 94) in one of its forms. The instrument represented (at Fig. 93) has one solid blade, while Fig. 94 is jointed so as to work by double lever. The former is more efficient. Ordinary urethral forceps (Fig. 93) should always have long, slender blades, with spoon-shaped jaws, slightly roughened on the con- cavity, and handles that cross each other, so as to prevent over-distention of the meatus when the jaws are opened. The flat, jointed, urethral Fio. 96. scoop of Leroy d'Etiolles (Fig. 95) still remains in favor. It is introduced, open {A), a little beyond the fragment, and then, by turning a screw at its handle, the little spoon-shaped beak is gradually brought to a right angle with the shaft (JB). Although this ingenious instrument has a certain degree of efficiency, yet, as the walls of the urethra are not protected by it from contact with the rough surface of the frag- ment, abrasion will almost certainly occur as the latter is being with- drawn. This liability is best avoided by crushing the fragment in the 296 LITHOTKITY. urethra, and for this purpose delicate lithotrites have been constructed ;■ but they all expose the walls of the urethra to danger, and are, prac- tically, unsafe instruments. The best of them is the " brise-pierre urethral " (Fig. 96) of Reliquet. This instrument can be used as a deli- cate, hook-like scoop, which is to be inserted behind the fragment, by appropriate manipulation. When this is accomplished, a stylet con- tained in the male blade is pushed down upon the fragment, to fix it in position. If, now, the fragment cannot be withdrawn without force, a tube, with sharp teeth at its extremity, which slides upon the stylet, is brought to bear upon the fragment, and it is reduced to powder, by turning a screw at the handle of the instrument, and also by rotating the stylet, which acts as a perforator. The male blade, which consists of this hollow tube and its contained stylet, is furnished with a rounded lateral process near its toothed extremity, which serves to push aside the urethral walls, and save them from injury during the crushing. The stylet may be withdrawn entirely, and warm water injected into the urethra to wash away detritus, if necessary. To get the scoop behind the fragment, let an assistant compress the urethra just beyond it to prevent the convexity of the scoop from pushing it back into the bladder, and then, by bending the penis to a right angle, or even beyond, and at the same time push- ing the convexity of the scoop against the lateral wall of the urethra, the beak of the instrument can be inserted between the latter and the fragment which, by a spoon- ing movement, is scooped into its con- cavity (Fig. 97). Next to this instrument, in safety and efficiency, is the straight " trUabe," or three-bladed lithotrite, used Fie. 97. by Civiale, originally employed by John Hunter (Fig. 78). Its mode of use hardly requires description. A simple loop of wire, in the absence of other instruments, may be improvised successfully ; and, in any case, this con- trivance might be useful in aiding to alter the position of the fragment, so as to bring it within the grasp of the forceps. "When the point of arrest of the fragment is found to be just within the orifice of the urethra, or in the fossa navicularis — a form of the accident that occurs most frequently in children, in whom the expulsive power is great, and used without restraint — it is generally advisable at once to enlarge the orifice, with a delicate bistoury, or Civiale's mea- totome (Fig. 43). There are cases of impaction in which the fragment is small enough to pass readily under ordinary circumstances, but is held in place solely by s2Msinodic contraction, so readily provoked in an irritable or unsound IMPACTION OF A FRAGMENT IN THE UIIETIIKA. 297 urethra. In such a case, if a very small bougie can be insinuated beside the fragment into the bladder, and left in place a few hours, its presence will often quiet the spasm, and lead to the spontaneous evacuation of the fragment. In any event this manoeuvre will tend to relieve reten- tion, which is often so distressing, in cases of impaction ; for the urine will generally find its way out alongside of the bougie. The spasm and retention produced by an impacted fragment in the urethra are liable to be soon followed by rigor and febrile reaction ; and these symptoms are often very severe in their character, considering the apparently trifling nature of the obstruction. If the difficulty re- main unrelieved, these symptoms persist, and there is danger of local ulceration, urinary infiltration, and abscess. It may become the duty of the surgeon, therefore, if the fragment cannot be withdrawn by the aid of instruments, to cut down upon and remove it at once. When deep in the urethra, this is not an easy operation, and it might be necessary to split the scrotum in order to reach the fragment. In front of the scrotum it is easy enough to out directly upon the fragment, and to get it out ; but, after a wound of this portion of the urethra, a fistulous opening is likely to remain, and this is not easy of cure. These considerations relating to the possible lodgment of calculous fragments in the urethra, after the operation of lithotritj', are equally applicable to those cases, occurring perhaps even less infi'equently, in which renal or vesical calculi are arrested in the urethra during spon- taneous effort to escape — no operation of any kind having been at- tempted. CHAPTER XVI. LITHOTBITT. lithotrity continued.— Position of the Patient. — Introduction of the Lithotrite. — ^Method of catching the Stone. — Precautions in crushing. — Manoeuvres for catching Stone not easily seized. — Subsequent Crushings after one Successful Effort. — How to find Last Fragments. — Complications in Lithotrity, their Signiiicance and Management. The position of the patient during the operation of lithotrity is of great importance, for upon it depends the position of the stone in his bladder. A movable stone, in a bladder partially filled with urine, will be found, with very rare exceptions, occupying its most dependent point. Tfie patient must be so placed, therefore, if possible, that the lithotrite when introduced may be carried directly to the stone lying at the bot- tom of the bladder. The shape of the bladder, which changes materially at different periods of life, must be considered before determining what part of its cavity, in different positions of the body, is the most depending. In the child's bladder, in the erect position, the neck is its lowest point. 298 LITHOTRITY. When full, the bladder — ^in early life — is pear-shaped, with its broadest part above, vertical in position, and lifted high out of the pelvis. A movable calculus always drops, therefore, into its funnel-shaped neck ; hence the more exaggerated pains which the child suffers. When he lies down upon his back in the horizontal position, the stone will neces- sarily roll backward toward the fundus of the bladder, which has be- come, by this change of attitude, its most depending portion. And, now, a lithotrite entering the bladder would tend to glide down a gently- inclined plane, at the bottom of vrhich its beak would almost of neces- sity come in contact with the stone. On the other hand, the old man's bladder is no longer pear-shaped ; the most capacious portion of its cavity is below, and the increased size at its base tends to tilt its vertex forward. In the erect position there is a distinct excavation below the level of its outlet ; a stone would, therefore, tend to gravitate into this cavity, and away from the neck of the bladder, which also has now lost in a great measure its conical shape. In the horizontal position a lithotrite, having freed the orifice of the blad- der on entering, would no longer tend to glide down an incUned plane ; on the contrary, its angle would project over a cavity, and, if pushed forward, the convexity of its beak would come in contact with the pos- terior wall of the bladder at a point above the level of its floor— the stone occupying the cavity below the shaft of the instrument, and, un- less of considerable size, not having been touched by it. If he should elevate the handle of the lithotrite in order to carry its beak into this cavity in search of the stone, the operator would do violence to the neck of the bladder and prostatic urethra — which is to be especially avoided. The difficulty is met by simply elevating the pelvis sufficiently, by means of a cushion placed beneath the hips, to cause the stone to roll out of the lower cavity of the bladder, and along its floor and back wall — now become its most dependent portion — to the point at which the litho- trite would naturally come in contact with this portion of the bladder. This change in shape of the bladder takes place gradually as life ad- vances. Where the prostate is the seat of enlargement, or where an hori- zontal "bar" has formed at the outlet of the bladder, elevating its in- ferior margin, it is more marked. It is in these cases that the " bas- fond " of the bladder reaches its greatest development. Here, then, the elevation of the pelvis is to be carried to the greatest degree — a hair cushion of six inches' thickness being often required, or even more. The pelvis is to be raised absolutely above the level of the shoulders. If the head be flexed forward and supported by a pillow, this position wiQ not be attended by discomfort. It was this power to determine the position of a stone in the bladder by modifying the patient's attitude that led Heurteloup to insist on the value of his operating-table, which could be lifted and depressed at either end, as on a pivot. Thompson finds a couch of somewhat similar construction of great value in searching for stone. INTRODUCTION OF THE LITHOTKITE. 299 It is obvious, then, that one of the conditions for successful lithot- lity is to place the stone at that point, within the cavity of the bladder, at which it can be found with most certainty by the lithotrite, and with the least necessity of search for it, and of consequent prolonged contact of the instrument with the bladder ; and that the sargeon has the power of effecting this by regulating the position of his patient. Before the patient is placed in position for the introduction of the lithotrite, from four to six fluid-ounces of urine should have been allowed to accumulate in the bladder. This presupposes a capacity of retaining the urine from one and a half to three hours. For a small stone, requir- ing the smaller lithotrite, the lesser quantity would suffice ; but this is the minimum. "When the stone is larger, a proportionally greater area is required in the bladder for safe manipulation with the lithotrite: If the patient should be unable to retain his urine long enough to allow the necessary quantity to accumulate, this is the best evidence that his bladder is not yet in a fit condition for the operation of lithotrity. Nothing is to be gained by the injection of tepid water, with catheter and syringe, as formerly practised. The soothing influence of the warm water is more than counterbalanced by the additional manipulations re- quired for its injection, and the consequent lengthening of the operation. It is better, practically, that the patient should be induced to hold his water for the required period, as he had previously been instructed to do for preliminary explorations ; and, in fact, that at the time of the opera- tion he should anticipate nothing more than a preliminary exploration. He will thus be saved, in a great measure, from the increased nervous susceptibility that always attends the anticipation of a surgical opera- tion, which, it may be remarked, affects the bladder more than any other organ of the body. If, as sometimes happens, the urine should be ejected as the lithotrite enters the bladder, in consequence of the sudden invasion of spasm, the lithotrite should be immediately withdrawn in the gentlest manner, and the operation deferred. It is evident that, for some reason, the bladder is not in a favorable condition ; and, under these circumstances it is wiser neither to attempt to coax nor force it, by injecting warm water — for this is the only alternative, if the operation is to be accomplished with- out delay. Intbodtjction' 01" the Lithotbitb. — A suitable instrument having been selected, and well oiled, the operator places himself on the patient's right side and inserts its beak into the orifice of the urethra, drawing the penis gently upon the lithotrite with the right hand, as though it were a glove-finger upon a finger, while he balances the instrimient lightly in the left, gradually lifting the handle as its beak advances. The handle is thus slowly raised until the shaft of the lithotrite becomes vertical, and, while it is still held in the left hand, the fingers of the right, thrusting the scrotum aside, follow the prominence of its angle as 300 LITHOTKITT. tlie point of the beak advances into the perinseum. The instrument is to be supported in this position until, by its weight, it sinks deeply enough into the perinaeum for the point of the beak to engage in the opening through 'which the urethra traverses the triangular ligament. If there should be any delay here, the fingers of the right hand may as- sist by slightly changing the direction of the beak, or, possibly, by lift- ing it a little, if below the orifice of the triangular ligament. When the point of the beak has fairly engaged in this narrow strait, the handle of the instrument should be transferred to the right hand and allowed to fall gradually, by its own weight, toward the feet of the patient. Just before the shaft of the lithotrite has become horizontal, the point of its beak, in the young subject, wiU have freed the upper margin of the orifice of the bladder and entered its cavity, and, a moment later, the convexity of its angle, having glided meanwhile along the floor of the prostatic sinus, frees the lower margin of the orifice, and a sense of freedom of motion of the beak of the instrument informs the operator that it has fully entered the cavity of the bladder. In a patient who has passed middle life, the lithotrite does not always enter the bladder so smoothly. A tendency to increasing excavation of the floor of the prostatic sinus, as well as the similar change of shape, already described, in the floor of the bladder, has the effect of elevating the inferior margin of its outlet. In this manner a sort of transverse barrier is opposed to the easy entrance of the beak of the lithotrite into the bladder ; and, when it does enter, there is a good deal of friction of the shaft of the instrument against this barrier during subsequent ma- nipiilation. This is a condition of very common occurrence after middle life, and not necessarily caused by, or complicated with, an enlarged prostate. When there is enlargement of the prostate, this transverse bar almost always exists to some extent, sometimes in an exaggerated degree ; and, in rarer cases, its central portion assumes the shape of a conical eminence which opposes the farther advance of the lithotrite, unless, indeed, it can be made to pass by being carried on either side of this " middle lobe." In addition to the obstruction liable to be thus offered to the passage of the lithotrite, if the lateral lobes should be irregularly or unsymmetrically enlarged, the prostatic portion of the canal, besides being increased in length, becomes also more or less tor- tuous in its course, and its walls will be found to be comparatively rigid and unyielding. It is easy to understand how the beak of a lithotrite might be impeded in its progress through such a passage, and also that great gentleness must be exercised to avoid abrasion of its delicate lining membrane. Pressure, applied by the operator's left hand at the root of the penis so as to aid in stretching its suspensory ligament, wiU very greatly assist the passage of the beak in such cases. Indeed, this manceuvre always aids the passage of the lithotrite while its beak is traversing the prostatic portion of the urethra. Without it the suspen- INTEODUCTION OF THE LITHOTRITE. 301 sory ligament is stretched entirely by the leverage afforded by the handle and shaft of the instrument, and the point of its beak is presented to the roof of the urethra in an unfavorable direction and with an unpleas- ant degree of force, altogether incompatible with the easy, gliding move- ment that is desired. When the urethra is surrounded by an enlarged prostate and nar- rowed from side to side by the encroachment of its lateral lobes, it is at the same time correspondingly increased in its vertical diameter; and this peculiar change of shape in the prostatic urethra, together with the delay in reaching the bladder in consequence of the increased length of the passage, is likely to lead to the error, on ths part of the operator, of depressing the handle of the lithotrite too soon. For the greater depth of floor and height of ceiling of the prostatic urethra under these cir- cumstances will readily permit the beak of the instrument to rise into its cavity, and the operator, regarding only the depth to which his litho- trite has penetrated, may readily deceive himself with the idea that its beak has entered the bladder, when, in reality, it is still in the prostatic sinus. , The difficulty experienced in inclining the beak of the lithotrite from side to side, by rotating its handle, will at once correct this wrong impression. By again elevating the handle of the instrument, so as to depress its beak, and very gently urging it forward, with patience and care it will probably soon glide into the larger cavity of the bladder. The great depth to which the lithotrite penetrates, in cases of enlarged prostate, before its beak is fairly lodged in the bladder, will pretty surely surprise the young operator. In this connection it is well to con- sider the very great lever-power developed by depressing the handle of the lithotrite when its beak is deeply lodged in the urethra. If this movement should be attempted prematurely — for example, before the beak had engaged in the narrow passage through the triangular liga- ment — there would be danger of forcing it with dangerous violence against the roof of the urethra, perhaps of producing laceration. But, after the beak has entered the prostatic sinus, the leverage is still greater, for the lower margin of the opening through the triangular ligament would now serve as a fulcrum to the lever, while the length of the shaft of the lithotrite and the weight of its handle give dangerous power to its longer arm. It behooves the operator, therefore, to manage it with a light hand, and much caution. Although obstacles may be encountered in introducing the lithotrite where there is an enlarged prostate, it is proper to remark that, in many of these cases, the enlargement of the prostate affects mainly its outer circumference ; it is " peripheral " rather than " central," and the urethra may be as free and capacious as could be desired. When the sense of freedom of motion conveyed to the hand of the operator announces to him that the beak of the lithotrite has fairly en- tered the bladder, he still maintains the shaft at the same angle with 302 LITHOTEITY. tlie patient's body it iiad when entering, and allows the beak of the in- strument to glide slowly onward, as far as it will, listening intently, so to speak, with his fingers, for its contact with the stone. When the cal- culus is movable, and the position of the patient has been judiciously adjusted, with the proper quantity of urine in his bladder, it will gen- erally happen that, before the convexity of the beak of the lithotrite is arrested in its progress by the posterior wall of the bladder, the stone will have been touched by it ; and the operator should be able to say, at once, on which side of the instrument the stone is lying. He now very cautiously turns its beak a little away from the stone, and, by gently with- drawing the male blade, opens the jaws of the instrument widely enough to grasp it. The beak of the lithotrite is rotated away from the stone before moving the male blade, in order to prevent the concavity of its jaw, as it is being withdrawn, from striking the stone and thus altering its position; and the previously-ascertained size of the stone deter- mines, by reference to the graduated scale on the handle of the instru- ment, how widely its jaws are to be opened. It is to be observed that the female portion of the lithotrite is held lightly but steadily in its place by the left hand of the operator, while the instrument is being opened, the convexity of its jaw pressing gently against the posterior wall, where this latter meets the floor, of the bladder ; the male blade only is moved, and by his right hand. The jaws of the lithotrite being now open, are to be turned toward the stone, by rotating the handle of the instrument, so as to incKne them to the horizontal position, or until further rotation is resisted, and gently closed upon it. As soon as the stone is felt to be fairly and firmly grasped between the jaws of the lithotrite, the instrument is rotated back again until its jaws are verti- cal, as before they were opened, and the button-trigger, at its handle, is pressed back by the thumb of the right hand, thus fixing the male blade, and at the same time bringing the screw into gear; then, by slowly turning the wheel, the screw-power is applied to the stone. Before turning the screw, the operator should satisfy himself, by the slight withdrawal and partial rotation of the lithotrite, with the calculus in its grasp, of the perfect mobility of the instrument in the bladder, and that no portion of the lining membrane of the latter has been included between its jaws. This caution, formerly very much insisted upon, has lost much of its force since the construction of the lithotrite has been made so perfect that the nipping of the bladder is almost impossible. Still, it should not be forgotten. Usually the practised hand will receive satisfactory evidence of the absence of entanglement with the walls of the bladder, while tm-ning back the jaws of the lithotrite to their original position, after picking up the stone, and in withdrawing it a trifle so as to insure the safety of the posterior wall of the bladder from contact, while the screw is being turned. As the jaws of the lithotrite are slowly closing upon the stone, the PKEOAUTIONS IN CRUSHING. 303 operator will recognize, possibly both by hand and ear, a sharp cracking, or a softer crushing sensation, according to the nature and degree of hardness of the calculus. Having screwed the male blade well home, he then slips the trigger forward by a motion of his right thumb, and opens again the jaws of the instrument. And now, as experience has demon- strated that when a calculus is large enough to make several fragments, under the crushing of the lithotrite, they all fall together at the bottom of the bladder, it is only necessary for the operator to turn the open jaws of the instrument toward the same spot at which the stone was first seized, and, on closing them, he will almost inevitably seize a fragment. This manoeuvre may be repeated again and again, from once to three or four times, or even more, according to the skill of the op- erator, and the tolerance of the bladder; but the whole proceeding should not occupy a longer time than from three to five minutes, the former for first crushings and sensitive subjects, the latter where the tolerance of the bladder has been proved. This is a rule that the lithot- ritist should always respect. It would involve possible risk of injury if an instrument were simply allowed to remain in an ordinarily healthy bladder for the space of five minutes ; how much more when all the manoeuvres of lithotrity are superadded in a bladder already irritated and diseased ! Pkbcautions in Cbushing. — To accomplish as satisfactory a result as possible, with the least risk of injiiry to the bladder, in crushing a cal- culus, there are other rules to be observed. In opening the jaws of the lithotrite by withdrawing the male blade, the operator should be cautious in limiting this movement to the assumed size of the stone or fragment, and never, if possible, bring the concavity of its jaw in contact with the neck of the bladder, as this contact always occasions pain, and might cause spasm. Always open the jaws of the lithotrite in the vertical position before rotating them in quest of a stone or fragment. It is a common error to use the lithotrite as a sound, or searcher; and, when a stone or fragment has been struck, to open the jaws of the instrument in close contact with the stone, through fear of losing it. This is bad practice. In withdrawing the male blade, to open the lithotrite, the stone or fragment thus sought is very likely to be moved out of reach by contact of its jaw. Where the stone has not been brought within the grasp of the jaws ot the instrument by skillful management of the patient's position, there are well-tried rules for finding it, with which every good operator must be familiar ; these will be shortly given in full. Again, all the movements of the lithotrite thus far described, viz., the opening and shutting of its jaws, the rotation of its shaft, and the application of the screw-power, are to be managed without altering the direction of the shaft of the instrument in its relation to the axis of the patient's body. Any deviation from the direction assumed by the 30i LITHOTRITT. lithotrite after entering- the bladder, is unnecessary for the successful performance of the manceuvres which have been described, and it will certainly involve friction or undue pressure upon, and possible injury to, those sensitive parts — the prostatic urethra and neck of the bladder — by which the shaft of the instrument is most closely embraced. It is f o be remembered that the urethra is occupied by a perfectly straight, unyielding instrument, which causes tension of the suspensory ligament of the penis, and impinges forcibly upon the lower lip of the outlet of the bladder; and that every change of direction at the ends of the instrument, which are free, bears almost entirely upon that portion of the canal included between the opening in the triangular ligament and the neck of the bladder. The operator, therefore, cannot be too careful to observe extreme gentleness and smoothness in all his manipulations, and to avoid every thing like jar or sudden motion. ^Maxcettvees foe CATcnrsG Feag5ie>-ts. — Sir Benjamin Brodie's favorite manoeuvre of gently striking the handle of the lithotrite in order to make the stone roll between its open jaws, although a success- ful expedient, has been justly criticised because it rarely fails to elicit an expression of pain from the patient. The practice of jarring the pelvis by a slight blow, applied to the crest of the ilium for the same purpose, is open to a similar objection. The increasing safety and certainty of modern lithotrity seem to be due largely to the fact that greater caution is exercised in guarding against mechanical lesion by using more perfectly-made instruments, and handling them with extreme gentleness. The principle has been established that it is safer for the surgeon to seek the stone, in a locality already ascertained, by a series of sj'stematic, well-practised manceuvres "with his instrument, than to sink the convexity of his lithotrite into the floor of the bladder, open its jaws, and then jar the instrument, or the patient's pelvis, in order to get the stone between them. In short, it involves less danger to the bladder, for the surgeon to go after the stone with his lithotrite, than to compel the stone to come to the lithotrite, held in a fixed position. The latter has been the English, practice ; the former, the method finally adopted by Civiale, and for this Sir Henry Thompson, the highest authority among living lithotritists, after fairly trying them both, expresses a decided preference. But, in truth, lithotrity as practised at the present day includes the advantages of both of these methods, their faults having been, in a great measure, eliminated by the teachings of experience. By careful adjustment of the patient's position, the exact point occupied by the stone is determined with so much accuracy, and it is brought so near to the jaws of the lithotrite, that very limited movements of the instrument are required in order to grasp it. The precise character of these movements is now to be described, and they are to be carefully studied by the operator who desires success, for he should have the details of all necessary manipulation clearly in his MAKffitrVRES FOR CATCHING FRAGMENTS. 305 mind, and through practice upon the dead body should have acquired the ability to apply them with precision as required. It has been already stated that in a patient judiciously prepared for the operation and properly placed in position, the lithotrite will strike the stone in a majority of oases, when introduced according to the rules which have been given. "When the expected contact of the stone does not take place and the beak of the lithotrite has reached the most depending point of the bladder without detecting any evidence of its position, then the operator proceeds as follows : He opens the jaws of the instrument, by withdrawing the male blade to the required extent, and inclines them first to one side, to an angle of about 45°, and then closes them ; failing to catch the stone, he inclines them to the same degree on the other side, and closes again. By one or the other of these move- ments the stone is almost certain to be caught. If not, the manceuvre is to be repeated, inclining the open jaws of the lithotrite to a greater angle, even to the horizontal position, if no resistance is encountered, and carefully closing them, first on one side of the bladder, then on the other. If it should happen, as is rarely the case, that the stone is not caught, or even touched, by any of these movements, and if the larger • lithotrite, generally required for a first crushing, has been employed, then it is wiser that the surgeon should very quietly withdraw the in strument, consider the whole proceeding as an exploration, and take time for further study of the requirements of the case — some of these not having been properly met. It is better that he should stay his hand and accept momentary disappointment, than incur the slightest unneces sary risk — especially to be dreaded after a first crushing — of unpleasant consequences from prolonged contact of the instrument with the bladder. Here the advantage is apparent of not having previously announced that the crushing operation was to be performed at a time fixed for the pur pose, as already suggested ; for the patient will have been spared not only its anticipation, but also the demoralization which might follow a suspected failure. And there are other contingencies, such as the oc- currence of an unusual amount of pain or of sudden spasm of the bladder on introduction of the lithotrite, or difficulty in seizing a full-sized stone with the lithotrite of largest curve, where postponement of the operation until another day would be judicious, the possibility of which confirms the wisdom of this policy. The experienced surgeon knows that it is useless to contend with the bladder in certain moods, and his tact leads him to defer action without hesitation, when necessary, and await a more favorable opportunity. When it has been ascertained during the preliminary study of a case that there is an excavation at the base of the bladder, behind the inferior margin of its outlet, where a stone, if present, would almost in- variably be found, and especially when there is enlargement of the pros- tate, an additional manoeuvre may be required. In this, the beak of the 20 306 LITHOTRITT. Fig. m.-(^Beliquet.) lithotrite, by rotation of the handle of the instrument, is swept round a half-circle, untU it looks backward toward the patient's rectum — ^as- suming what is called the "reversed" position. To accomplish this manoeuvre, it is necessary to depress the handle of the lithotrite between the thighs of the patient, changing the oblique direction of its shaft until it is in a line with the axis of the patient's body, or even below it (Fig. 98). This movement lifts the beak of the instrument toward the centre of the bladder, '' so that, while being re- volved in its cavity, there is less danger of rough contact with its walls. Very possibly this rota- tion of the instrument may result in contact with the stone, and afford enough indication of the position of the latter to enable the operator to grasp it at once. If not, he should proceed to incline the open jaws of the lithotrite, first to one side to an angle of 45°, and close them, and then to the opposite side and close. For this manoeuvre the lithotrite with smoother jaws is preferably used. The instrument with largest curve and longest jaws is rotated into the reversed position with some difiiculty and pain to the patient; moreover, a stone so large as to require its employment could be almost certainly recognized and seized without reversing the instrument, cei^ tainly without reversing it completely. For very small stones — where there is an excavation at the base of the bladder, or to find a last fragment — stUl another manoeuvre will be found useful, and for this the lithotrite with broad, smooth blade (Fig. 82) is ""^-....^ to be preferred. The in- strument being lodged in the bladder, is rotated in- to the reversed position, and gently withdrawn, un- til the concavity of its beak is almost in contact with the lower margin of the outlet of the bladder. The male blade being now held firmly in position, the female blade is projected until it touches the posterior wall of the bladder, and, the han- dle of the instrument being raised enough to allow the broad extremity of the female blade to impinge lightly upon the floor of the bladder, the latter is gently drawn home — raking in, as it were, any fragment that might lie in its way. Fig. n.—(Bdifpt(t.) SUBSEQUENT CRUSHINGS. 307 In both of these latter manceuvres, in which the reversed position is emplo3'ed for seizing the stone, the jaws of the lithotrite, with the stone or fragment in their grasp, are to be rotated back again into the upright vertical position in the centre of the bladder (Fig. 99) before the screw-power is applied. By the aid of the three manoeuvres which have been described, or of a combination of them, with possibly some modification required by ex- ceptional cases, a surgeon of ordinary dexterity will be able to manage successfully any movable vesical calculus, if not excessive in size or hardness, without serious injury to the bladder. But careful study of the details of manipulation and practice upon the dead body should not be neglected. It is always to be borne in mind that these movements are to be conducted invariably with deliberation, and that gentleness and smoothness of motion are especially desirable. Every thing like a jerk or sudden movement should be studiously avoided. In opening, closing, and rotating the lithotrite, as little change in the direction of its axis as possible should be permitted ; this change in direction is very liable to occur while the male blade is being screwed home, and at this moment vibration and lateral motion should be guarded against with the greatest care. In withdrawing the lithotrite after crushing, care is required lest there may remain so much debris between its jaws as to cause abrasion of the neck of the bladder or of the urethra. The scale at the handle of the instrument, with which the eye of the operator should be familiar, will teU him if the jaws are well closed. If there be any doubt on this point, or if there is complaint of pain as they engage in the neck of the bladder, let him return the beak of the instrument to the centre of the cavit}-, and unload the jaws more completely by shght, successive move- ments of opening and closing. Subsequent Crushings. — It happens in a certain proportion of oases, where the stone is small and the urethra healthy and capacious, that the patient finds himself completelj' relieved of his symptoms after a single operation. Where this is not the case, an interval of from three days to a week should be allowed to elapse before a second operation is under- taken. The length of the interval will depend upon the amount of reaction following the operation, and in some degree also upon the amount of debris discharged. After a first crushing this is usually not great, especially if the stone is hard — the fragments being mostly too large to pass. It is not customary to await the discharge of debris, unless, indeed, the amount be very considerable, in which case it is well to get rid of all that will pass within a reasonable time. I'be main point to be considered, in deciding how long to wait before a second crushing, is, whether the reaction caused by the first operation has sub- sided, or nearly so. This is to be determined by the amount of com- plaint elicited by pressure over the pubes, by the degree of irritability 303 LITHOTRITT. of the bladder as shown by the length of the interval between the calls to urinate, and the condition of the urine as to the presence of pus, as compared with the state of the patient before the operation. As soon as it is evident that no progressive trouble has been caused in the bladder, and that existing irritation is subsiding, the second op- eration should be undertaken. As a rule, it may be assumed that the bladder wiU show less sensibility after a first operation has been well borne. But exceptions are not infrequent. The presence of two or three sharp, angular fragments of a large, hard stone would tend to keep up irritation. The object of the surgeoii is now to reduce fragments to powder : he can, probably, make use with advantage of a lithotrite with shorter, smoother jaws, and allow himself a little more time for the operation. In other respects the manceuvres required are the same as those already described. The escape of detritus after a second operation is usually greater ; but this is not to be looked for too anxiously. If the object of pulveriz- ing the fragments be thoroughly accomplished, the I'esult may be safely left to take care of itself, unless the expulsive power of the bladder be defective. Too great ansietj' to get rid of the results of a crushing is likelv to result in impaction of fragments in the urethra. The surgeon's increasing familiarity with the degree of tolerance of the patient's bladder will enable him to regulate the proper intervals of subsequent crushingsas required. Usually, when conducted with proper precaution as to care and gentleness, these are borne better and better. The intervals between the calls to pass water become gradually longer, and other evidences of irritation of the bladder diminish in like degree. At length, sand and fragments cease to pass, and the surgeon has diffi- culty in finding a fragment in the bladder to crush, or fails entirely. As already stated, this result may follow a solitary crushing, or it may re- quire a score of successive operations, or even more ; usually, the num- ber is from three or four to ten, before the evidence becomes apparent that the stone has been removed. Is the patient cured ? It is not always easy to answer this question, and it is very important that it should be answered with certainty, for the retention of a small fragment might become the origin of a new cal- culous formation. The charge has been brought against the crushing operation that patients are more liable to relapse after it than after cure by the knife. The charge is probably unfounded in truth, but it obviously owes its aspect of probability to the results which have followed want of care in getting rid of last fragments. Thus, the detection of the last fragments, which is, in fact, the proving of the cure, becomes a point of much im- portance in the operation of lithotrity. Careful search should be made, therefore, with the lithotrite with short, broad jaws, by employing all tha CATCHING THE LAST FRAGMENT. 3O9 manceuvres which have been described, if necessary, to verify the ab- sence of any remaining fragment. Where all symptoms of vesical irrita- tion have disappeared, and the microscope discovers no traces of blood or pus in the urine, the patient may be pronounced to be free from stone. But where the urine remains turbid, as is generally the case — for the evi- dences of cystitis always disappear slowly, and, in old cases, never en- tirely — and this symptom is increased, or blood is detected after motion, as in riding, and there is not absolute relief from tenesmus at the close of the act of urinating, then a decision should be deferred, and the search repeated. A small fragment is more readily caught when the bladder contains a diminished quantity of m-iue. The position of the patient should be varied by more or less elevation of the pelvis, according to the nature of the case, remembering that while a small fragment is usu- ally found well back from the neck of the bladder, nevertheless, from its lightness, it is almost certain to be carried forward toward the outlet as the urine escapes. This latter circumstance is taken advantage of by employing a lithotrite with a perforated shaft, through which the urine may be permitted to escape, or injected, as desired, so that the amount of water in the bladder may be varied during the search. By placing the patient in a standing position, leaning slightly forward, with the jaws of this instrument held open at the neck of the bladder, and then allowing the urine to flow out. Sir Henry Thompson succeeded, in a verv difficult case, in catching the fragment. Of course, in this manoeuvre, the jaw of the male blade is held in contact with the outlet of the blad- der, and only the female blade moved, both in opening and closing the instruQient. Civiale's " trilabe " (Fig. 78) is also recommended by this skillful operator. It is to be held open at the neck of the bladder, in a similar manner, so that its three branches form a sort of pyramidal cage, with its apes downward, and in this, as the urine escapes through the hollow shaft of the instrument, the fragment is caught.' When there are sacculi in the walls of the bladder, or even slight depressions which have formed between interlacing hypertrophied muscular fibres, a small fragment might become so fixed in one of these as to escape detection. In such a case, full, free, and repeated injections of tepid water into the bladder would be likely to detach the fragment and bring it away, or, at least, within the reach of the lithotrite. It is favorable for the surgeon that, in searching for last fragments, he has usually to deal with a blad- der in an improving condition, the tolerance of which he has already proved and established. Under these circumstances there is room for ' I succeeded in a case, after frequent disappointment, by the following rather rouph and somewhat unjustifiable manceuTre. After opening the lithotrite in the usual position in the bladder of the patient, who was a little old man, I passed my right arm beneath his bended knees, and, holding the lithotrite and penis steady with the left hand, lifted his pelvis from the bed and brought it down again with a slight jolt. All that can be said in favor of this manoeuvre is, that it was twice successful, and that it was followed by no harm. — Van Bdeen. 310 LITHOTRITT. more freedom in manipulation, and, in the great majority of cases, there will be little difficulty in final success. Complications. — It is well to consider what modifications of the operation may be rendered necessary by the presence of complications ; for, although, when the stone has been discovered early, nothing is usu- ally more simple and sure than its cure by lithotrity, there will be inevi- tably a certain proportion of old, neglected, and aggravated cases en- countered in practice, which, by the aid of trained inteUigence and skill, may also be brought within the scope of the operation. For these the alternative is lithotomy, with its increased risks to life. Even when the calculus has been discovered, while j'et of small size, the sensibility of the urethra and neck of the bladder is, in some cases, so excessive and persistent as to constitute a positive obstacle to lithotrity. As a rule, where there is no serious alteration of texture, this extreme sensitive- ness is gradually blunted by the gentle and judicious use of instruments during the preparatory treatment. But in some cases, happily rare, this result does not follow; and each exploration, however carefully con- ducted, is succeeded by increased frequency and urgency of the calls to urinate, with pain in the bladder, radiating, from its neck as a centre, to the hips, sacrum, perinaeum, and hypogastrium. Exaggerated nervous susceptibility, of this kind, is not necessarily accompanied by pain on deep pressm-e above the pubes, or by increase in the quantity of blood or pus in the urine, and it subsides in a day or two, often sooner, to be renewed with undiminished force after each successive exploration. It is readily distinguishable from the consequences of mechanical injury to the urethra or bladder, from too rough use of instruments, by the absence of persistent febrile reactions, and of the positive symptoms of inflam- mation. Occasionally the intense nervous irritability of the subject will mani- fest itself in the shape of a chill, sometimes followed by fever and sweat, sometimes not. This phenomenon occurs more frequently, possibly, in persons who at any time have been exposed to malarial poisoning, but not necessarily. A chill may thus follow each attempt at exploration of the bladder. Here the free use of quinine is sometimes beneficial. This persistent hyperesthesia is more often encountered in the young, but also in a fair proportion of old, broken-down subjects of urinary dis- ease, and it is often due to perverted sensibility of the nerves which supply the sexual surfaces — mainly the prostatic urethra — and to the peculiar degradation of general nerve-power often associated with this morbid condition. It is analogous to certain forms of irritable strict- ure, and also to the nervous affection of the deeper portions of the ure- thra and neck of the bladder, already described as neuralgia of the vesi- cal neck. It is often associated with more or less pusillanimity of character, and its victims not unfrequently become addicted to the habitual use of alcoholic stimulants or opium. COMPLICATIONS. 311 In a case of this kind whioli has resisted gentle approaches and failed to yield to quinine, when the surgeon has satisfied himself that the usual causes of exaggerated pain are absent, and that the urinary sur- faces are in other respects in fair condition, his proper course is to have the patient placed thoroughly under the influence of sulphuric ether, and proceed at once to crush his stone. Of course, when the urethra and bladder are thus rendered insensible to rough contact of the instrument, it will be incumbent upon the opei-- ator to employ even more deliberation, and more scrupulous care in his manipulations than usual, for he is deprived of the evidence of the patient's sensations, which ordinarily serve as a warning against neglect of gentleness, or precipitation in movement. With these precautions there need be no hesitation in the employment of anassthetics. At pres- ent sulphuric ether is preferable, as by its skiUful administration the pa- tient can be more certainly rendered perfectly motionless without danger to life. It has been hitherto considered wiser to abstain from the employment of anaesthetics in lithotrity save in exceptional cases, but, with the sys- tematized manoeuvres and the perfected instruments now in use, there is no reason why the trained and careful surgeon should deprive his pa- tient, or himself, of the great advantages which it not infrequently ofi'ers in cases which are neither grave nor exceptional. It is true that in the great majority of the cases which present themselves for lithotrity, the trivial character of the pain of the operation renders ansesthesia entirely unnecessary, and it should never be employed to do away with the usual sensibility of the parts, in an ordinary case of stone ; it is far better that these should be rendered tolerable by the regular systematic train- ing to the contact of instruments during the preparatory treatment. This preparatory training is as necessary for the surgeon — to familiarize him with the condition of the patient's organs — as it is for the patient, to accustom him to the contact of instruments. For lithotrity in chil- dren, anaesthesia is a necessity ; and, in women, the recognized propriety of its employment would tend to increase the usefulness of the operation. Experience has proved that the dangers anticipated from its use have not been realized, and we are justified in the conclusion that in careful and judicious hands they are no more to be feared than in other operations of surgery, where increased risk is more than overbalanced by increased advantages. Atony of the Madder is a complication for which especial measures ai-e required. It was formerly regarded as a serious, if not an insuper- able, objection to the crushing operation ; at the present time, in view of the success attending its management, atony is rather considered an advantage than otherwise, through the freedom from exaggerated and spasmodic contractions of the bladder which its presence insures to the operator. The loss of contractility may be partial — affecting only por- 313 LITHOTRITY. tions of the bladder, acd not the whole organ. It may be complicated with exaggerated contractilitj', even of other portions of the bladder- walls — ^recalling the condition of the uterus known as " hour-glass con- traction." By this latter combination of symptoms the phenomenon is explained, of calculi being retained in unusual positions in the bladder, contrary to gravity ; as, for example, above and behind the pubes, giving rise to suspicion of sacculation or encysted calculus, when no such con- dition exists, and interfering sometimes "^vith the success of the ma- noeuvres of lithotrity. Atony is also variable in degree, in the same patient, at different times. One day he may be able to empty his blad- der completely ; a few days later the surgeon may find a residual accu- mulation amounting to four or five ounces. As a rule, the contact of instruments employed in explorations, and especially manoeuvres with the lithotrite, stimulates a weak bladder to stronger contractions. But this recovery of power is not permanent; the atony returns, and often in a greater degree. It has been observed that atony has followed the successful cure of stone by lithotrity, assuming the relations of effect to cause. Such a result is neither unphysiological nor improbable. The phenomenon of contractility in muscular fibre is a peculiar manifestation of vital force, and one of its peculiarities is that undue excitement is fol- lowed by corresponding loss of power. If the excitement be excessive and prolonged, the consequent exhaustion may be permanent. The vesical atony may have been recognized only during the search for stone, in which case the latter should be left unmolested until the former has been treated, and the tolerance of the bladder established. The tendency of the bladder to fall into acute inflammation upon drawing off its contents would be greatly increased by the mechanical irritation of lithotrity, and there might be induced a grave form of general cys- titis, tending to a fatal result through invasion of the kidnej's. By avoiding the dangers peculiar to atony, the treatment of calcu- lous patients with this complication is usually' followed by satisfactory results. It must be borne in mind, however, that it is a condition which exists more commonly than is generally supposed, and often escapes detection until bad results force it upon the surgeon's notice. TVhen present it is a necessity for the patient to be taught to use a catheter for himself, whether he is to be lithotrized or not ; and, where lithotrity is contemplated, this is an indispensable condition. When this complication exists, it is always a matter of probability that the calculous formation in the bladder has been preceded — in fact, that it has been caused — by the atony, both perhaps preceded and caused by enlarged prostata In addition to the catarrh and possible atony which are likely to accompany it, an enlarged prostate may constitute an obstacle to lithotrity in two ways : by preventing the ready introduction of instruments into the bladder, and by hindering the escape of frag- ments, both of which difficulties have been already considered. When COMPLICATIONS. 313 associated with an enlarged prostate, atony is not only not unfavorable to lithotrity, but in many cases a positive advantage; the manceuvres of the operation are quietly borne, for they are painless, there is no danger of fragments being crowded into the urethra by spasmodic contractions of the bladder, after the operation, and, as to evacuation of debris, this can usually be accomplished by judicious management, without delay or danger. The conduct of the case simply involves the necessity for more time and care. Eniaeged Prostate, with Irritability. — Of all the complications of stone which interest the lithotritist, perhaps the most troublesome cases are those in which an enlarged prostate is associated with exag- gerated sensibility of the neck of the bladder, with a tendency to spasm ; and these are not uncommon. Patience and great delicacy of manipulation are necessary in their management ; the patient should be trained to lie on his back as much as possible, with the pelvis raised ; uva ursi, buchu, and alkaline diluents, are to be administered in accordance with the grade of the cystitis ; and anodyne suppositories in the rectum, if well borne, are often of the greatest service. The patient is an old man; his daily habits and peculiarities are to be studied; and, with due respect to hygiene and dietetics, they should be interfered with as little as possible. The question will probably arise as to the propriety of employing an ansesthetic. If the stone be small, so that its debris may be got rid of promptly, and there is no serious organic disease, this question may be answered in the aifirmative ; and, after a fair trial of alleviating means without result, the surgeon should act at once. The proper course would be to select a favorable opportunitj', angesthetize the patient, and, having pulverized the stone as thoroughly as possible, consistent with safety, proceed at once, by the aid of an evacuating catheter and the injecting apparatus (Fig. 88), to bring away the debris. This proceeding is, of course, attended by risk, but, with the requisite skill and judgment on the part of the surgeon, the sviccess is often very gratifying. When the stone is larger, requiring more than one operation for its removal, and especially if there is a possibility of the presence of obscure renal disease, which cannot always be determined in advance, then the risks become greater. Acute cystitis is liable to supervene, or ursemic poisoning may explode in any of its manifold forms, and place life in imminent danger. The case of the late French emperor illustrates this point. Where stricture of the urethra exists at several points in the canal, and the disease is of long standing, lithotrity is of doubtful utility. With a large stone and the prospect of numerous repetitions of the opera- tion, the chances of the impaction of an escaping fragment in the defec- tive urethra become very prominent, and, in most cases, this is a serious accident, even where the canal is healthy. When there is much cystitis and irritability of the bladder or urethra, the case is still more unprom- 314 LITHOTRITT. ising. It must be remembered that no treatment can certainly restore the walls of a strictm'ed urethra to their original flexibility, and that local pus-secreting surfaces in the canal of any duration are rarelj- if ever again covered entirely by healthy epithelium. A very slight amount of mechanical irritation from instruments or calculous debris after so-called " cure " of stricture would almost certainly renew local inflammatory excitement, with tendency to spasmodic contraction at the damaged points of the canal. A preliminary treatment of the strictured urethra of indefinite duration, by dilatation and incision, would be unavoidable, and the subsequent use of a full-sized instrument by the patient him- self and his intelligence and docility are of necessity assumed. For a patient in whom these qualities were wanting, if under the age of fifty, lithotomy would offer at least equal chances of a safe cure. For a younger subject, with a smaller stone, the risk of possible impaction being fairly assumed, the tendency of modem practice is growing grad- ually more favorable to lithotrity. In such a case, after most careful preparation, the stone should be thoroughly reduced to powder, and the escape of 'detritus should be rather delayed than courted. A case is not suitable for lithotrity in which the cystitis is intense in character, and of long standing, and accompanied necessarily by hyper- trophy of the walls of the bladder, with contraction. The cystitis may possibly have existed before the formation of the stone, may be due to stricture, or other causes than stone ; epithelial degeneration may have developed itself in its mucous membrane, or cancer, in some other form, in the walls of the bladder. A judicious trial of means calculated to reduce the grade of the inflammation would be proper in a case present- ing this aspect, and, meanwhile, accurate diagnosis is to be sought for ; but, as soon as the inefficiency of these means becomes evident, or the presence of cancer is assured, the idea of lithotrity should be abandoned. Repeated and continued hcemorrhage after each exploration, in a case of stone, is suggestive of the possible existence of villous growth, or at least of a very unusual amount of congestion of the mucous mem- brane of the bladder, and, in either case, the prompt removal of all cause of irritation from the bladder, by the knife, will afford the best chance of cure, if, indeed, the case do not prove too desperate for any operation. The presence of a large hydrocele of the tunica vaginalis, which can usually be got rid of; or of an irreducible hernia, which is likely to prove more troublesome ; or of an anchylosis of the hijijoint, with inversion and adduction of the thigh from hip-joint disease, may so far interfere with the introduction of the lithotrite, or indeed of all rigid instru- ments, as to compel a resort to lithotomy. In hypospadias, when the deformity is excessive, the urethral orifice may be too small to admit a lithotrite, and too thin and ill-formed to justify enlargement by the knife ; but, generally, by employing additional ^ AFTER TREATMENT. 315 care in manipulation, this complication does not prove insuperable, although it is always a source of annoyance. It may be laid down as a rule sanctioned by experience, that in cases of stone presenting complications which render lithotrity of doubtful pro- priety, where the earlier efforts at exploration are followed by an aggra- vation of the patient's symptoms which does not subside promptly, and the necessity of lithotomy becomes imminent, it is better to decide upon the cutting operation at once, unless the case prove to be one of those in which no operation whatever is advisable. The temper of calculous patients is often of a character to bear disappointment badly, and the depression likely to follow the occurrence of unexpected pain or difficulty, if prolonged by repeated trials, might compromise the success of the cutting operation when too long delayed and undertaken as a last re- source. CHAPTEE, XYII. LITHOTRITY. LHhotrity continued. — Alter- Treatment. — Precautions and Care after Crushing Operations, -wltii Con- sideration of Complications liable to arise, and the Methods of meeting them. — Lithotrity in Chil- dren. — Lithotrity in Women. The after-treatment in lithotrity comprises the management of the patient after each attempt to crush a stone or fragment, and also the measures required, after the last fragment has passed, to confirm the cure and prevent relapse. All the intercurrent symptoms, conditions, and accidents, liable to follow the manipulations of lithotrity, are also to be considered. On the first two or three occasions that the patient passes his water after the operation, he will suffer necessarily some in- crease of pain, but with the usual precautions this will require no further interference. If the calls to empty the bladder become more frequent, however, with persistence of the increased pain, and especially if there should be any tendency to spasm of the bladder, it is advisable to employ an opiate suppository, or enema, at once. Spasmodic contrac- tions are especially dangerous while freshly-made fragments are in the bladder. Next to a just estimate of the necessity for short operations and gentleness in manipulation, perhaps the most important point in the modern practice of lithotrity is the rule which requires the patient to keep the horizontal position for at least twenty-four hours after the crush- ing of the stone has been effected. Its object is to prevent sharp, an- gular fragments from coming into contact with the sensitive neck of the 31 g LITHOTKITT. bladder until their edges have become rounded off by attrition, and thus to avoid the more frequent recurrence of the desire to empty the blad- der which would be provoked by their presence, and to escape the vio- lent spasmodic contractions which would be likely to force into the urethra fragments too large as yet to pass readily. By this precaution the impaction of fragments in the urethra, an accident formerly so much and so justly feared, has become rare, and may be rendered almost im- possible. Where the sensibility and contractility of the bladder are exaggerated, as is generally the case, it is advisable not only to keep the patient on his back, but also to maintain the pelvis in an elevated position by a cushion placed, beneath it ; if the symptoms are excessive, an anodyne suppository will render this restraint more tolerable to the patient, and his confinement to the horizontal position should be pro- longed to forty-eight hours or more, or until any aggTavation of symp- toms caused by the operation has begun to subside. A urinal of proper construction having been provided, the patient should be instructed, when the desire to void urine comes on, to roll over on to his side and use it, without raising his shoulders. This manoeuvre may be awkward at first, like having a stool for the ILrst time in the horizontal position, but it is imperative. A diiEcult patient should have been trained to it during the preliminary treatment. Usually after crushing, in an ordinarily favorable case, the cushion is removed from beneath the patient's hips, and he is directed to keep his bed for twenty-four hours, and then allowed, with proper precautions, to resume his usual habits. If he has suffered much pain from the op- eration, or any reaction is feared, it is proper to order warmth to the feet and a hot fomentation or mustard-poultice to the lower part of the belly, or a caoutchouc bag of hot water to the perinseum (Fig. 74). If there is reason to suspect that the patient is threatened with a chill, ten or fifteen grains of quinine may be given at once, with a quarter of a grain of morphine or its equivalent, in hot ginger or any aromatic tea. This is preferable to the wine or " toddy " recommended by English authors ; alcoholic stimulants are rarely admissible in inflammatory conditions of the urinary surfaces, save in extreme exhaustion, or where death is threat- ened through failure of the heart's action ; their use invariably imparts a more irritating quality to the urine. In patients beyond middle life, where the urine as it reaches the bladder habitually contains acid in excess, a mild alkaline dUuent should be used regularly.' Food should be judiciously selected, and taken in moderate quantities at regular in- ' The urea, from waste of tissue in advanced life, is present in the form of uric acid in the urine, in addition to the normal acidifying influence of phosphoric acid in the shape of acid phosphates. The citrate of potassa to the amount of one to two drachms a day, in a sweetened vehicle flavored with essence of lemon, taken with flaxseed-tea in liberal quantity, rarely disagrees with the stomach, and is usually acceptable to the taste. It is equivalent to fruit-juice in correctmg excess of acidity in urine. The citric acid disappears in the process of digestion, and the alkali is eliminated by the kidneys in the form of carbonate, as is proved by the effervescence of the urine on addition of acid AFTEK TREATMENT. 317 tervals. Exposure to cold, especially of the lower limbs, and at the water-closet, is to be avoided. These directions apply to an ordinary, favorable case, where the patient is not obliged to keep his bed, except as a matter of precaution. When complications are present exceptional measures may be required. If, for example, there are atony and a very irritable bladder, with a dilated " bas-fond," and- the patient has been subjected to the necessary pre- paratory treatment, the evacuating catheter may be employed at once, and the injection made in the upright position, immediately after the operation. By a recent French author the immediate evacuation of dihris by injection is laid down as the regular rule after each crushing.' This practice is not in accordance with the policy sanctioned by accumu- lating experience, and adopted by the masters of the art, which incul- cates short sittings and the avoidance of all unnecessary contact of in- struments with the hladder. Immediate evacuation is only proper as an exceptional proceeding. The reasoning of Sir Henry Thompson' on this point is unanswerable : " On no account," says he, " should the bladder be injected or washed out after the first sitting," etc. In an ordinary case, if the patient should not be able to pass water after the operation, as sometimes happens, and the pain, from this cause, becomes urgent, a soft, large-eyed catheter should be introduced, and, unless spasm be present, it would probably tend to allay excitement and irri- tability to make one or two injections with warm water. But this is not done to aid the escape of fragments ; and ofBciousness is always to be avoided. The cause of the retention is either an impacted fragment, or disturbed innervation of the bladder ; most probably the latter. The course to be pursued, in case the catheter should encounter a fragment in the urethra, has alreadj' been considered. Where nervous disturb- ance predominates, with pain as the prominent symptom, the comfort- ing influence of opium is all-powerful ; where this does not agree, hyoscyamus is of value; so, also, are conium and belladonna. Codeine sometimes answers, when opium acts unpleasantly ; and the bromide of sodium, with the addition of a small quantity of chloral, has a quieting influence. The simple presence of the surgeon, conveying assurance of the absence of danger, is often the best remedy. It must be remem- bered that the emotion of fear has a remarkable influence in stimulating vesical irritability, and that this cause of eccentric action of the blad- der is very often present, even when stoutly disclaimed. There are no circumstances under which tact and judgment are so necessary as in the management of hyperasthetic patients, who at the same time lack self- control, and possibly, also, intelligence and other qualities of the higher order. Accurate knowledge, which confers the power of correct prog- ' Reliquet, "Traits des Operations dea Voies urinaii-es," Paris, WlO, p. 602. ' "Practical Lithotomy and Lithotrity," London (second edition), 1871. 318 LITHOTRITY. nosis aud the riglit to speak positively, togetber witb great patience, are very desirable qualities in the surgeon in this contingency. But the disturbance of nerve-power may be confined to the bladder alone, in the form of atony, or impaired power of contraction ; and this may be developed, as a consequence of the operation, slowly and par- tially, or, in rarer instances, suddenly and completely. Retention under these circumstances might be aided by tumefaction of the mucous mem- brane of the neck of the bladder and prostatic urethra from instrumental contact during the operation, a condition -which is no doubt always present in some degree, accounting in part for the delay in the early passing of fragments. It usually subsides promptly, but sometimes is sufficient, with the addition of defective expulsive power, to prove ob- structive. It is well to be on the watch for retention from these causes, especially as it is liable to come on insidiously some days after the operation. The treatment required is the introduction of a soft, flex- ible catheter, to evacuate the urine, and this should be repeated at proper intervals. It is desirable, in most cases, that the patient should be taught to pass the instrument for himself. If the irritation present be moderate in degree, a warm-water injection may be employed once a day by the surgeon, to assist the escape of detritus, if necessary. The tone of the bladder is improved by gradually lowering the temperature of the water injected, and, by judicious management in this way, this form of atony not unfrequently gets well. Hmmorrhage, to a trifling extent, occurs not unfrequently after the crushing operation, and requires no notice. When severe, the possi- bility of tumor, or villous growth, is to be borne in mind. Thompson details a fatal case of hsmorrhage from the bladder, from this cause,' and another in which, after careful ^os<-»zorfe»i examination, no cause could be discovered, except that " the whole mucous membrane of the bladder was greatly congested." An instance of very free haemorrhage on attempting lithotrity is also recorded by Aston Key,' in which it was judged proper to proceed at once to lithotomy. These, however, are rare cases. Haemorrhage, occurring in connection with lithotrity, requires usually nothing more than increased circumspection in the management of the case, and is not likely to interfere seriouslv with its successful result. Epididymitis and orchitis are liable to explode at any time during the progress of a case of lithotrity, usually, but not necessarily, on the occasion of some slight additional violence — such as that produced by the stoppage of a fragment in the urethra. This complication occms infrequently, and in most instances unexpectedly ; the reason why it should happen in only one case in twenty, with apparently similar provocation in all, not being always easy to explain. It subsides under ' Op. dt. ' " Guy's Hospital Reports." UEINAKT FEVER. 319 tlie usual treatment in a few days, involving simply delay in the prog- ress of the case. Ukis'AEY Fbvek. — In the after-treatment of lithotrity, or in fact throughout the whole management of a case, there is no phenomenon ■which so promptly arrests the attention of the surgeon as the occurrence of a chill, and there is nothing in the way of a complication more likely to happen. Its suddenness, the invariable unexpectedness of the in- vasion, and, above all, the element of doubt as to its significance, give great interest to this symptom. It is usuallj' followed by fever, ter- minating in more or less profuse perspiration, and, in a few hours, by a return to the usual conditions of health ; and, also, by some loss of weight and strength, with a tendency to repetition. In the great majority of cases it has no serious import (Thompson). It is what is called in common parlance a " nervous chill." By this we understand that it is not the initial sj'mptom of an attack of acute inflammation, or of pyemia. Chills of this soft occur more readily in individuals who have passed middle life, and seemingly in those who have been exposed to sexual irregularities, or to malarial poisoning. For urinary chill the treatment required during the paroxysm is the same as that applied in ordinary ague. All means should be used to promote free sweating — for this reason especially, that the shock to the nerves of the urine-secreting organs has for the moment impeded their eliminating function, and the vicarious action of the skin can with least delay supply their defalcation. The free use of the sulphate of quinine has a certain degree of power to prevent the recurrence of urinary chill. It is approved practice to administer ten grains or more, immediately after an opei'ation, as a prophylactic, in a case where a previous operation has been followed by chill. There is no absolute regularity in the periodical recurrence of urinary chills, as in chills due to malarial cause. Like those of pyaemia, they are irregular, not only in the period of their recurrence, but also in regard to severity, duration, amount of febrile reaction, and subsequent sweating. It is obvious, therefore, that an opinion as to the significance of a urinary chill can only be formed after patient waiting, and most careful observation. The surgeon should know what dangers the occurrence of the chill might foreshadow, and watch for these. Probabilities would favor an invasion of acute cystitis, suddenly superadded to the partial chronic in- flammation already present, in some degree, in every case of stone. This would tend to involve the whole body of the bladder, starting from its neck ; and, in an old or broken-down subject, it might extend through the ureters to the pelves of the kidneys and their secreting structure, leading to the worst result. At first the presence of this complication would be indicated by pain on pressure over the hypogastrium, with sus- tained frequency of pulse; and afterward, in a grave case, by dry tongue, jactitation, and symptoms of ansemia. Hot fomentations and 320 LITHOTEITT. mustard-pou] tiees to the lower belly, absolute quiet, opium in suppository or subcutaneously, quinine, demulcents, and systematic nourishment, are the principal remedial measures. If there are large and sharp fragments in the bladder, the pelvis should be kept elevated ; and, if the symptoms tend to assume a chronic character, the propriety of recourse to lithoto- my is to be considered without delay. An invasion of cystitis, after lithotrity, resembles very much, in the group of phenomena which it presents, and their extreme urgency in some cases, the symptoms caused by the impaction of a fragment in the urethra. In fact, the conditions are very much the same ; the presence of uncontrollable spasm, threatening mechanical injury to the surfaces in contact with rough stone fragments, being the leading feature in both. The patient suffers constant and severe pain in the bladder, perinsBum, and anus, aud every few minutes the urine, mingled with pus and blood, is expelled with- irresistible desire and urgency, and with pain of still greater sharpness, while his agitation and nervous excitement are steadily increasing, and, with them, the danger to the bladder. In both conditions the first indication is to control the spasm, if possible, before serious injury has been produced, and for this purpose opium is the most reliable means, aided by chloroform, if necessary, to secure more instan taneous effect. If the urgency of the symptoms is not promptly sub- dued by this treatment, the next step is to remove the source of the danger — the sharp, irritating fragments. The mode of procedure where fragments are impacted in the urethra has already been detailed. When it becomes necessarj' to remove fragments promptly from the bladder, one of the several methods of lithotomy is to be employed. It is obvi- ously the duty of the surgeon, on the occurrence of symptoms, after li- thotrity, looking toward an invasion of acute cystitis, to determine at once if they are caused by the impaction of a fragment at the neck of the bladder, or in the prostatic urethra. This can only be done by introdu- cing a proper instrument into the bladder. Sometimes, by thus pushing a fragment back into its cavity, aU. urgent symptoms will cease at once. This proceeding is better accomplished under the influence of an anaes- thetic. If no fragment is found in the urethra, the diagnosis of threat- ened traumatic cystitis is established. Opium should be administered to replace the anaesthetic, and if the cystitis cannot be controlled promptly, lithotomy should be resorted to without hesitation. Two things are clear, then, when excitement of the bladder, attended by spasm, comes on soon after the operation of lithotrity, whethei chill be present or not: that there is danger of serious cystitis and suppurative inflammation, with indefinite extension ; and that prompt and intelligent action is required at the hands of the surgeon to avert this possible result. ChiU does not necessarily precede this traiin of symptoms. When it occurs later, during their progress, it is suggestive of parenchymatous URINARY FEVER. 321 cystitis, with formation of abscesses in the thickness of the bladder- walls ; of abscess in the prostate ; of peri-cystitis ; of formation of ab- scesses in the secreting portion of the kidneys. With the possibility of these dangers awaiting the patient, which lead almost certainly to fatal results, it will be readily understood why prompt recourse to lithot- omy is advised in uncontrollable cystitis, following the. crushing oper- ation. By removing at once the cause of irritation, it offers the better chance of safety to life. Where old and latent pyelitis has possibly preexisted in a case, it is liable to be stimulated into renewed activity after an operation of lithot- rity. This condition would be indicated by pain on pressure over one or both kidneys, with a well-marked hectic movement, preceded by a chill — than which there is no more unpromising group of symptoms. It is possible that the chill may indicate commencing pyemia. The continued and increasing frequency of the pulse and altered aspect of the features, with the other peculiar characteristics of this grave condi- tion, will serve to identify it. Although grave, it is not necessarily fatal. Abscesses may form in accessible situations, and the patient sur- vive, after a struggle. When the larger articulations or serous cavities become involved, there is little hope. The pulse niay become frequent, and remain so, without the occur- rence of any preceding chill, which, for example, is an exceptional oc- currence in fever from septic poisoning. Absorption of putrid' material into the blood gives rise to a train of characteristic symptoms witli which the surgeon of the present day is tolerably familiar. The coinci- dence of recent abrasion of the mucous membrane with purulent and de* composed urine presents a combination of conditions favorable to the occurrence of septicsemic poisoning. Yet this grave form of disease is not common in our country — much less so than the writings of recent French surgeons would lead us to infer that it is with them. The " in- toxication urineuse " — a phrase first popularized by Velpeau — so con- stantly referred to with apprehension, would seem to include pysemia and inflammation of the urinary organs, complicated with uraemia as well as septicaemia. These serious conditions might undoubtedly coexist in the same case under the influence of unfavorable circumstances, such, for example, as aggrayated hospitalism, but such coincidence is rare. In order to preserve a clear perception of the pathological influences due to lesion of the urinary organs, which may afi'ect a patient exposed to dan- ger, as after lithotrity, it is well to bear in mind that the epithelium of the bladder, when intact, is a safeguard against absorption, as demon- strated by the experiments of Susini ; ' and, also, that because altered urine, when extravasated, produces death of the connective tissue with which it comes in contact, it is not therefore equally fatal to life if ab- sorbed in minute quantity into the blood. There are vague opinions ' " Do rimpermeabilit^ de I'Epithelmm vesical," Th^se de Paris, 1867. 21 322 LITHOTEITT. held on these subjects which are well expressed in the language of Vel- peau's famous lecture, already referred to — not improbably inspired by it — and which, like aU vague ideas, tend to perpetuate impressions both incorrect and exaggerated. (For UErfrAET Fevee, see p. 45). LiTHOTEiTT IN Chtldeex. — The use of the knife for the cure of stone in children is so prompt, so safe, and, through the aid of ansesthe- sia, so free from pain, that below the age of twelve lithotomy is justly regarded as preferable to the crushing operation. There are no statis- tics of the results of the crushing operation in children which present results as favorable as those of lithotomy. Lithotrity has, then, but very doubtful advantages to claim over the cutting operation in early life. On the other hand, there are at least two serious disadvantages which experience has proved to be inseparable from it. These are the great liability to impaction of fragments in the urethra, through the absence of any prostatic impediment before puberty, which permits the vigorous and continuous contractions of the young bladder tc^ force them irresisti- bly through its funnel-shaped and dilatable neck, into the urethra, with- out hinderance, and the danger of peritonitis in early life, rendered greater by the anatomical facts that the bladder lies so much more in the cavity of the abdomen, and is more largely invested by the peritonaeum, than in the adult. The manoeuvres of lithotrity are in aU respects the same in the child as in the adult, and, by employing an anassthetic, the manipulations of the. operation can be effected with equal facility; modern instruments can be made sufficiently strong and of sufficiently delicate proportions for the smaller urethra of the child ; and its flexibility and tolerance of pressure in early life fully compensate for the greater sharpness of its curve ; but, still, the very serious objections just stated remain in full force, and no means suggested by experience have thus far succeeded in removing them. The extravagant and uncontrollable paroxvsms of spas- modic contractions of the bladder, -which are so characteristic of stone in the child, will almost certainly force fragments into the gradually- narrowing passage. These paroxysms, when they have become habit- ual, will recur inevitably after an operation of lithotrity, performed under the influence of ether or chloroform, and with increased severity as soon as the anaesthetic influence has subsided. This objection loses its force in a case where the stone is small enough to be thoroughly reduced to powder at one sitting, which is not unfrequently the case where the existence of the disease has been dis- covered early ; and these are, in fact, about the only cases in which lithotrity is to be preferred in children. The temptations which anaes- thesia offers to the surgeon to prolong the operation, with the object of thoroughly pulverizing a small calculus at one sitting, must not influence him too strongly, however, for the liability to peritonitis is one of the important exceptions to infantile tolerance of surgical operations. As a LITHOTRITY IN THE FEMALE. 323 rule, the older the child the better, as the parts are more developed, but it is noticeable that children with stone tend to remain long undevel- oped, in consequence of the disease. The oases so frequently encoun- tered among the poor, where calculus has existed almost from birth, and the child has reached the age of puberty, are best treated by lithotomy. Chronic peritonitis ' as well as chronic pyelitis, may exist, and relief oy the knife is the best treatment. Lethoteitt m the Female.— It would be naturally assumed, in consequence of the more direct approach to the stone through the short and capacious urethra, and the easy escape of fragments after the opera- tion, that lithotrity is more easily accomplished in the female than in the male. But, in practice, this is not entirely true. There are certain peculiarities in the shape and relations of the female bladder by which these obvious advantages are, in some degree, neutralized. The uterus, which lies immediately behind, and in contact with it, if enlarged or misplaced, interferes both with its shape and its capacity for uniform distention. In women who have borne children there is usually more or less prolapse of the anterior wall of the vagina, and the bladder is necessarily, through its close attachment, dragged down with the re- laxed vaginal wall, so as to project, in extreme cases, even through the vaginal outlet. In every case the uterus projects into the cavity of the bladder from behind to some extent, when the cavity of the latter is distended ; and this prominence is usually in' the median line so as to give rise to what Civiale describes as a has-fond on either side of the central prominence. In the young woman the urethra and neck of the bladder are on a level with its floor, but, as the lithotrite enters its cavity, no smooth, fixed, inclined surface is recognized, such as that pre- sented by the trigone in the male ; and, later in life, there is a distinct tendency to the formation of a depression or has-fond at the base of the bladder, by which the inferior margin of its outlet at the neck is thrown ' The following case, reported by Eeliquet {op. at., p. 626), is valuable as evidence afforded, by post-moriem examination, of the morbid appearances in a fatal case of lithot- rity in a child : " In the hospital service of Prof. Richet I lately watched the treatment of a little boy with stone. He was fifteen years old, but looked no more than eight or nine. He suf- fered with very frequent and severe attacks of spasm in urinating, in which his efforts in straining would bring down a large prolapse of the rectum, which would go up again, however, as soon as the attack passed off. The following description of the peritoneal cul-de-sac was sent me by M. Hybord, house-surgeon, who made the autopsy : ' The peri- tonaeum covering the intestines and the internal surikce of the abdominal wall shows no evidences of change, but that covering the bladder and reflected upon the rectum is deeply colored. At points it is very red and injected, and the vascular injection involves especially the sub-peritoneal connective tissue, the surface being smooth, without trace of false membrane, or even loss of transparency. On the front and sides of the rectum the vascular congestion is more intense than elsewhere, showing still the course of the smaller vessels deeply stained in red, al though the specimen has been a good while in alcohol. The recto-vesical cul-de-sac is unusually large ; the peritonseum covers not only the seminal vesicles, and prostate entirely, but extends an inch and a quarter below the apex of the latter ; on the front of the rectum it descends to within a half-inch of the inus, and, when the finger is carried well down into the cul-de-sac, it reaches to within 'ess than this distance of the cutaneous surface of the perinaeum.' " 324: LITHOTOMY. into relief ; in this depression the calculus is usually found. Thus, the manoeuvre so successful in the male, of elevating the pelvis so that the stone rolls backivard to a point at which the angle of the lithotrite must necessarily strike it in gliding down the trigone, is not so readily accomplished in the female. In a woman who had borne children it would be necessary, more likely, to reverse the beak of the lithotrite, and engage the calculus between its open jaws by means of a finger in the vagina, by which the floor of the bladder could be lifted up. An- other, and more trifling impediment, is the unfavorable situation and narrowness of the urethral orifice, which, less easily managed than that of the male, often refuses to admit the beak of the lithotrite without special care in manipulation. On the whole, then, the female bladder, having no prostate at its outlet to serve as an impediment, and no tri- gone at its base with external attachments to form a fixed floor, con- tracts more uniformly upon its contents, and expels them, through the short, large urethra, more fully and promptly than the male bladder, especially in early Ufe. Later, however, it is liable to become irregu- larly dilated, especially at its base, to lose contractile power, and possi- bly to incur displacement ; thus, the finding of small calculi and last fragments is not unlikely to be attended with difiiculty. But for the large calibre of the female urethra, impaction of fragments would fre- quently happen, for the uniform and continuous expulsive efibrt resem- bles that of the male before puberty, where there is no prostate to in- terrupt it ; and, by reason of the greater nervous excitabUity and liability to paroxysms of spasmodic contraction in the female, this accident does occur more often than would be thought probable. In such event the manipulation required for the removal of the fragment would be at- tended with less difiSculty than in the male. For obvious reasons the employment of anaesthetics in lithotrity, in women, offers advantages which, in the hands of the judicious sm-geon, are counterbalanced by no dangers which would justify their rejection. CHAPTER XVIII. LITHOTOMT. PreventiTe Treatment of Stone, General and Local.— Solvent Treatment of Stone.— Electrolytic Treat- ment-Lithotomy.— Selection of Cases based on Statistics ; the Condition of the Patient ; the Condi- tion of the Stone.— Choice of Operation.— Description of Operations.— The Lateral Operation.— In- struments employed.— Modification requked for very Large Stones.— After-Treatment— Lateral Operation in Children. — The Median Operation.— Snpra-pnbio Operation.— Complications of Lithot- omy. — Eelapse after Lithotomy. As has been already amply set forth, there are two methods of formation of stone in the bladder: one, where a kidney-stone lodges and grows in the vesical cavity; the other, where from obstruction PKEVENTIVE TREATMENT OF STONE. 325 (enlarged prostate, stricture), or other cause (atony), there are stagnation of urine, partial decomposition, with precipitation of crystals and amorphous salts, and a consolidation of the latter by mucoid pus at once into a nucleus of stone. As both of these causes are readily de- tected by the skilled surgeon, the question naturally arises, What can be done in a prophylactic way to prevent the formation of stone in the bladder, where the tendency is believed or known to exist ? Very much can be done; an attempt will be made in the present section to show how much, and in what manner. The prevention of stones forming upon a nucleus (foreign body) which has been introduced from without is hardly worthy of consideration. A foreign body of this sort, when known to exist, should be at once extracted. Stone, as found previously to advanced life, is, for all practical pur- poses, always a stone of uric acid. Thompson ' says : " Nineteen out of every twenty of such stones have uric acid for their basis, the remain- ing one in the twenty being oxalate of lime ; " hence it is evident that, to prevent stone of this class, such measures should be brought to bear upon a patient, who is known to have a calculous tendency-, as militate against the formation of uric acid in the kidney. This formation of uric acid is the result of imperfect assimilation of food, coupled with faulty elaboration of the blood, such as exists in all patients having the gouty diathesis. In this way stone becomes hereditary, and the ten- dency to gravel is transmitted from father to son, from generation to generation. The connection between gout and calculus is more strongly maked bj' noticing the other maladies from which patients with gravel suffer, and by observing the occasional well-marked instances of inter- change in the type of the symptoms in a given case ; as, the disappear- ance of habitual gravel being marked by an outbreak of the gout. Not every patient with gout has stone, but the tendency to over-acidity of urine in gouty individuals is very marked, and habitual deposits of urates, uric acid, or even attacks of gravel, are hj no means uncommon. Hence in patients, where the gouty diathesis is marked, care should always be particularly bestowed upon the condition of the urine. Such patients will often be found to suffer from nephralgia, to have pink deposits, or red sand, in the morning urine, perhaps throughout the daj'. The alkaline tide, which should be observed two or three hours after each meal, will be feeble, perhaps inappreciable, on account of its mixture with the strongly-acid urine already in the bladder in small quantity when the tide comes on. Such a patient is ripe for stone. After a profuse sweat on a hot day, after a dinner out, with a free sup- ply of wine, after some passing febrile disturbance, or hepatic conges- tion, leading to an increased supply of uric acid, already present in excess, a few crystals, larger than usual, start into existence in the heavy mother-liquid in the pelvis of the kidney, become joined together, ' " PreYentive Treatment of Calculus," 1873, p. 10. j.2Q LITHOTOMY. rapidly increase in size, and the patient has kidney-stone, liable at any moment to pass into the bladder, and, remaining there as a nucleus, to be built up into a calculus of large dimensions — a monument of neglect of prophylaxis. The methods of treating over-acid urine, and battling against the tendency to the formation of stone in the kidney, will be detailed under the head of nephralgia from over-acid urine, and when describing the treatment of kidney-stone. The same rules hold good here. What prevents kidney-stone, prevents bladder-stone as well. The habitual use of Vichy or other alkaline water as a daily beverage in modera- tion (the harmlessness and eiEcienc.y of citrate of potash have been especially demonstrated by Roberts's experiments noticed page 367); the free imbibition of fluids of all sorts ; a draught of water between meals, and on retiring, to dilute the acid tide of the urine of fasting — these means, habitually employed, aided by intelligent hygiene, and attention to all the functions, will serve in a marked manner to keep the urine normal. Muscular exercise should be encouraged in every possible way, and life in the open air. Where the patient's pursuits in life are of a sedentary nature, dry friction of the skin with hair gloves, exercise with Indian clubs, or even dumb-bells, practice in a gymnasium, or with a lifting-machine, are all substitutes of great value, where nothing better can be obtained. When, from any cause acting temporarily, there seems to be a sudden tendency to aggravation in the morbid condition of the urine, when the liver seems to be torpid, and especially if the bowels are a little slug- gish, nothing is more useful than a course of a few weeks of some mineral water containing the sulphate of soda. This salt has the power of sweating the intestine, and relieving the kidney from overwork, while it freshens the activity of the great abdominal glands, and, serving as a laxative, still proves at the same time a tonic, not being followed by any prostration, but, indeed, aiding digestion. The best method of administering sulphate of soda is in a natural mineral water. Thompson ' has proved by experiment that the solutions prepared by Nature far surpass, in efi"ect, the same draughts concocted by the apothecary. He evaporated down slowly in a water-bath a pur- gative dose of one of these waters, and found the effect of the dried residue to be far inferior to the original solution; nothing more, in fact, than what would be produced by the same drugs mingled by the chemist. The mineral water which seems to be the most useful is the Friedrichs- halle water, of which the active ingredients are sulphate of soda (gr. 58) and of magnesia (gr. 49 to the pint). The proper dose of this is about seven ounces, with two or three omices of hot water, enough to make the whole pleasantly warm — to be taken an hour before breakfast in the morning. This will usually produce one or two pleasant stools, ' " Preventive Treatment of Calculus." LOCAL PREVENTITE TREATMENT OF STONE. 327 an effect far out of proportion to the quantity of the drug taken ; while another agreeable feature of this water is, that its effect usually remains the same while the daily dose is being gradually diminished. The hot water is added to bring the draught up to the natural temperature of the body, as well as to dilute it slightly, for the water is condensed to a uniform standard for exportation. This morning-dose may be continued indefinitely without detriment, and when intermitted does not leave constipation behind. Thompson advises that, after having taken this water for several weeks, it should be mixed with Carlsbad water and hot water in the proportion of live or six ounces of Carlsbad to three or four each of Friedrichshalle and hot water — this to be continued for several weeks, and then the course to be terminated by a couple of weeks of Carlsbad alone ( | v-viij) raised to a temperature of 90° or 100° Fahr., by placing the tumbler which con- tains it in hot water. These expedients are all useful, and most excellent to meet emergen- cies, in the prevention of kidney-stone, but final reliance in all cases must be placed upon intelligent hygiene, in which exercise, air, and elimination by the skin are to be primarily considered. The food should be rather light, plain, mixed, containing a large share of green vege- tables and fruit, as well as cereals, from the fact that the latter contain a large amount of alkaline phosphates. Alcohol and sugar should be avoided — as well as an excess of fat (Thompson). Attention to the above expedients constitutes the preventive treatment of stone due to blood-conditions. Local Preventive Treatment of Stone. — The second class of stones, as ordinarily encountered, are due to local origin. They depend on stagnation of urine, and inflammation of the mucous lining of the blad- der, attended by decomposition of urine. Such stones are found in old men, with enlarged prostate and atony, in cases of old stricture, etc. They are composed of the mixed phosphates (fusible calculi), and often grow verj' rapidly. The subject of their prevention has been already mentioned at length, in connection with the different morbid conditions liable to give rise to atony, with stagnation, and the means to avert the threatened complica- tion, stone, have been amply detailed. To recapitulate, these means are : 1. To overcome all obstruction to the free outflow of urine, if possi- ble, as in the removal of stricture by dilatation. 3. To reduce vesical inflammation, empty the bladder periodically, and wash out its cavity by means of the regular gentle use of the catheter in all cases where, from atony, or paralysis, or obstruction (large pros- tate), the viscus cannot empty itself; employing warm water in injection, and any of the medicated fluids suggested at page 197). If the stone has been already crushed, an injection of two or three drops of dilute 328 LITHOTOMY. nitric or hydrochloric acid to the ounce of warm water, during and after the treatment, is advisable to oppose any continued precipitation of the phosphates. Solvent Treatment of Stone. — This method, undoubtedly effective in many cases of kidney-stone, is practically powerless to contend with vesical calculus. If stone in the bladder is large, it would be folly to attempt to dissolve it either by internal medication or vesical injection. Efforts in both of these directions have been made for centuries, but in no single reported case with demonstrated success. In all of the cases reported cured, where calculus was detected by a competent authority, before the treatment, when an examination after death could be obtained, the bladder was still found to contain stone. The most brilliant exam- ple of this kind is found in the fact that the four patients, whose cures were certified to by the trustees appointed by government to examine into the merits of Mrs. Joanna Stephens's remedies, were each found to have stone in the bladder when they died.' Mrs. Stephens's remedies, which were purchased by the EngHsh Parliament in 1739, for £5,000, consisted chiefly of snails, ashes, egg-shells, and soap — that is, the alka- lies, potash, and Kme. If a stone is small enough to be managed by any solvent treatment, it is much more speedily and effectively dealt with by one or two crushings. Ekctrolytic Treatnient of Stone. — Efforts in this direction, although effective for small calculi, are utterly unpractical. It must require more time and give more pain to find the small stone, get it between the poles, and act upon it by electricity, than it would to crush and destroy it in one or two sittings. LITSOTOMY. In the consideration of the treatment of stone, the subject of lithoto- my is introduced last, because it is an operation of far less importance than its powerful rival lithotrity : to the latter it is yearly yielding more and more of the cases which, by common consent, formerly fell solely within its own domain. That lithotomy is an important operation, and eminently surgical, is undoubted ; that it requires a cool head and steady hand for its proper performance, none wiU dispute ; that it is often brill- iant in its results is equally self-evident; but the function of the sur- geon is not to perform brilliant operations, but to cuje disease and re- lieve pain with as little risk to life as possible, and this lithotrity accom- plishes far more cortainlj', in many cases, as has been shown when deal- ing with that subject. As the means of diagnosis improve, and become more widely spread, stones are detected earlier, and yearly the number of calculi is greater which come within the scope of lithotrity — an oper- ation which, carefully and gently performed, upon a proper subject, is nearly as harmless as passing a catheter. Lithotrity owes its present ' Quoted by Thompson, from Alston's " Lectures on Materia lledica," ISW STATISTICS. 329 exalted position largely to the untiring, honest, and able elTorts, during the present century, of Civiale and Sir Henry Thompson. But not all stones and not all patients are suitable for lithotrity. Li- thotomy still holds its place as one of the grandest operations of surgery, and still has no rival in at least fifty per cent, of all cases of stone, taken collectively, at all ages. Lithotomy is respectable for its longevity ; but it is idle in a text-book of the present day to discuss the unfavorable opinion of Hippocrates, who believed that wounds of the bladder were deadly, or the barbarous method of " cutting on the gripe," the " apparatus minor," or the " ap- paratus major " of musty antiquity. Nor, again, does space allow a de- tailed description of the many cutting operations which have been pro- posed and successfully performed for the removal of stone from the bladder — operations bearing the names of many illustrious men, and modifications of these the names of many more, to whom all honor is due. Practically, the surgeon requires but three operations to meet the necessities of all cases, and these three only will be described at length — they are the lateral, the median, and the high operation for stone. Selection of Cases. — After the thorough discussion of this subject in connection with lithotrity, already given (p. 273), but few words are necessary here. If the patient's condition will allow any operation, and it is not considered wiser, on account of the size of the stone, the age of the patient, or other circumstances, to palliate and make life comfortable, without the risk of an operation, which indeed may often be done for those who are wealthy and surrounded by ease and luxury — if, then, an operation is decided upon, lithotrity is to be practised, when feasible; otherwise one of the operations of lithotom}-. The age of the patient assists largely in arriving at a conclusion. As a rule, all children under the age of fourteen are to be cut, unless the stone is so small that it can be reduced to powder at one, or, at most, two crushings, under ether. This rule is founded on the universal experience of practical surgeons as well as upon a study of statistics. Statistics, as a rule, are utterly false guides, as far as showing the true state of affairs in lithotomj' is con- cerned, and their collection does not demonstrate absolute truth. The statistics of one man are all selected cases; another surgeon, though distinguished, may, for that very reason, have had an exceptionally large number of difficult cases to attend to, and consequently his results might be defective guides. Statistics, again, are sometimes largely of hospital, at others of private patients. In the same way the statistics of special operations are not free from chances of error. The excellent showing of the median operation in America (especially the successes of Markoe, Little, and Walter, the statistics of which, as recently pub- lished,^ give 139 cases with five deaths, one in 27-|-), forms a brilliant con- trast with the results of Dupuytren's bilateral operation, having a ' J. W. S. Gouley, op. cit, p. 347. 330 LITHOTOMY. mortality of one in 4^ cases,' or of the recto-vesical one in 5, or the supra-pubic, one in 3|- (Humphrey). These statistics are none of them finally conclusive ; for, as a rule, small stones are selected for the median operation, and the largest for the recto-vesical and the high operations, and, had the cases operated on by these latter methods been subjected to the median section, the mortality would undoubtedly have been enor- mous ; while, if the patients who recovered under the median operation had had their small stones removed by other and severer methods, many more of them undoubtedly would have died. The general statistics of all operations, at all ages (of which several have been collected, numbering thousands of cases), give a general mortality of about one in 6^ to one in 11. Statistics of the lateral operation alone are much better, and of the median best of aU — except the brUliant results obtained by our coimtryman Dudley, of Kentucky, who, oat of 207 cases of lithotomy, only lost six, or one in 33^ cases. The late Valentine Mott was also a very skillful and successful operator, but he has left no record of his results. Gross, in 115 operations of his own, has a mortality of one in 11^^. The most valuable statistics, however, possessed by the profession, are those of Thompson.' They include 1,827 cases. These cases, col- lated from English operators, show a general mortality of one in eight cases, and that, too, although the reports of certain eminent gentle- men were refused, as containing sources of error. But, that this esti- mate of one in eight is utterly useless for practical purposes, Thompson shows, by an analysis of the cases according to their ages. He found that one-third of the cases occurred during the first seven years of life, one-half before the end of the thirteenth year. The average mor- tality under twelve years was one in sixteen cases for all operators, a result which lithotrity, viewing its difficulties in the young, could scarcely- equal. Between twelve and sixteen, puberty conies in to in- crease the mortality to one in 9^ cases, after which it again decreases. Hence it becomes a matter of personal judgment in cases between twelve and twenty — the stone itself being suitable — whether it would not be better to crush. After twenty, in all cases, where neither the stone nor the condition of the patient contraindicates it, lithotrity is to be preferred. Between twenty-one and forty-eight inclusive, Thomp- son's statistics of lithotomy show a mortality of one in 8|- cases ; and, from forty-nine to eighty-one inclusive, one in 3f cases. To briefly recapitulate: the conditions of the patient requiring (with the rarest exceptions) lithotomy, when his age, and the size and character of the stone, would seem to call for lithotrity, are only four : 1. Peculiar susceptibility, where the patient is liable to have a chill after the introduction of any and every instrument into his bladder. ' Eve, of Nashville, only had eight deaths in eightv-seveu operations, one in 10|.— " Transactions of the American Jledical Association," 1871. ' " Practical Lithotomy and Lithotrity," second edition, 1871. SELECTION OF CASES. 331 3. Where the grade of vesical inflammation is high, and gentle manipulations with instruments seem to increase it, or to produce much hemorrhage. Here the lateral operation will usually put the bladder at rest at once. 3. Tight, unmanageable (resilient) strictures complicating stone. 4. Certain conditions of enlargement of the prostate, making it im- possible to introduce instruments. The conditions of the stone calling for lithotomy are four : size, num- ber, composition, position : 1. Size. — If a stone is decidedly over medium (one inch diameter) size, and at the same time composed of any thing except the phosphates, if any operation is called for it is lithotomy. 3. Number. — ^Most cases of multiple stone do better if cut. 3. Composition. — If the stone is small, its composition is a matter of not much importance ; if much over an inch, it is all-important. The con- stant appearance in the urine of uric acid, oxalate of lime, or the mixed phosphates, or the examination of gravel or small stones previously passed by the urethra (if any), will often throw great light on this sub- ject, as wiU also the quality of the click when the exploring instrument strikes the stone, the sound being sharp and clear for hard, dull for soft stones. 3. Situation. — Encysted stones, if molested at all, require the knife. Severe general or local disease (especially cancer or Bright's disease), unnatural size of stone, advanced age, and debility, make it often advisable to palliate rather than assume the risk of any operation, especially among the wealthy, who can command every comfort. With large stones, in broken-down patients, Thompson estimates that cutting operations kill one out of three. Choice of Operation. — Having now decided what cases of stone require lithotomy, it remains to discuss the circumstances calling for one or the other operation. Young children do well hy any operation, but the lateral is undoubt- edly the best, as the incision is not liable to injure the seminal ducts and a free outlet is afforded for the extraction of the stone. If the latter is quite small, the median operation is perhaps as good ; but, where it is large, the violence done in dilating the vesical neck is objectionable. It is exceedingly rare for children to have infiltration of urine, although the limits of the prostate are undoubtedly often surpassed by the incision in the lateral operation. Peritonitis from violence is what is to be feared in children, and there is little danger of this (even with large stones) from the lateral operation. The median section, however, in children, has the advantage of being generally attended by less haemorrhage, and is useful for small stones; the older the child, the less objectionable the operation. With the adult, the same rule holds good — the median opera- 332 LITHOTOMY. tion for small stones, tte lateral for large. But small stones in the adult are preferably dealt witli by lithotrity ; hence the application of the median method is rarely advisable, except under two circumstances, namely, where there are many stones, all small, and where, with a single small stone (less than one inch in diameter), the patient's irritability is such that chill or constitutional disturbance follows every attempt to use instruments in the bladder. Where the stone is small or large, but the bladder more than ordi- narily irritable and inflamed, the lateral operation, with free incision of the prostate and vesical neck, is to be preferred. In the case of very large stones, and indeed as a matter of prudence for all stones over one and one-haK inch diameter, a modification of the lateral operation is called for, namely, bilateral section of the prostate to make more room for extraction ; or, if the stone shows exceptional proportions, the combination of crushiug with cutting (perineal lithot- rity) and extraction of the stone in fragments, or the supra-pubic opera- tion. The medio-bilateral operation of Civiale does not afford so good an external opening for the extraction of the stone as the lateral, with bilateral section of the prostate, and, according to Thompson, is at- tended by as great heemorrhage. Bilateral external incisions present no advantages over the single lateral cut. Recto-vesical external incisions, though greatly facilitating the extraction of large stones, are never- theless very likely to be followed by recto-vesical fistulas. The recto- vesical operation, performed by opening the bladder through the rectum behind the prostate, leaving the peringeum untouched, and sewing up the incision afterward with Sims's silver suture, although it has been practised with success, is difiBcult of execution, and only applicable to stones which can usually be more safely dealt with by lithotrity.' THE LATERAL OPERATION. The lateral operation dates back to Pierre Franco, of Provence, about the middle of the sixteenth century, and claims the names of Jacques in the seventeenth century, and Eau, his pupil, in the eighteenth. It was popularized and practised with great success ia England, by Chesel- den, in the last century, and it is his operation which is still performed. Instruments employed. — The instruments necessary for this opera- tion are the searcher (Fig. 70), a staff of proper size with a long curve deeply grooved on its convexity (Fig. 100), the groove encroach- ing on the right lateral aspect of the staff toward the point. The handle of the staff should be broad, heavy, and marked with deep, crossed lines, so that it may be held firmly with greater ease. The groove should not ' In the female, the vagino-Tesical section is a good one. According to Emmet (oral communication), tiie wound, if kept clean by irrigation, heals promptly without suture • or, failing, it might be brought together subsequently with silver ligatures. INSTEUMENTS KEQUIEED. 333 run oif at the beak, but stop abruptly, leaving the last quarter of an inch blunt and round. The scalpel should be firm, seven or eight inches long, with a stout shank, and solid back, the blade about three inches long (Fig. 101), the cutting edge about one and a quarter inch. Blizard's probe-pointed knife (Fig. 102 — A, English pattern), long, straight, vpith a stiff back, and (Fig. 103 — -S, American) a ribbed handle. ii\ V ll Fig. 100. Fig. 101. Fio. 102—^. Fig. 102— .B. The blunt gorget, possibly useful where the patient is fat, and the peri- nseum deep (Fig. 103). The scoop (Fig. 104), several forceps of differ- ent sizes, with extremities roughened in the inside to hold the stone firmly, one with crossed handles (Fig. 105), so as to be opened sufficiently in a deep perinseum without stretching the wound unduly ; another with its blades sharply curved (Fig. 106), so as to catch stones behind the 334 LITHOTOMY. pubes, or in the " bas-fond." A heavy pair of forceps, with a central raised ridge of heavy teeth pointing backward (Fig. 107) in each blade, to catch and break stones which are found to be too large to extract safely, with an extra screw for attaching the blades, and drawing the jaws together. For the same purpose an instrument known as Maison- neuve's (Fig. 108), having its female blade terminate in a deep scoop. It is used as follows : The scoop (a) is introduced carefully through the perineal wound until it has entered the bladder, after which, by a lateral Pia. 104. Fis. 105. FiG. 106. motion, it is insinuated under the large stone. Now the male blade (c 5), with its inner shaft (ee) withdrawn, is gradually pushed down against the stone, and screwed firmly by the wheel (d) until it holds the cal- culus fixed. Finally, the inner sharp " bit " at the end of the central shaft (e) is, by rotating the handle, driven through the stone (e), thus perforating it, and, by the assistance of the wheel (d), splitting it into fragments. A metallic tube, one-third inch diameter (Fig. 109), with an open end, and a large eye — furnished with an obturator for easy introduc- tion — through which to wash out debris. Another tube, one-sixth inch diameter, provided with a globular head, about a half-inch diameter, hav- ing large holes in the globular head pointing backward (Fig. 110), and piece of rubber tubing on its proximal extremity — this to be used with INSTRUMENTS REQUIRED. 335 a Davidson's syringe to wash out debris. A shirted canula for hasmor- rhage (Fig. Ill), and a tenaculum whicli unscrews at the handle (Fig. 112, Keith's tenaculum), for the same purpose. Prichard's anklets and wristlets (Fig. 113). A soft French olivary catheter, brandy, hot and cold Fig. 108. Fig. 109. Fig. 110. water, sponges, towels, ligatures, ether, etc. These make up the neces- sary list of instruments. At least five assistants are necessary : one for the ether ; one to steady each knee of the patient ; one — the post of honor — to hold the staff; one to sponge and act as general assistant. The Operation. — The patient is prepared beforehand as for any other capital operation, and in addition has the perinseum shaved and receives a full enema about two hours before the operation, to clear the rectum, after which he abstains, if possible, from again passing water. 336 LITHOTOIIT. He should be etherized in bed, and then carried to a small, firm table, and comfortably arranged on an old blanket. The anklets and wristlets are adjusted (or the hands and feet bound together with bandage). The pelvis is now drawn to the lower edge of the table, facing the light, a piece of old carpet and a pan with saw- dust placed beneath to catch the blood and urine. The operator passes the staff, feels the stone with it, and then intrusts it to his assistant of honor, and, taking his seat on a low stool, facing the pa- tient's pelvis, with all his instruments systematically arranged within eas}- reach of his right hand, is in readiness to com- mence. Should the staff fail to strike the stone, it may be withdrawn and the searcher introduced. Should this also fail to detect it, after a careful and pro- longed sounding, the operation should be deferred. Some of the best operators l^ j0^^'\^,,^ ^ '.' have been deceived in their diagnosis, 0>'-''^ ^^ t^ll and have cut patients in whom no stone i^G- 111. Fig. 112. . , , , • t , ■,. i existed ; so that it has become a cardmal rule never to cut a patient in whom the stone cannot be felt after he is upon the table. The sbund may fail to detect it, if it lies in a deep 6«s- fond, but not so the searcher. The holder of the staff usually satisfies himself that the sound strikes the stone. It is not essential that the end of the staff should Fig. 118. rest against the stone. As long as it is certainly in the bladder, nothing more is required. The chief assistant stands at the patient's left, holds the staff vertically, steadily, and firmly hooked up under the symphy- sis, with its long curve a little bellied out in the median line of the LATERAL OPERATION. 337 perinseum, and keeps the integument of the latter taut by pulling the scrotum up around the staff. The assistants steady the knees, while the operator impresses his mind finally with the shape and size 'of the long outlet of the pelvis by running his fingers down the rami of the ischium, touching their tuberosities, feehng the symphysis pubis, and the coccyx. The surgeon should picture to himself a pelvis lying before him, m position, denuded of soft parts (Fig. 114), and recall the general inverted heart-shape of its outlet (Fig. 115). Fis. Ui.— (^Thompson.) The operator now introduces the left index-finger into the rectum assures himself that the sound enters at the apex of the prostate, and passes centrally through its canal, and that the rectum is empty and collapsed. Then, withdrawing his finger, he searches, with the thumb or finger of his left hand upon the raphe of the perineum, for the groove in the staff, which, in a thin person, can always be obscurely felt. , If he cannot feel it, he takes the handle of the staff from his assistant, and, by depressing it several times, while he makes pressure upon the pefi- nasum, he satisfies himself of the position of the groove, and returns the staff to his assistant. The scalpel is now entered a little to the (patient's) left of the raphe, from one and a quarter to one and a half inch in front of the anus, the point of the knife, guided by the nail, being made to enter the groove of the sound and open the urethra at the first cut. If the point enters the groove, it is to be pushed along for a quarter to half an inch — if it fails to strike the groove, it is made to pierce more or less 22 338 LITHOTOMY. deeply — and then, with a single bold stroke, the first incision is made laterally to the right, about three and a half inches long, terminating exactly midway between the tuber ischii and the anus. The scalpel is again entered into the groove, and the urethra amply opened. The practised lithotomist sometimes uses the same knife to complete the operation, but, as a rule, it is better, at this stage, to change the scalpel for Blizard's knife. The probed point of the latter, following the guid- ing index-finger, is passed into the groove, and the surgeon takes the handle of the staff, depresses it somewhat, and, following the groove, pushes his knife along until its point is arrested by the abrupt termina- tion of the groove at the end of the staff. He now increases the angle between his knife and the staff by depressing the handle of the former, and, remembering the position and shape of the prostate, he cuts his way out, his incision through the prostate being at about an angle of 30° with the horizon, his external incision at an angle of about 50°. A glance at Fig. 115 shows at once the relation between the in- cisions and their relation to the prostate and anus. A gush of urine usually follows this incision. If the external incision has not been bold enough, it may now be en- larged with a few strokes of the scalpel. If the above directions are followed, there is little danger of that disagreeable accident, cutting into the rectum. Instead of dividing the prostate with the knife, nu- merous ingenious lithotomes have been devised, which in- cise to a greater or less dis- tance, according to a pre- viously - arranged gauge, or can only cut to a limited ex- tent, as in the bisector of Wood, and that of Post, of New York. The single-cutting " lithotome cache," of Frere Come, and the double instrument of Dupuytren, with their many modifications, of which that of Briggs, of Nashville, is simple and efficient, all of these are undoubtedly good ; but the surgeon should learn early to depend as much as possible upon his brains and his fingers, and as little as pos- sible upon instruments, if he would acquire self-confidence, without which any operation for stone is unsurgical. Hence it is advisable for Fio. U5.—(_Thmipson.) LATERAL OPERATION. 339 the young surgeon to familiarize himself with the use of the scalpel and Blizard's knife, and to do all his cutting with these instruments, or even with the scalpel alone, remembering that the greatest average lateral dimensions of the adult prostate are only one and a half inch, and that a depth of incision one-half, or at most five-eighths of an inch, into one side of the prostate should be a limit never surpassed — dilata- tion wiU do the rest. Having now completed the incisions, the index-finger of the left hand should be gently introduced into the bladder, and the sound with- drawn. The finger usually comes at once in contact with the stone. The bladder's neck is now to be dilated slowly but thoroughly with the finger — if the perinseum be deep with fat, with the blunt gorget, carried in along the groove of the stafi^, 11 the stone has been pre- viously measured, and is less than one inch in diameter, or if there are many small stones, the surgeon should proceed to extract at once. If, however, the stone is above one inch in diameter, Blizard's knife should be reintroduced on the finger, and the prostate cut on the (patient's) right side. After being satisfied that the neck of the bladder is nicked, the prostate sufficiently cut, the whole wound dilated and dilatable, the forceps is passed into the bladder as the finger is withdrawn. One blade is depressed into the floor of the bladder, the other is widely opened, and usually, on closing them, the stone will be caught. Fail- ing in this, search laterally and further back in the bladder must be made, the direction of the blades being changed, until the stone is seized. In cases of deep perinseum the small end of the scoop is in- troduced until it touches a stone, and then the forceps is followed along upon the scoop as a guide until it enters the bladder and strikes the stone. It should never be forgetten during these manoeuvres that the bladder, usually already much inflamed, is often nearly empty, clasping the stone, and that any roughness or force may inflict serious (perhaps fatal) injury upon the patient. The utmost gentleness, deliberation, and care are necessary during this, stage of the operation ; indeed, the catching and skillful extraction of the stone is often a more delicate proceeding than any other part of the operation. If it is found that the stone has been seized in a faulty diameter, it should be dropped or pushed out of the jaws of the instrument, perhaps rolled over with the finger, and another attempt made to catch it cor- rectly. Extraction should be slow, the traction being made in the line of the external incision, downward and outward. Lateral motions should be given to the forceps during extraction, the force being about two-thirds lateral, one-third extractive. It must be remembered that the most fatal source of danger in lithotomy is bruising and lacerating the neck of the bladder in forcible efforts at removing the stone ; and, if, after the exercise of a sufficient amount of force — the amount to be learned only by experience— the stone will not engage in the outlet of 340 LITHOTOMY. the bladder, it is far more brilliant morally, and better surgerj', to break the stone and carefuUj extract the pieces, than to remove by force a handsome specimen to show, with the risk of having to attach to its history, " Result fatal." After one stone has been extracted, if it is found to be smoothly rounded and presenting no facets, there is probably no other present ; if it has facets, the reverse is almost, if not quite, certain to be the case. Phosphatic calculi are often multiple, uric acid less commonly so, oxalate of lime often single. In any case after extracting one stone, careful search should be made for another with the searcher, and the small end of the scoop through the perineal wound. Should any stone break dur- ing extraction, and in those rare cases where a quantity of debris is found in the bladder, partly adherent to ulcerated patches of mucous membrane, the large end of the scoop is to be used to spoon out the earthy matter, and then copious injections of tepid water are to be thrown into the bladder with the Davidson's syringe through the large tube (Fig. 109), or the bulbous-headed irrigator (Fig. 110), untU the bladder is clean. When the stone is found to be encysted, or fixed in position by some faulty contraction of the bladder behind the pubis, or in the fundus, the dexterity of the operator may be taxed to seize it with the forceps, but intelligent eflForts, gently and carefully prolonged, wll usually overcome the difficulty. If the stone is deeply encysted, it may be impossible to liberate it. The neck of the cyst may be nicked in several places, efforts made to gnaw off any projecting portions of stone, and gradually to insinuate the narrow blades of a small curved forceps to extract it. Each case must be coolly studied out at the time ; no definite rules, covering all contingencies, can be given. Veet Laese Stones. — Where the stone is found to be too large to extract safely, it must be broken, a procedure by no means modem, as it is referred to by Celsus. This is not an easy task in an irritated blad- der, contracted about a large calculus. If the heavy-jawed forceps (Fig. 107) can be made to grasp the stone, it may be thus broken up. Should the large calculus slip from the bite of this instrument, .the more formi- dable crusher (Fig. 108) may be resorted to, or an instrument devised by Civiale (Fig. 116), who employed it a score of times with extremely suc- cessful results.' The instrument is favorably mentioned by Thompson. Civiale employed it for stones weighing about one ounce and a half, and over. It is somewhat complicated, but serviceable. With one of these instruments the stone is to be carefully broken up, and the fragments removed with great circumspection, as their rough, broken anglra are fertile sources of laceration and severe contusion. When practicable, any prominent sharp edge should be protected by the finger of the operator, on its way out through the soft parts. The debris is dealt ' "La Lithotritie et la Taille," Paris, 1870, p. 440, el seg WHEEE THE STONE IS LARGE. 341 with by syringing through a tube, as already described. Crushing a large stone in situ, although a serious proceeding, and necessarily jeop- ardizing the success of the operation, is nevertheless countenanced by high authority, and has proved wonderfully serviceable. Mayo, of Win- chester,^ extracted successfully by this process a stone weighing four- teen and a half ounces, which certainly could not have been otherwise removed, Scemorrhage during the operation is rarely profuse. The lower part of the bulb is generally out into. Spurting-points should be tied as they occur, or twisted. When the bleeding-point is deep in the wound it is difficult to tie, and removing the tenaculum may loosen the ligature. To meet such an emergency, it is proper to tie in a tenaculum, and for this purpose Keith's idea (Fig. 112), of having a tenaculum from which the handle may be unscrewed, is a good one. Thompson •" says, " I believe I have saved a life on one or two occasions by tying in a tenacu- lum." In one instance the in- strument was left in ten days, when it came away spontane- ously. Gross's artery-compres- sor (Fig. 117) is suitable for the same purpose ; the artery is seized and compressed, the han- dle unscrewed, and the blades left in the wound. Digital pressure for several hours of the pudic artery against the ischio-pubic ramus may serve to arrest arterial hiBmorrhage, otherwise uncon- trollable. Ice and iced-water irrigation is an adjuvant which may be resorted to. Even the • pudic artery may be tied by taking a short, stout, curved needle with a holder, introducing it through the soft parts close to the anterior border of the bone, bringing it out about three-quarters of an inch deeper, and then firmly tying the liga- ture which it carried. > "Mecl.-Chir. Trans.," vol. xi., 1821, p. 54. » Op. cit, p. 44. Fia. Mi.—{T?iompmn.) A, Forceps. 5, Part to be fastened upon the forceps by screws. <7, Part to be inserted through B. C steadies and fixes position of stone, i?, Drill intro- dnced through tube E is rotated to perforate and break up stone. 342 LITHOTOMY. Veiioiis hemorrhage, unless profuse, may be disregarded ; if se. vera, it calls for plugging of the -wound. This is effected with the " shirted canula " (Fig. Ill), or any female catheter will do, with a sufB. ciently large square piece of muslin having a hole in its centre, tied firmly around the tube, at about an inch from the extremity which en- ters the bladder — or even a soft sponge perforated by a female catheter. This is introduced deeply into the wound, and the flaring sack around the central tube is closely packed with small pellets of lint, sponge, or oak- um, the whole kept in place with a snugly-applied T-bandage. Generally all oozing may be arrested by simply bringing the thighs together, and bandaging the knees, thighs, and ankles. The mutual pressure of the two surfaces of the wound answers admirably well. After-Treatment. — If the patient seems to be sinking during or im- mediately after the operation, before he has emerged from his ansesthesia, and, consequently, when he cannot swallow, an excellent means of stimu- lating him consists in passing through one nostril a soft French olivary catheter (about size 8) past the pharynx into the oesophagus, and throw- Fis. 117. ing into his stomach small doses of brandy with a syringe. The cathe- ter may be left in during the whole operation, and does not interfere with the administration of the ether. One caution is necessary : It is prudent, before injecting the brandy, to notice whether any air comes out of the catheter during expiration, as the instrument may possibly have passed into the trachea ; if time allows the slower absorption, in- jection into the rectum may be substituted. The patient is placed upon a mattress, with the hips upon a rubber cloth and folded compress, and napkins placed under him, which, by being frequently changed, indicate the amount of hsemorrhage. Urine passes freely at first through the wound, always more or less tinged with blood. The wound swells so much sometimes, before suppuration i^ established, that part of the urine on the second day flows through the meatus, or, indeed, retention may come on. The latter is relieved by gently introducing a female catheter or a finger through the wound. Opium may be given from the first to control pain, to be pushed ju- diciously on the appearance of any evidence of peritonitis. Diet should be light, but sustaining. If the patient has been addicted to stimulants, LATERAL OPEKATION IN CHILDREN. 343 he should not be deprived of them in moderation, and the same is true of opium." The wound usually closes by granulation. As suppuration comes on, there is not infrequently a slight chill, with (surgical) fever, but the patient is, on the whole, comfortable, and delighted to be free from his old pain. Sometimes the wound becomes coated with urinary salts. This is prevented by frequent syringing with warm water, to which a few drops of dilute nitric acid have been added. (Certain complica- tions are described after the median operation.) LATERAL OPERATIOIT IN CHILDBEN. In children the staff is smaller, with a shorter, sharper curve, as the bladder lies high ; hence, the staff must be hooked well behind the sym- physis. The incisions are made in the same manner as in the adulti The lower end of the rectum is often prolapsed in children with stone ; this is reduced before. the first incision, and kept in with the finger. There is little danger of cutting it, with the exercise of any ordinary care. The incision at the neck of the bladder usually, if not always, cuts entirely through the limits of the prostate, which is very minute before puberty, but it is a matter of no importance. Infiltration of urine does not occur after it. There is much more danger in making too small an incision, and lacerating and bruising the parts during extrac- tion of the stone. The lateral incision of the prostate avoids the seminal ducts. There is danger in children, if the membranous urethra and bladder-neck have not been sufficiently cut, that an attempt to introduce the finger and dilate the latter may require so much force that the mem- branous urethra is torn across and the bladder pushed before the advan- cing finger. The mention of this accident will insure against its occur- rence. Another caution must be given, namely, that the first opening into the urethra should be sufiiciently ample to insure its easy discovery upon search, so as to avoid the necessity of making several openings at different angles in a small tu-ethra— an accident which might be followed by stricture. All care is necessary in extracting the stone. Hsemor- rhage in young subjects is very de^'italizing. All the blood that is pos- sible should be saved. Children cut by the lateral operation rally with surprising rapidity. Every surgeon of large experience recounts cases where, on visiting the child twenty-four hours after the operation, he finds him up and playing * A patient, past middle life, from whom I removed, by the lateral operation, eight phosphatic stones weighing collectively two ounces three hundred and twenty grains, had been so tortured by pain during a number of years by his malady, which had been unrecognized, that he acquired the habit of opium-eating. His daily dose was seventy grains of opium and two or three ounces of laudanum. After the operation his pain ceased, and his opium was rapidly out down to a very small daily dose. But, although he did well in every other respect, his wound absolutely refused to granulate during sev- eral weeks. On this account he was allowed to resume his large doses of opium, and, when he reached nearly his habitual quantity, his wound rapidly granulated and went OD to speedy union ; after which bis opium was again reduced. — Keyes. 3U LITHOTOMY. about the room — ^possibly out-of-doors with his companions. Accidents, however, do occasionally occur with the young, and due care should be exercised in the after-treatment to meet all symptoms appropriately — especiallj' any indication of peritonitis, a complication of lithotomy pro- portionally much more common in childhood than in later life. THE MEDIAN OPERATION. The median is known classically as the Marian operation, devised in the sixteenth century, and afterward largely adopted and improved in Italy. Allarton has been its apostle in England, and the modem opera- FlG. 118. Fig. 119. tion is known by his name. In this country Markoe first brought it into particular prominence, and the names of Little and Walter are also con- nected with it. Each of these three surgeons has enjoyed remarkable success with this operation. INSTRUMENTS EEQUIRED— OPERATION. 345 Instetjments EEQUIRED. — The only instruments necessary, differing from those employed in the lateral operation, are three : a staff, director, and knife. The staff, of appropriate size, has a central groove, with a broad flare. Markoe (Fig. 118) and Little (Fig. 119) have each adopted a staff. The groove of the latter is deeper, furnishing, its au- thor believes, greater convenience and certainty in dividing the mem- branous urethra. A ball-pointed probe, or a director, known as Little's (Fig. 120), is generally employed, and a straight, stout, sharp-pointed bistoury, generally made to cut slightly upon the back for a short dis- tance from the point. G.TlEMANN-CO, Fie. 120, Operation. — The patient bound in the lithotomy'- position, and the staff introduced in contact with the stone, the operator passes the index- finger of the left hand into the rectum, familiarizes himself with the feel of the parts, and accurately locates the apex of the prostate, just where the staff enters it. He now transfixes the perinseum about half an inch above the anus, with the sharp-pointed bistoury, the cutting-edge up- ward, entering the point of the same, guided by his finger in the rectum, into the central groove of the staff, at the apex of the prostate. The double-edged point is now advanced very slightly into the groove, so as certainly to enter the urethra, and barely nick the apex of the prostate. Finally, the knife is made to cut forward and divide the membranous urethra within, and, the handle being elevated in the vertical plane, the blade is swept around so as (theoretically at least) to avoid the bulb, and cut its way out along the raphe, the external incision being from one and a quarter to one and a half inch long. Thompson prefers making the incision from without centrally inward. The director is now passed along the staff into the bladder, and, these two being sepa- rated in an angular way, the neck of the bladder is dilated, some urine flowing out during the process. The staff is now withdrawn, and a fin- ger introduced through the wound, with which the dilatation is com- pleted, without cutting the prostate or the neck of the bladder. The stone — necessarily not very large — is withdrawn, as in lateral lithotomy, and the general after-care of the patient is the same. The operation yields excellent results ; the patient sometimes retains control over his urine from the first. The wound usually heals rapidly. The objections to the operation are : its general inapplicability except for stones which lithotrity is more capable of managing, and the tempta- tion to use violence during the extraction of a too large stone. It-is emi- 346 LITHOTOMY. aently applicable for small stones, in a bladder wbicb will not, tolerate the use of instruments without chill or other disturbance, for multiple small stones in the adult, and for oldish boys, too young for Hthotrity, who by reason of budding and advancing puberty are not very good subjects for the lateral operation. Where rather large stones are extracted by this method, incontinence, sometimes lasting several years, may occasionally ensue. The median operation has been variously modi- fied, as by being combined with single or double prostatic incision, but mainly in relation to the means resorted to to dilate the prostate. Instead of the finger, Arnott's fluid-pressure has been advocated and employed. It acts too slowly to be useful. Teale has devised a branched metaUio dilator, and Dolbeau '- another, the latter to dilate twelve millimetres, which is the average limit fixed by Dolbeau, from experiments on the dead subject, to which dilatation can be carried without any laceration or injury. The dilator is applied first to the outer wound, and then grad uaUy inward, until the passage is dilated to the required limit, not far from half an inch, after which, in Dolbeau's operation, which he calls " perineal lithotrity," the stone, if of greater diameter than two centi- metres, is crushed with a forceps resembling the heavy-jawed forceps (Fig. 107), and the detritus carefully extracted. The objections to the operation are, that calculi which could be so dealt with safely can, for the most part, be more safely cured by lithotrity, while, if the stone is large, the lateral operation, with double section of the prostate, and crushing in situ, is undoubtedly preferable. STTPRA-PTJBIC OPERATION. The high operation for stone, designed by Franco in 1561, has still a respectable advocacy. It is applicable only to large stone, where the choice must otherwise be a perineal operation, with the additional danger of crushing i?i situ/ or, recto-vesical section, with its possible result- ing fistula ; and, finally, in cases of deformed pelvis. Humphrey,' who speaks with authority upon the subject, and is quoted by Thompson, states that the dangers in the high operation do not increase in so great a ratio with the size of the stone as they do in the lateral operation. For the proper performance of the high operation for stone, two con- ditions are essential : the bladder must be distensible, the abdomen not too fat. The Operation. — The pelvis is elevated several inches, so as to keep the abdominal viscera from gravitating toward the bladder. The cavity of the latter is injected. An incision is made in the median line, three or four inches upward, from the symphysis pubis. The linea alba is exposed, and divided below, for about a quarter of an inch. Into this opening the aponeurotome (Fig. 121) is passed, and the linea alba ' " De la Lithotritie perinSale," etc., Paris, ISTS. 2 " Trans. Prov. Med. Ass., 1850," vol. xvii., p. 103 COMPLICATIONS OF LITHOTOMY. 347 divided with it, for about two inches upward. Now, the " sonde a dard " (Fig. 122), with the dart concealed, is introduced. By depressing its handle, the point is carried up close behind the symphysis pubis, where the " dart " is pressed out, and made to appear in the lower angle of the wound. Upon a groove in the stylet which carries the dart, the ante- rior wall of the bladder is incised nearly down to the neck. The hooked gorget (Fig. 123) is now caught in the upper angle of the incision in Fia. 121. Fio. 122. the bladder, and firmly held up by an assistant, while the stone is extracted. If the latter is very large, the wound in the bladder may be widened by lateral incision. COMPLICATIONS OP LITHOTOHY. Shock, exhaustion, septicaemia, pytemia, erysipelas, possibly tetanus, may be encountered after lithotomy, and require to be met according to general surgical principles. Unusual complications in the way of hsemorrhage, besides those already alluded to, may occur in connection with the hemorrhagic diathesis, or in those rare cases of irregular arterial distribution, where the main pudic trunk is defective, and its place supplied by an accessory pudic lying close along the border of the 34.8 LITHOTOMY. prostate, or where tbe artery of tlie bulb is given off farther bact than usual, or the main artery of the prostate enters the gland in a position exposing it to injurj-. These complications are met by especial atten- tion to the means of arresting hemorrhage, already detailed in describ- ing the lateral operation. Secondary hsemorrhage sometimes comes on several days after the operation. Thompson has had four cases, two of which were fatal. The wound is small ; ligature can rarely be applied. Thompson advises perchloride of iron, carried in upon lint at the end of a probe, or the actual cautery. Perchloride of iron might be injected. South reports arrest of the hemorrhage in several cases by pressure on the pudic artery, long continued. Peritonitis, more common in the child, may complicate the operation in the adult. The rectum may be wounded, or the perineal wound mav inflame from mechanical injury or diathetic cause, resulting possibly in sloughing of a part of the rectum. Fistula may be left behind, reten- tion may follow the operation, or temporary or even permanent incon- tinence, and even occasionally sterility, from obliteration of the ejacu- latorv ducts by section or subsequent inflammation. Epididymitis may come on, as after any operation involving the prostate. Cystitis may run high from injury to the bladder during extraction of the stone ; chronic disease in the kidney may be kindled into an acute state. All of these complications are to be met according to suggestions already laid down in other parts of this treatise. By far the most common complications after operation are inflam- mation of the parts around the bladder-neck (cellulitis), and infiltration, both due to the same cause — ^mechanical violence in extracting too large a stone, or jagged fragments, through an insufficient opening. Lack of vitality in the patient undoubtedly conduces to these results, and iniil- tration may be due to an incision surpassing the limits of the fibrous capsule of the prostate. But that infiltration is more often dependent upon tearing and laceration during the extraction of large stones, is ad- vanced by Thompson, supported by the fact that in children infiltration is rare, although the incision, as a rule, in the lateral operation, gener- ally surpasses the limits of the prostate, and notwithstanding the fact that in children the cellular tissue is particularly loose. Relapse of stone is liable to occur if any fragment is left in the blad- der, and no part of the operation requires more care than the thorough evacuation of debris, in any case where a stone has been broken inten- tionally, or accidentally crushed during extraction. If, after healing of the wound, any symptoms referable to stone should continue, a careful search may detect the fragment, while yet small, and furnish an oppor- tunity for the use of the Uthotrite. THE URETERS. 349 CASE OP IHSTBXJMENTS FOE, STONE. The following instruments might be grouped into one case. They are sufficient to meet all the ordinary requirements of stone : Thompson's searcher. Thompson's litliotrite, heavy and light. Evacuating catheter. Urethral forceps. Lateral lithotomy-staff, small and large. Median lithotomy-staff. Lithotomy-scalpel. Straight, sharp-pointed, narrow, stiff-backed bistoury. Blizard's knife. Blunt gorget. Little's director. Scoop. Lithotomy-forceps, with crossed handles. Lithotomy-forceps, with curved blades. Crushing-forceps, with extra piece. Tube with globular head, for washing bladder. Shirted canula. Keith's tenaculum. CHAPTER XIX. DISEASES OF TEE URETEBS Anatomy. — ^Anomalies. — Chronjc Inflammation. — ^DUatatlon. — Stricture. — WoundB. The ureters are the excreting ducts of the kidne3'S. They run down on either side behind the peritonaeum from the'kidney over the brim of the pelvis to the base of the bladder, and pass through its coats in an oblique, valvular way, making two of the angles of the trigonium Lieu- taudii, of which the internal orifice of the urethra is the third. The structure of the ureters is mainly muscular. There is an inside mucous membrane, then come the circular and longitudinal layers of unstriped muscle, bound together by connective tissue. Not very infrequently the ureter is double or triple ; the abnormality existing through the whole length of the canal, or, more commonly, the several branches uniting above at a distance of one or more inches from the pelvis of the kidney, to form one canal from that point on into the bladder. Occasionally there is but one ureter. Sometimes the ureter ends in a blind extremity, in which case the kidney cannot functionate, and atrophies. 350 DISEASES OF THE KIDJfET. The diseases of the ureter are few and unimportant, being for the most part a continuation of other disease. Chronic inflammation of the ureter extending upward from the bladder, or downward from the Md- nev, exists, but is hardly worthy of consideration. Pressine (by tumor or otherwise) upon any portion of the ureter causes the canal above to become enormously distended, so that it may reach the size of the thumb or even larger. This occurs markedly in extrophy of the bladder, and is sure to happen if a kidney-stone becomes lodged in the canal on its way to the bladder. Stricture may follow the injury done by a cal- culus in its passage, or malignant or tubercular disease may extend to the ureter from the bladder or kidney. The blood in hematuria may come from the xu-eters. The ureter may be ruptured by external violence, or severed by a wound — ^injuries leading often to fatal extravasation of urine. CHAPTEE XX. DISEASES OF THE KIDNEY. Anatomy.— Anomalies. — iDJnries.— Suppression of Urine. — ^Fephralgia. — ^PhoBphatic TTrine. — Oxaluria.— Gravel and Kidney-Stone. — ^Nephritic Colic. — Pyelitis, Pyelonephritis, and Peri-nepliritic Abscess.— Pyelitis, Pathological Lesions.— Causes. — Calculous Pyelitis. — ^Peri-nephritic Abscess. — Treatment of Pyelitis (calculous). Solvent Treatment, Nephrotomy.— Hydronephrosis.— Kidney Cysts.— Hydatids.— Tubercle.— Cancer.— Ablation of Kidney.— Syphilis of the Kidney. The scope of this work does not warrant a description of all organic and functional kidney-diseases.' Only such surgical diseases are here dealt with as are most frequently encountered by the practitioner in- terested in genito-urinary surgery, such morbid states as are hable to be attended with, or complicated by, functional or organic bladder-disease, or such as may require instrumental interference for their relief. Ais^ATOiTT. — The kidney Kes on either side in the lumbar region, high up, its upper border reaching above the last two false ribs. It has the familiar shape of the kidnej'-bean, is surmounted above by the supra renal capsule, like a cocked-hat, and lies outside of the peritonaeum sur- rounded by fat, with its hilum directed inward. The healthy adult kidney weighs from four to six ounces. It is surromided by its own in- vesting fibrous capsule, close inside of which lies the secreting or cortical portion of the kidney, dotted by its innumerable Malpighian bodies, and containing the convoluted uriniferous tubes ; these terminating in the converging straight tubes which unite to form the pyramids, the medullary portion of the kidney. Tlie pyramids terminate in nipple- like protuberances called papillae, which dip into the cavity known as ' For such information the student is referred to text-books on urinary diseases — Roberts, Rayer, Civiale, Dickenson, lloreland, and others. CONTUSIONS AND WOUNDS. 351 the pelvis of the kidney, each papilla surrounded by a cup-like cavity in the pelvis known as a calix. All of these calices unite to form the cavity of the pelvis of the kidney from which the ureter is given ofif. The two kidneys are sometimes united at their upper extremity, forming what is called the horseshoe-kidney, usually lying astraddle the spine. Some- times there is but one kidney, in which case it is much larger than usual. Occasionally there are three or more. Instead of being fixed behind the peritonaeum in the lumbar region, the kidney may be only loosely connected there, and may become displaced in the abdomen, and freely movable (floating kidney). Still more rarely the kidney is found in an abnormal position in the cavity of the bony pelvis, or elsewhere. If one kidney is absent, atrophied, or diseased, the other remaining healthy, the latter undergoes gradual conservative hypertrophy, greatly increasing in size. CONTtrsiONS AND -WOtrNDS. The kidney is rarely wounded by any accident not in itself fatal. When the patient survives such an accident, more or less infiltration of the tissues by urine is sure to follow. The kidney itself inflames, caus- ing partial or entire suppression, with blood in the urine, hot skin, high pulse, thirst, headache, pain running down to the testicle, vomiting, etc. Perhaps abscess results. Contusions are more common. The kidney may be ruptured or lacerated by a fall, by crushing violence, or by a severe blow. Such rupture may be caused where the signs of external violence are insignificant. If the anterior surface of the kidney be ruptured, the urine may escape into the peritonaeum, giving rise to fatal peritonitis ; if the posterior, the sub-serous tissues will be infiltrated, and chills, with high fever, will precede the formation of pus. The contusion may injure the vitality of a portion of the kidney, but not be attended by actual laceration. In such a case there would be more or less acute traumatic nephritis, terminating possibly in abscess. The symptoms of laceration of the Tiidney vary in degree according to the extent of damage done. Collapse usually comes on at once with strong tendency to vomit, as in injuries of the testicle. There is pain over the injured organ, pain running down the ureter into the testicle, and in the testicle itself, retraction of the testicle ; often pain across the hypogastrium, and a heavy, numb feeling in the thigh. The urine, which may require to be drawn at first through the catheter, will be usually bloody, scanty, and dense, possibly containing blood-casts of the uriniferous tubules, and frequently long, thin clots — casts of the ureter. The prognosis, if the laceration be extensive, is almost necessarily fetal ; if it be slight, the patient may survive. Treatment consists in absolute rest, opium to quiet pain, and the use ?f the catheter and enemata to secure evacuation of the discharges. 352 DISEASES OF THE KIDNEY. Frequent and careful examinations must be made over the site of the injured kidney, and an exploratory incision as soon as the existence of pus is suspected. An early and free incision is of great importance, as pus tends to burrow downward and forward, giving rise to great consti- tutional irritation. If no pus be discovered, the infiltrated urine may be evacuated, and, in any case, an early, free, and deep incision can do no harm. STJPPEESSION OP URINE. In suppression no fluid comes down the ureters into the bladder. Suppression may be caused by fright or strong mental emotions, by in- jury to the kidneys, or the onset of an inflammatory attack, by the effect of cold or other cause ; sometimes, especially if the kidney be the seat of previous chronic disease, by operations on the bladder or ure- thra, or even by the introduction of a sound or Hthotrite {see Ueetheal Fevee), by the passage of kidney-stone, etc. The si/mj?toms are depression, languor, with apprehension, more or less fever, with hot, dry skin, and hard pulse. There may or may not be chill, vomiting, headache, and pain in back and loins, with constipa- tion. No urine is voided, or only a little high-colored secretion. In- stead of these active symptoms, suppression may come on gradually from advancing chronic kidney-disease, the amount of urine passed from day to day gradually diminishing. In the latter case there is usually anasarca, in the former not. Meanwhile the urea and products of tissue-meta- morphosis are accumulating in the blood, and the patient becomes poi- soned by them. Drowsiness and stupidity, perhaps delirium and coma, come on ; there may be convulsions, and the patient dies in from two to five days, unless the flow of urine can be reestablished. Before death the skin and breath have a urinous, cadaveric smell ; there may be localized paralysis. Diac/nosis is easy. In retention the bladder is full, and can be felt above-the pubes, the difficulty usually being to introduce a catheter. In suppression, the catheter glides in readily, but the bladder is found nearly or quite empty. Treatment. — Dry cups and hot fomentations over the kidneys. Hot air bath and hydragogue laxatives, to favor excretion of urea by the intestinal mucous membrane, the free use of warm drinks, flaxseed-tea, etc. ; and, if there be no inflammatory condition, fuU doses of the acetate or citrate of potash and of infusion of digitalis, constitute the treatment. Turpentine should be avoided. Hyoscyamus may be given, and mor- phine subcutaneously. In old cases of chronic bladder and kidney disease, suppression is an exceedingly dangerous symptom, and does not yield readily to treat- ment. It signifies extension of inflammation to the excretive structure of the kidneys, and is the normal termination of this class of diseases. NEPHEALGIA— CAUSES. 353 NEPHRAI,GIA. Pain over the region of the kidney is a symptom by no means con- fined to diseases of that organ. It is found with many morbid bladder and prostatic conditions, and very often is simple lumbago, not depend- ent upon any internal malady. In bladder and prostatic diseases the pain in the back is more likely to occupy the sacral region, particularly the saoro-iliac synchondrosis on one or both sides. In lumbago the pain is usually much worse in damp weather, or on the approach of a storm is aggravated usually by motion of the trunk, particularly in rising from a sitting posture. There is a popular impression that all kidney-dis- eases are attended by pain in the back, the severity of the disease regu- lating the amount of pain. This impression is incorrect. Some kidney- diseases are attended by pains in the back, others are not. There is, however, a variety of pain in the back, which has its seat in the kidney, and which is known as nephralgia. This pain is deep seated, felt in the back over the kidney, usually unilateral, often extending down around the side, following the course of the ureter, sometimes continuing on into the testicle, sometimes complicated by bladder-symptoms sugges- tive of stone in the bladder, or of chronic cystitis of the neck. The pain varies in intensity, and is usually made worse by fatigue. Pressure generally aggravates, sometimes relieves it. Often the patient cannot lie in bed upon the affected side. The pain is usually a dull, deep ache, occasionally sharp, darting, pricking, in character. It may come on gradually, or suddenly, and remains, according to its cause, from a short time up to many years, perhaps until death. Nephralgia is in reality a symptom, but may come on in a severe form independently of any organic disease. Causes. — ^The main causes of nephralgia are very acid urine, kidney- stone, organic kidney-disease (pyelitis, cancer, any morbid deposit or tumor), and many other morbid conditions, special diseases, abdominal aneurism, etc. It may owe its origin to, and be kept up by, perversion of the sexual function, or ungratified sexual desire. Over-acid urine is in itself a sufficient and a not infrequent cause. The urine in health is slightly acid, especially after fasting. As a rule, however, in the healthy state there is an alkaline tide (as Roberts has denominated it) to the urine, which comes on after each meal, and lasts several hours. The heavier the meal the later but the more lasting the tide. In the morn- ing, with American habits of living, it occurs at about 10.30 o'clock. The urine, then, shortly after breakfast, should be normally neutral, or even faintly alkaline, and, when it is not so, a diagnosis of over-acid urine may be safely made.' The causes of over-acidity of the urine are ' If the patient has neglected to pass water before breakfast, the very acid urine col- lected during the night may not be neutralized by, the alkaline tide. Simple mention of this fact will preclude error ; nor is it necessary to test only the urine voided during the 23 354 DISEASES OF THE KIDNET. the rheumatic diathesis, old age, the use of wines and liquors, but es- pecially of fermented malt liquors, ale, beer, etc., and of sweet, spar- kling wines (champagne). The latter of the above-mentioned causes act directly as irritants to the urinary tracts by producing large quan- tities of sharp-pointed crystals of uric acid which mechanically scrape and irritate all portions of the mucous membrane. The urine may be over-acid while its true character is masked by some bladder or kid- ney inflammation which furnishes enough (volatile) alkali to neutralize the whole flow. This source of error has to be constantly guarded against. There are no inflammatory conditions, acute or chronic, of any portion of the urinary passages which are not distinctly aggra- vated by over-acid urine, while some of them are caused in the first in- stance by it. Hence it becomes a part of the hygiene of the urinary pas- sages (p. 40) to see that the alkaline tide exists, say at eleven o'clock in the morning, and, if it does not, to cause it to do so by attention to hygienic laws and the internal administration of a suitable alkali. In all cases of nephralgia where careful examination fails to detect any tumor of the kidney, or any disease of the bladder or prostate, suspicion should fall at once upon an over-acid state of the urine as being the cause, or possibly retained kidney-stone with pyelitis, or pyelitis from some other cause (cheesy tubercle, etc.). Diagnosis. — ^To decide between these affections, a careful examina- tion of the urine is necessary after excluding bladder and prostatic dis- ease. In pyelitis there will be constantly more or less pus in the urine. In nephralgia due to over-acid urine the alkaline tide is usually absent; crystals of oxalate of lime and of m-ic acid may be found in the urine when passed, while the color is usually deep, and the specific gravity constantly high. There may be also in the urine more or less pus pro- portionate to the amount of irritation produced by the acid urine and the duration of the complaint. Such urine when left to stand in a glass may become almost solid on cooling, by the precipitation of pink amor- phous lu-ates, or, if the latter ingredient be not sufficiently abimdant to produce this result, a blue line, like the bloom on a plum, wiU. form around the top of the glass just at the edge of the luine. Finally, after a few hours such inrine may begin spontaneously to deposit large red crystals of uric acid upon the sides and bottom of tie glass. Frognosis. — The deep-seated, dull, boring pain over one or both kidneys may last for years, kept up by over-acid urine, in patients of sedentary habits whose nervous tone is depressed by overwork, alcohol, or tobacco. Nephralgia very often coexists with irregular use of the sexual organs, or ungratified desire. The treatment is slowly but surely effective unless there exists oi> ganic mischief. It consists in a properly-regulated hygiene, much out- few hours after breakfast, for this is alkaline often where habitnal over-acidity exists none the less. The practical test is this : nrine should be voided on rising in the morning, and Dot again till 10.30, at which hour it should be neutral. PHOSPHATIC URINE— SYMPTOMS. 355 door exercise, Turkish, Russian or other baths, dry frictions of the skin daily with hair gloves, rather light diet, the avoidance of overwork and of the abuse of alcoholic beverages (particularly fermented liquors) and of tobacco. In persistent cases of pure nephralgia in young adult males the hygiene of the sexual organs is almost invariably at fault, and re- quires attention. An acquaintance with this fact is the key to success- ful treatment in many cases. The means detailed above, aided by half- drachm doses of citrate of potash three times daily, or the plentiful use of Vichy or other alkaline water, will usually sooner or later get the better of the complaint. If a laxative is needed, about | vij of Fried- richshalle water, to which a little hot water is added, may be taken with benefit one hour before breakfast every morning. PHOSPHATIC TJEINE. In connection with the above, the converse state, over-alkaline urine, should be referred to. Here the urine is habitually neutral or alkaline, while the alkaline tide is unduly marked. The fluid is pale, of light specific gravity, and often, after standing a few hours in a glass vessel at ordinary temperatures, it commences to decompose. Such urine, when passed, often has a faint mutton-broth or chicken-soup odor, and the last drachm or more of the flow is very apt to be as white as milk, from an excess of precipitated amorphous phosphates. This white flow is not constant. It may come only with the alkaline tide after breakfast. It is a cause of unceasing anxiety to many patients, who believe it to be seminal fluid. The urine when set aside shows the glossy, irides- cent, phosphatic pellicle very quickly, instead of the faint bluish line at the top of the fluid on the glass, which is produced by urine rich in urates, Phosphatic urine is apt to contain crystals of oxalate of lime when passed, and to show at once or shortly afterward innumerable vib- riones, the rapid development of which is undoubtedly due to the pres- ence of phosphate of lime. Phosphatic urine alternates from time to time with over-acid urine, so that the same patient may have for a few days a dirty-brown sediment of urates in his chamber, which he some- times mistakes for blood, and then for a few succeeding days a dense white deposit which, if his sexual relations be not perfectly natural, he is pretty sure to consider seminal fluid. The alternations sometimes seem to depend upon the greater or less amount of mental worry and physical exercise, the quantity and quality of the food, and the condition of the digestion. Sometimes both deposits exist in excess at the same time, so that the discharge may be creamy as it comes from the bladder, and deposit an enormous amount of urates and phosphates, recalling the solid urine of snakes and birds. The, symptoms found with phosphatic urine are usually those of las- situde, listlessness, a feeling of general weakness, often attended by 356 DISEASES OF THE KIDXET. despondency. There are usually, also, duU, continuous pain in the back of the head, and unsatisfactory digestion. Phosphatic urine depends usually upon nervous exhaustion, and ia often associated -with weak digestion, a diet formed mainly of the cere- als and starchy food, with a dislike for meat. Excessive use of tobacco aggravates any existing tendency to the production of phosphatic urine ; masturbation, or excessive venery, often leads to it by exhausting the nervous force; mental anxiety and worry produce it temporarily. Thus, students who study all night, before some critical examination, are cer- tain to have an excess of phosphates in their urine on the following day. In the same way, any continued mental tension, anxiety, or fatigue, may produce it. As may be inferred from its etiology, this affection is mostly confined to youth and early adult age. The treatment consists in removing the cause, if possible, reestab- lishing mental quietude, cutting off tobacco, tea, and coffee, encouraging pleasant out-door relaxation, with travel, change of scene, and air. As medicine, phosphoric acid (Horsford's acid phosphates) with or without a little strychnine, iron, or quinine, and perhaps some bitter vege- table infusion, or tincture, are usually employed, and would seem to be indicated as appropriate tonics. The cause of phosphatic urine is evi- dently associated with morbid action of the ganglionic nervous centres, affecting the secondary assimilation of food, and those remedies which are most effectual in correcting this curious and unpleasant condition are measures which place the patient under the influence of more favor- able conditions of life temporarily. Hence, a trip to the mountains, camping out, sea-voyage, etc., are more potent in securing relief than any drug. OXALTTKIA. The octahedral crystals of oxalate of lime, together with (l^s fre- quently) the dumb-bell crystals, the little spherules and the amorphous dust of the same, are not infrequently found in the urine, either alone or coexisting with crystals of uric acid, and with deposits of amorphous phosphates or urates. Such urine is often acid, dense, and high-colored. Sometimes the crystals appear accidentally in the mine from the free use of rhubarb, or indeed of tomatoes. Usually, but not necessarily, the crystals appear in cases of disturbed or exhausted nerve-power, and im- perfect digestion. They are found also with some diseases of the brain and spinal cord. Nervous prostration, produced by excessive venery, is quite likely to be associated with them. In short, nervous, irritable, hy- pochondriacal individuals, especially of the gouty temperament, particu- larly if young, with perverted, over-stimulated, or ungratified sexual desires ; if overfed, under-exercised, and leading a sedentary life — such patients frequently have oxalate of lime in their urine, and suffer from an interminable series of unusual complaints, with which they are pretty GEAVEL AND KIDNEY-STONE. 357 sure to tormeut their physician as well as themselves. The oxalate of lime is not a cause of the disorder, but rather a symptom. These cases are met by hygiene, change, and a proper regulation of all that has gone astray. If enough of any alkali be given to render the urine abundant and limpid, the oxalate of lime will usually disappear for a time ; and this course is advisable, as well as the frequent use of baths, to free the blood as much as possible from any effete materials which may have been collecting there. The true curative treatment, however, is purely hygienic, and based upon a correct appreciation of the causes. As a rule, the less medicine taken the better. The mineral acids and strych- nine seem sometimes to do good as tonics. GrBAVEL AND KIDNEY-STONE. The solid substances naturally held in solution, and excreted with the urine, are sometimes precipitated in the crystalline form in the kidney-tubules, or at other portions of the urinary passages, and voided as crystals, always visible with the microscope, sometimes to the unaided eye. This is gravel. The cause of its precipitation lies in the fact that the urine becomes too concentrated — too heavy with organic constitu- ents. As most frequently met with in practice, gravel is composed of uric acid, and forms the red sand which quickly collects around the sides and bottom of the vessel containing the urine. The gouty constitution predisposes to the formation of this red sand, especially when aided by a sedentary life and high living, more nutriment being ingested than can be disposed of, especially meats and alcoholic beverages, among which new fermented liquors and sweet, effervescing wines hold the first rank. Gravel is more frequently seen in summer than at other seasons, on ac- count of the greater activity of the skin, which leaves less fluid to be ex- creted by the kidneys, and consequently leads directly to a concentra- tion of the urine. The tendency to the formation of gravel is often hereditary. The symptoms occasioned by gravel are those set down for nephral- gia, and, added to them, often symptoms of a low grade of cystitis or urethritis — the smarting, burning sensations on urination being espe- cially prominent. All bladder or urethral inflammations are greatly ag- gravated b3'' the existence of " red sand " (sharp crystals or concretions of uric acid) in the urine. Treatment. — After what has been so frequently repeated in previous sections, of the ill effects of highly-acid urine, it is needless to delay long with the consideration of gravel. An abundance of alkaline diluents for a few days will always cause the red sand to disappear, and the symp- toms occasioned by it wUl shortly afterward cease to be troublesome in pure cases of gravel. The true treatment is preventive ; that is, so reg- ulating the food, drink, exercise, and hygiene of living, that the offensive ingredient may cease to appear. To effect this, the constant use of some 358 DISEASES OF THE KIDNEY. mild, pleasant, alkaline fluid (such as Vichy water) is often desirable. It is well to take a draught of this, or some other fluid, before retiring, and between meals, for the purpose of diluting the lu-ine of fasting. From gravel to kidney-stone is but a single step. It is only neces- sary for some of the crystals to be detained for a time in the kidney and there form a nucleus, and we have at once kidney-stone. Such detentions of crystalline material in the kidney do occur. Attentive examination of sections of kidneys after death will sometimes reveal numerous yellowish or brown strias nmning from the papillse toward the base of the pyramids. These depend upon the precipitation of amorphous urates in the straight kidney-tubules, and are usually caused by the post-mortem cooling of the body, which diminishes the solubility of this ingredient and occasions its deposit. In still-bom infants, and in children dying within forty-eight hours after birth, these striae are not infrequently found composed of uric acid. A similar precipitation of urates, uric acid, or oxalate of lime, may occur during life. If it be washed out by the urine accumulating above, we have some sand or amorphous dust in the voided fluid. But such concretions may become impacted and permanently lodged in the luinary tubules. Here they may cease to grow, or may increase in size in the kidney-substance, leading, perhaps, to the formation of cysts, by occlusion. Finally, these concretions, when washed down by the urine, may fail to escape from the pelvis of the kidney and become lodged in one of the calices or in the pelvis itseK. A nucleus once existing in this situation becomes a foreign body, and goes on increasing in size by the deposition of new crystals or amorphous matter furnished by the urine. The precipitation may occur primarily in the infundibula or pelvis of the kidney. The number, size, and shape of these kidney-concretions vary infinitely. Several hundreds of them have been found in a single kidney after death. They vary in size from a pin's-head to a nut, and may reach the weight of several drachms in old cases. They are usually smooth, oval in shape, or with facets from mutual friction, if several of them lie together ; or they may assume every variety of prolongation and arborization. They may be rough on the surface, especially if composed of oxalate of lime, or, if they excite pyelitis, their surfaces may become in- crusted with triple and amorphous phosphates. Blood-clot, portions of hydatid cysts, or little masses of concrete pus, may serve as the nucleus for renal calculus. The symptoms of kidney-stone are variable. As long as they are small and do not excite inflammation, or become engaged in the orifice of the ureter, the patient may not be informed of their presence by a single unnatural sensation, so that an autopsy may first reveal an unsuspected kidney-stone. Occasionally they attain large size, and even destroy extensive portions of the kidney by pressure, without occasioning any symptom to attract the patient's attention. Again, symptoms of kid- NEPHRITIC COLIC. 359 ney-stone, with paroxysms of pain, may exist for a time, and then cease, either because the stone has occluded the ureter and led to atrophy of the kidney, or because it has become encysted and has ceased to irritate the mucous membrane, or to oppose the escape of urine. Sooner or later, however, kidney-stones usually manifest their presence in one of three ways, either by setting up inflammation of the pelvis of the kid- ney (calculous pyelitis), by their passage into the bladder (nephritic colic), or by remittent or persistent nephralgia. The aching pain in the small of the back, with all its accompanying symptoms, as detailed under the head of nephralgia, may depend on kid- ney-stone. This pain is usually made worse by pressure, but there is no distinctive character to it which enables the surgeon to decide positively whether the pain depends upon retained stone or other cause. When, however, the cause lies in kidney-stone, while the crystals in the urine remain the same, it may sometimes be noticed that the blood-disks, oval, round, and spindle-shaped epithelial cells and scattered pus-cells, which the urine is pretty sure to contain, become increased in quantity after exercise, while they sensibly diminish, or perhaps entirely disap- pear, after rest in bed for a few days. Tlie treatment of stone retained in the kidney will be considered under the head of Calculoits Pyelitis (solvent treatment). NEPHKITIC COLIC. When a kidney-stone engages in the orifice of a ureter and attempts to pass into the bladder, it gives rise, usually, to well-marked symptoms. Kidney-pains may sometimes be occasioned by the dislodgment of a calculus from an infundibulum into the pelvis of the kidney, or from one portion of the pelvis into another. They become most severe, how- ever, when the ureter is entered. The pain is marked by its paroxysmal character. It commences suddenly, perhaps seizing the patient while at a meal, or at any time when seemingly in the best of health, perhaps most frequently shortly after rising in the morning. It shoots down the ureter into the scrotum and to the end of the penis. The testicle of the affected side is often strongly retracted. Sometimes in a severe paroxysm the whole scrotum and penis are drawn up into a hard knot, as it were, giving the patient the idea of squeezing, dragging, twisting, of these organs. The pain may also extend down the thigh on the affected side. There is usually an incessant desire to pass water, with sometimes almost entire suppression. What little urine is voided comes away high-colored, and in small quantities at a time, often tinged with blood and mixed with epithelium from the kidney. Pain attends urina- tion, chiefly toward its close, running down to the end of the penis. During the paroxysms, especially if severe, faintness, nausea, and vomit- ing, come on ; the skin is covered with a cold sweat ; the patient tosses 360 DISEASES OF THE KIDNEY. restlessly about, seeking relief, but finding none.' In the intervals of the paroxysms there is a sense of soreness and discomfort, perhaps amounting to continued pain, or the relief may be more positive, if the concretion be small. Usually, after a number of paroxysms, lasting from a few hours to many days, suddenly all pain ceases at once. The calculus has dropped into the bladder, and the suffering is over. Instead of this happy termination, the stone, after having engaged in the upper end of the ureter, may drop back into the pelvis of the kidney. Relief of the severe pain follows, but the patient's condition is an unenviable one, for perhaps the stone is too large to pass. Again, the paroxysms of pain may extend over a long series of days or weeks, coming on, perhaps, at a certain hour every day, or at longer intervals. In one (personal) case, the paroxysms came every Sunday, in the afternoon, for several weeks. This periodicity may be so marked as to give rise to the idea of some malarial element in the case. It is needless to add that quinine does not control the paroxysms. In this way the symp- toms may linger along indefinitely, tiring out both patient and surgeon. A termination always to be feared is, impaction of the calculus in the ureter. In such cases, the patient will indicate some spot along the course of the ureter where he feels constant pain, increased by local pressure. The pain will be less severe than during the paroxysms, but it will be constant. A stone is most apt to halt near the outlet of the ureter into the bladder. If the ureter is blocked up almost entirely, the function of the kidney on that side will be interfered with. The ureter above the obstruction, and the pelvis of the kidney, will fill up with urine, subjecting the secreting structure of the kidney to pressure, and perhaps occasioning drowsiness, headache, with sj'mptoms of mild uraemia. If the other kidney be diseased, or its ureter obstructed, these symptoms will be by so much the more certain to ensue. If the other kidney and ureter be sound, enough urine may trickle past the stone to prevent these symptoms from being marked. In such cases the ureter above the stone gradually dilates, as does also the pelvis of the kidney, pressing upon and causing the gradual atrophy of the kidney-substance, so that after death the ureter may be found as large as the small intestine, con- taining perhaps several stones, while the kidney is replaced by a fibrous sac, more or less distended with purulent fluid, inflamed or ulcerated; orperhaps by a mass of semi-solid pus (pyo-nephrosis), or hydro-nephrosis may come on. The effect upon the ureter at the point of impaction of the stone is to cause ulceration, with perhaps the growths of granulations which bleed easily, and may give rise to hsematima. Sometimes, after being lodged for a whUe, a stone will finally pass, but the ulceration of the ureter left behind by it may go on to the formation of stricture and the production of the same results as if the stone had remained. ' If the paroxysms be severe and long continued, more or less fever, with great thirst, hot skia, and quick pulse, results. NEPHRITIC COLIC— DIAGNOSIS— TEEATMENT. 361 After a stone has finally entered the bladder, the symptoms cease. The constant desire to urinate is rarely aggravated by the presence of the small foreign body, although sometimes irritability is increased. Any thing which will pass the ureter will also pass the urethra, if the latter be not strictured. Such, indeed, is usually the case, and, after the cessation of the pains in an attack of kidney-colic, the urine should be carefully watched ; for the little calculus, which caused so much distress in getting into the bladder, may reach the outer world without giving any evidence of its passage. It is always a satisfaction to find the stone, both to confirm the diagnosis, and to insure against the fear of subsequent stone in the bladder. Sometimes the stone is large enough to cause considerable pain in passing the urethra, or indeed it may be- come lodged there. Lastly and not uncommonly, the stone once in the bladder and the patient relieved, he recovers from his irritability, and forgets his pains, thinking himself well. In this dangerous state of un- concern he lives perhaps for years, the stone constantly growing by new accretions, but not occasioning much distress, until finally, from some new exciting cause (cold, exercise), or in the natural course of events, he suddenly breaks down with a sharp attack of acute cystitis, and upon search a stone of some size is found in the bladder. Diagnosis. — Kidney-colic is not liable to be mistaken. In severe nephralgia from highly-acid urine or gravel, there may be similar paroxysms of pain, but the testicle is not so apt to be retracted, nor the paroxysm to be so severe. The passage of blood-clots or of hydatids through the ureter, as well as kidney-stone, occasions true colic. An inspection of what is passed by the urethra can alone clear up such cases, which are exceedingly rare. The patient's previous history or ante- cedents often furnish valuable presumptive evidence. An individual having once passed a stone, is always liable to have another one form, unless he regulates his life so as to avoid the causes of acid concentrated urine. Treatment. — During the paroxysms, prolonged immersion of the whole body in very hot water, or the local use of dry cups and hot fomentations, may produce relaxation. If the pain become unbearable, ether by inhalation should be given, suiScient to moderate it. Knead- ing the course of the ureter is occasionally of service. A sudden change of position may sometimes dislodge a stone after it has become engaged in the orifice of a ureter; but, once engaged, it is better that it should pass. Opium or belladonna may be used by the rectum when the pains are protracted, and the attack promises to be a long one. It is of the first importance to promote a free secretion of urine, so as to act upon the stone from behind, by an abundance of liquid pressure. This is effected by warm drinks, half-drachm doses of acetate or citrate of potash every few hours, or half-ounce doses of infusion of digitalis, until free diuresis is produced. These means should be persisted in intelligently, 362 DISEASES OF THE KJDNET. if the stone become impacted in the ureter. If the stone fail to reach the bladder, being retained in the kidney or impacted in the urethra, the solvent treatment for stone is applicable {see Calcuxous PxF.T.ms). If the stone reach the bladder, but fail to escape through the urethra, diluents should be continued and the urine retained until the bladder is full, so that each act of urination may be accomplished in a full stream. If it still faU to pass, the lithotrite is the natural remedy. On no account should a nucleus for fut-ure vesical calculus be left behind. After one attack of nephritic colic, the patient must be instructed in the proper course of life to follow in order to avoid the formation of another stone. The diet should be low and largely vegetable, and the use of all acoholic stimulants interdicted, especially the use of new fermented liquors. Plentiful out-door exercise should be taken, and the reaction of the urine be wUtched. Vichy water or some mUd alka- line diuretic should be adopted as an habitual beverage to keep tbe luine abundant and diluted. The patient should also acquire a habit (Roberts) of taking a full draught of water between meals, and on retir- ing, so as to dilute the urine of fasting, which is normally concentrated and over-acid. The alkaline tide after taking food insures against the formation of stone during those periods. PYELITIS, PYO-NEPHBOSIS, AND PEBI-NEPHEITIC ABSCESS. Pyelitis is an inflammation of the pelvis and caHces of the kidney. Like most other inflammations of the urinary passages, it is usually en- countered in practice in the chronic form, undergoing perhaps from time to time acute exacerbations. The pathological appearances in the acute form are, a uniform redness of the mucous membrane, frequently dotted in a punctate manner with little ecchymotic spots, or perhaps with free blood on the surface of the membrane. There may be false membranes attached or blocking up a ureter, otherwise the fluid contained in the kidney is a mixture of urine, pus, blood, with more or less epithelium. In chronic pyelitis the membrane is thickened, tough, pale, bluish-gray, crossed by branching vessels. There may be spots of ulceration. Eayer ' describes vesicles of the size of a pin's-head studding the mucous mem- brane in many chronic cases. Rarely the ulcers are covered by deposits of triple phosphates. Sometimes the surface of the membrane is dis- tinctly granular. There are found, perhaps, within the pelvis of the kidney, cancerous or cheesy tubercular deposits, hydatids or other ento- zoa, Mdney-stones incrusted or not with phosphates, etc. Where there has been obstruction of the ureter, the condition known as pyo-nephrosis is liable to be encountered after death, namely atrophy, more or less complete, of the secreting or tubular portions of the kidney with dilatation of the pelvis and calices, the kidney being, perhaps, * Op. cit., vol. iii., p. 4. PYELITIS— CAUSES. g63 replaced by a large pouched sac filled with semi-solid pus or pus and blood, with precipitated phosphates and urates. The septa between the pouches may be calcified or imperfectly ossified. Sometimes the pus is absolutely solid, and seems to be stratified, so that it can be removed in layers ; often it is cheesy, with soft spots. Sometimes the pus collected in the kidney pelvis has ulcerated its way out, giving rise to peri-nephritic abscess. It may point exteriially, leaving behind a fistulous tract which usually remains permanent. Occasionally after pyelitis, the kidney atro- phies instead of becoming pyo-nephrotic. Pyelitis is more often double than single. If it depend upon a cause acting on one side only (im- pacted stone), the other kidney may be healthy, although enlarged by conservative hypertrophy. Pyelitis is usually entertained by some cause and the problem for treatment is not so much to remove the inflammation from the pelvis of the kidney, as it is to remove the cause which keeps it up. Causes. — ^Pyelitis is not an idiopathic disease. Of all the numerous causes which may occasion it, two are in constant action in the commu- nity, and furnish the bulk of the cases. These are — 1. Chronic prolonged obstruction to the free escape of urine from the bladder, and chronic inflammation of the latter organ. 3. The retention of kidney-stone, or, more rarely, its impaction in a ureter. The first of these causes is constantly at work in stricture and pros- tatic hypertrophy. Here the bladder becomes inflamed, the damming back of the urine is felt by the kidneys, and their mucous membranes are kept constantly more or less congested, until finally, from some prov- ocation, such as cold or retention, or the use of instruments in the bladder, an acuter phase of inflammation is set up in the latter organ, which is very prone to travel rapidly up the ureters and locate itself permanently in a chronic form upon the pelves of the kidneys. Here it remains in a subacute state, suffering occasional exacerbations of acute- ness, and liable to become complicated by inflammation of the secreting structure of the kidney, attended by ursemio symptoms and speedy death. Pyelitis under these circumstances is mild in character, does not occasion any severe symptoms, and goes, for the most part, unnoticed by patient and surgeon. Its presence may always be inferred in old cases of ob- structive prostatic and urethral disease, and it must be remembered that in these diseases danger to life is more to be apprehended from this than from any other quarter. By far the most frequent cause of such pyelitis as manifests itself during life by positive symptoms referable to the kidney, is stone re- tained in the kidney. By the same mechanism as in the bladder will stone in the kidney sooner or later give rise to inflammation of the mu- cous membrane upon which it rests. Stone impacted in a ureter in- evitably leads to the same result by distention of the pelvis of the kid- 3gj. DISEASES OF THE KIDNEY. nej with retained urine, and bj tlie secondary decomposition of the fluid, the mechanism being similar to that causing cystitis with atony, from prolonged retention of urine. Hence any thing which will cause pro- longed distention of the pelvis of the kidney, retention of lu-ine, blood, entozoa, false membrane, etc., blocking up a ureter, is able to occasion pyelitis. Pressure of the pregnant uterus in the female probably acts in the same way, in inducing that fatal form of pyelitis attending lying- in women, even where there is no pysemia. Besides the above causes, a host of others may be enumerated as more rare. Thus, the irritating action upon the kidneys of turpentine of constantly over - concentrated, over-acid urine ; the existence of chronic forms of Bright's disease; the deposit of cancerous or tubercu-' lar matter in the walls of the kidney pelvis ; foreign bodies other than stone ; worms, hydatids, clots, etc. Pyelitis also attends certain dis- eases as a complication at times, the eruptive fevers, typhus, cholera, etc., and is found not infrequently with pysemia and carbuncle. Symptoms. — Pyelitis is usually attended by pain in the back, of the same character as that described in the section on nephralgia. This pain is made worse by pressure, and is usually confined to the affected side, although there may be pain over both kidneys when only one is dis- eased. When the affection depends on kidney-stone, usually there have been some attacks of nephritic colic more or less marked. Occasionally, however, the disease comes on in an insidious manner, with little or no pain in the back, what symptoms there are being referred to the bladder. Sometimes paroxysms of pain, resembling nephritic colic, are experienced where there is and has been no stone. Early in the disease the urine will usually bo found to contain blood-disks, a little excess of mucus, ■with, many small, round, oval, spindle-shaped, and irregular epithelial cells, such as abound in the pelvis of the kidney. There is a trace of albumen depending on the blood, and the urine reacts acid. As the disease advances the epithelial scales are replaced by pus-cells, not in clusters, but evenly distributed through the urine, giving it a uniform, turbid appearance when voided. The amount of pus steadily increases in quantity, the urine usually remaining strongly acid ; on standing, this pus settles down into a dense, greenish, oily-looking deposit. Violent exercise increases the nephralgia and the amount of pus in the urine. Often the pus diminishes greatly in quantity for some days, and sud- denly reappears in excess. This phenomenon is especially noticeable when the kidney has become sacculated. The pus retained in a saccu- lus accumulates there, untU finally it bursts its barriers and reappears in quantity for a day or two, w'hen it wiR again cease to flow abundantly, untU the saoculus has had time to refill. The pain in the flank is often greater when the pus is not flowing, and any swelling existing there is apt to become more prominent. These variations in the amount of pus are less marked when both kidneys are affected. In rare cases there PYELITIS— SYMPTOMS. . 365 may be no discharge of pus whatever, as -when the ureter is absolutely occluded. Chills of varying duration and intensity are often present, especially if the kidney is sacculated and contains large amounts of pus. These rigors may assume the quotidian or tertian type, and recur v^fith great regularity, especially in the evening. One symptom of pyelitis is vei-y liable to lead to error of diagnosis, especially if the pain in the back has not been prominent and no tumor exists in the flank. This symptom is frequent micturition. The irri- tating properties of the pus in the urine stimulate the bladder to re- peated contractions, and many a case of pyelitis has been treated as chronic cystitis, povyerful injections being thrown into the bladder in the vain hope of controlling the formation of pus, which is supposed to have its origin there. The bowels usually act irregularly, diarrhoea and constipation alternating with each other, due to inflammatory adhesions between the dilated kidney and the colon, or to the mere mechanical pressure of a distended pyo-nephrotic kidney upon the large intestine passing over it. When the kidney becomes dilated and sacculated by the pressure of accumulated pus, a tumor is formed, which is tender on pressure, sometimes affording a feel of deep fluctuation, more or less perceptible to sight and touch, according to its size, sometimes becom- ing appreciably smaller after a free discharge of pus in the urine. The position usually occupied by such a tumor is in the flank between the last ribs and crest of the ilium. On the right side the transverse colon may separate the tumor from the liver, but this diagnostic sign may be absent, from inflammatory adhesions having taken place between the coverings of the two glands. The tumor formed by a pyo-nephrotic kid- ney is occasionally large enough to extend across the middle line of the abdomen. As the disease advances the patient becomes cachectic, pale, and de- bilitated. Hectic fever may set in and close the scene, the patient being worn out by constant suppuration, or poisoned b}' the urea, which cannot find an exit through his altered kidneys. Ulceration of the pel- vis of the kidney may occur, especially if it contain stone, and, through Sin opening thus made, pus and urine may infiltrate the tissues, forming peri-nephritio abscess. This points in the back or under Poupart's liga- ment (simulating psoas abscess), or opens into the bladder or pleural cavity, into the lung, or, more commonly, into the intestine — rarely into the peritoneal cavity. A distended, sacculated, pyo-nephrotic kidney in the same way may contract inflammatory adhesions to all the surround- ing tissues, and finally break and burrow in any of the above directions. The tumor subsides rapidly when the pent-up matter has found an out- let, but, unless the calculus or other oifending body escapes, or is ex- tracted through the opening, a permanent fistula is pretty sure to remain. When such an abscess breaks into the bladder, bowel, or lungs, the 366 DISEASES or THE KIDNET. subsidence of the tumor is attended by a copious discharge of pus at the anus, urethra, or mouth. After the abscess has discharged itseK and remained fistulous for a time, in some favorable cases, it may gradually shrivel and dry up, owing to total atrophy of the kidney, and in such cases, if the other kidney be healthy, the patient recovers completely. Peri-nephritic abscess does not necessarily depend for its origin upon antecedent kidney-disease. It may come on as the result of fatigue, and a straining exertion of the muscles about the kidney-region, from cold or other cause. Three exceedingly interesting examples of peri- nephritic abscess, not caused by or attended with any kidney-disease, are reported by Dr. H. J. Bowditch, in a paper read before the Boston Soci- ety for Medical Observations, May 4, 1868. In each of these there was a distinct tumor in the right loin, with the usual train of symptoms, chills, hectic, etc. ; in each there was pulmonary and pleuritic complication, with discharge of pus by the mouth, the matter having made its way up along the sheath of the psoas muscle into the pleural cavity ; and in each there was marked relief of all symptoms, and idtimate recovery after a timely opening into the tumor, which was made in two of the cases before fluctuation could be distinctly felt. In two of the cases the kidney was recognized by the exploring finger free in the cavity of the abscess, but neither microscopic nor chemical test applied to the urine revealed the presence of kidney-disease. These cases demonstrate the advantage of early opening for peri-nephritic abscess. Instead of breaking externally, a pyo-nephrotic kidney, after its secret- ing substance has become atrophied, may consolidate into a hard, cheesy mass, and cease to give trouble. One perfectly good kidney is sufBcient for life. Unfortunately, the disease is most often double. Prognosis. — The prognosis of pyelitis depends upon its cause. The milder cases, occurring with stricture or prostatic disease, cease to he troublesome after successful treatment of the latter. The forms oc- curriog with fevers, pleurisy, and zymotic diseases, often get well quickly, if the primary disease spares the patient. In pyemia and carbuncle, the complication aggravates the prognosis. Depending upon local cancer or tubercle, the afiection does not get well. With hydatids or calculus it is severe, but not necessarily fatal. Double pyelitis is generally fatal. \^T]ere there is pyo-nephrosis the chances of recovery are not great, but with one sound kidney there is alwaj's hope. Autopsies have revealed wasted, withered sacs, perhaps clasping a stone, or a mass of hard, concrete pus, whose existence had never been suspected diu'ing life. Discharge of the pus by other than the natural channel is often speedily fatal, except in favorable cases where the opening occurs through the loins. Treatment. — ^When pyelitis depends upon bladder, prostatic, or ure- thral disease, its treatment is identical with that of its cause. The same is true of cancer, tubercle, etc. In fever, zymotic, or scorbutic disease, PYELITIS— TEEATMENT. 367 the main malady must be treated, care being exercised to prevent the urine from becoming too acid, and concentrated. Where it is attended with considerable haemorrhage, tannin, gallic acid, acetate of lead, opium, ergot, or other styptics, may be advantageously tried. During an acute attack of pyelitis, with great pain, high fever, fre- quent urination of bloody purulent matter, wet cups over the kidney, hot baths, hot local fomentations, warm diluent drinks, and opium to allay pain and spasms, are the main features of treatment. In chronic cases, however, such as are not infrequently met wdth in practice, where there is reason to suspect kidney-stone, and where constant suppuration is wearing out the patient, the surgeon's duty lies in putting him into the best possible hygienic conditions, giving him the advantage of rest, country air, and a sustaining diet, with such tonics as iron, quinine, and cod-liver oil. Roberts speaks highly of large doses of muriated tincture of iron. Alkaline diluents will sometimes diminish the amount of pus, by making the urine less concentrated. Wine is often serviceable, and in some oases the mineral acids improve the digestion, increase the strength, and better the condition of the urine. The vegetable astrin- gents, alum, and the terebinthinates, are occasionally useful as stimulants to the mucous membrane in chronic cases. If there is reason to suspect kidney-stone, the solvent treatment should be persistently employed — unless, of course, there is pyo-nephro- sis with a palpable tumor, and reason to believe that the secreting portion of the kidney is atrophied to such an extent that but little urine escapes thfough it. An excellent essay on the solvent treatment of calculus is given by Roberts.', A kidney-stone may be presumed to be composed of uric acid, or oxalate of lime. For the former the solvent treatment may be hopefully employed, and it will do no harm in the latter instance. Where, however, from the previous passage of oxalate of lime calculi, or the presence in the urine of a considerable number of crystals of the same, there is reason to believe that the concretion is formed of this substance, or where, from kidney-ulceration, the stone is covered with a layer of the secondary (mixed) phosphates, little can be expected from the solvent treatment. The best method of carrying out this treatment consists in the steady administration of citrate or acetate of potash. The citrate is preferable in doses, for an adult, of not less than forty to sixty grains, well diluted in water. This quantity should be given every three or four hours. On account of the impurity of the citrate of potash, as ordinarily found in the shops, Roberts's plan is to prepare it directly by the combination of citric acid with bicarbonate of potash, as in the following formula : 5. Potass, bicarb., 3 xij. Acid, citric, 3 viij. gr. xxiv. Aquae ad., § xij. M. ' " Urinary and Renal Diseases," second American edition, 1872, p. 298. 368 DISEASES OF THE KIDNET. This prescription yields 3 j of citrate of potasli to the fluid-ounce. The dose for an adult is from six to eight fluid-drachms, diluted with three or four ounces of water. This treatment should be persisted in steadily for months, or until the symptoms yield. If the stomach tire at the constant administration of alkali, the treatment may be inter- mitted, to be subsequently resumed. Vegetable bitters and tonics may be administered at the same time. "N-NTien there is pyo-nephrosis, with sacculation of the kidney and a tumor which can be felt in the flank, two courses of treatment are open : 1. The general treatment by tonics, astringents, and hygiene, keep- ing up the patient's strength in every way, and encouraging him to wait for final atrophy of the kidney and desiccation of the pus, using all the means suggested above for chronic pyelitis, with continued suppuration. 2. The operation of opening, or even removing the kidney. It may often be questionable which method should be adopted. The first has been successful, and may, perhaps, often be so, when only one kidney is involved, when the tumor formed by the distended kidney is not inordinately large, and the general health does not sufTer very greatly from the continued suppuration ; or, again, when pyo-nephrosis exists, and the kidney is already almost wholly atrophied. On the other hand, this first course must necessarily be pursued when there is reason to believe that both kidneys are implicated, or when the patient's general health is so lowered by the continued suppuration that an ex- tensive operation would probably prove fatal. In certain cases, how- ever, an operation is advisable ; where, for instance, there is reason to believe that calculus is the origin of the pyo-nephrosis, and that only one kidney is diseased, and where the general health is good. More particularly is an operation called for when the tumor is very large, and has approached reasonably near the surface, or when there is peri-ne- phritic suppuration, for, in such cases, by a timely opening, perforation of the pleura, peritonfeum, or intestine, may be averted. If operative interference be decided upon, it is proper to beg-in with an exploration. This is best made with the aspirator. The exploring trocar is thrust into the most prominent part of the swelling posteriorly, where there seems a natural tendency to point. There is no fear of wounding the peritoneum if the back or flank be perforated, as the kid- ney is an extra-peritoneal organ. After the matter has been evacuated, search may be made in the cavity with the canula for any calculus which might occupy it. If none be found it is not possible to state that the disease is not of calculous origin ; nor, if calculous matter be found, can the converse of this proposition be affirmed with absolute certainty. In Dr. Peters's case (p. 379) the abscess was punctured with the aspirator, pus evacuated, and finally, on withdrawing the instrument, a fragment of stone was found impacted in its extremity; yet, after the kidney bad been extracted, the case proved to be one not of calculous pyelitis, but EXTEA-EENAL ABSCESS— TEEATMENT. 369 of inflammatory (cheesy) pyelo-nephritis. The patient had pseudo- tubercular epididymitis, with fistula, and pseudo-tubercle of both vasa deferentia and vesicula3 seminales. As a rule, however, if stony matter can be fislt, calculous pyelitis may be safely diagnosticated, and an opera- tion rationally undertaken for its relief. If no stone be discovered, but a quantity of pus be evacuated, the operation may be repeated at inter- vals, to the great relief of the patient. Should stone be found, or even strongly suspected, if the patient's general condition will warrant an op- eration, nephrotomy should be performed. This consists in cutting down upon the most prominent portion of the tumor posteriorly, or making the same incision as for ablation, opening the sac of the abscess, or sac- culated pelvis, turning out the pus it contains and extracting the stone, if there be one. The wound is to be dressed open, to allow all pus and urine to drain freely away. There is rarely any occasion, in simple pyelitis, for ablation of the kidney. With pyo-nephrosis this may some- times be necessary, but even here, as a rule, it is as well to make a free posterior opening to allow pus and urine to escape, and give the blad- der rest. Extra-renal abscesses should always be opened early, even if qo attempt be made to perforate the pelvis of the kidney. The openmg, in these cases, should be kept fistulous, and after a time a stone may appear, and be extracted through the fistula. A great number of cases where renal and extra-renal abscesses have been opened, and (often) stone extracted therefrom, to the great relief of the patient, are quoted by Eayer,' among which are remarkable, as examples probably of pure nephrotomy for calculus where there was no renal tumor, two cases, both terminating successfully. The first is Park's case of the archer of Meudon, condemned to death, who had siiffered from kidney-stone, where vivisection was made, the peritonaeum and probably the kidney opened — nothing is said, however, of the extraction of stone. The patient recovered. The other is the celebrated case of Hobson, who, having kidney-colic severely and frequently, but no tumor, induced Marchetti, a surgeon of Padua, to cut him. The operation was performed, the pelvis of the kidney opened, and two or three little stones extracted. Prompt recovery followed, and after a time the patient's wife extracted a stone from the fistula as large as a date-stone. After this the patient never had any more kidney-pains. Ten years subsequently the fistula was still open, and a probe was passed by Dr. Bernard into the pelvis of the kidney. The patient was in full health, and proposed, on the following day, to take a horseback-ride of forty or fifty miles. Nearly all authorities are of accord as to the propriety of a speedy opening of extra-renal abscesses ; but where the abscess is renal, and it becomes a question of true nephrotomy, i. e., cutting into the substance or opening the pelvis of the kidney, there is great diversity of opinion. ' Op. cU., vol. iii., p. 206, et seg 24 370 DISEASES OF THE KEDNET. The surgery of the future, however, will be more bold in this direction, since the successful termination of Simon's case of ablation of the kid- ney,^ and it may not be too much to predict that more experience wUl prove that operations on the kidney, in selected cases, where one healthy organ is left behind, will be as generally advocated, and will give results as satisfactory as ovariotomy. Cases are recorded where the kidney has been opened, a stone extracted, the fistula healed, and another successful operation of the same sort performed later upon the same patient." Usually, after nephrotomy, a permanent urinary fistula remains, but sometimes even this may not occur. The advisability cf ablation of the kidney in bad cases, and just what circumstances call for it, future experience must decide. As to the unadvisability of nephrot- omy, the three rules laid down by Rayer are perfectly good : 1. Do not perform nephrotomy, if there be reason to suppose that both kidneys are diseased; exception to be made for extra-renal abscess, which should always be opened early. 2. Do not operate if the pus find free exit by the bladder, and no renal tumor exist, and if the other kidney be performing its duty satis- factorily. [Future experience may negative this proposition.] 3. Do not operate if the bladder or prostate be incurably diseased, or grave lesions of other viscera exist. (For Ablation of the Kidnet, see page 379.) HTDEO-NEPHKOSIS. ^Tien there exists an obstruction, congenital or acquired, to the escape of urine from a kidney, the fluid accumulates in the pelvis of the organ, and may gradually dUate it, leading to atrophy of the secreting structure of the gland, and resulting in a sacculated cyst. T\Tiere pus has accumulated instead of watery fluid, pyo-nephrosis, already described, is the result. In those cases where the obstruction is congenital or partial, so that the pressure of accumulated urine is not excessive, but gradual and continuous, pus does not form, and we have true hydro-ne- phrosis. Hydro-nephrotic kidney sometimes assumes enormous propor- tions, simulating ascites or ovarian cysts, and as such has been tapped, and its contents evacuated through the abdominal walls. Roberts quotes a case reported by Glass,' where thirty gallons of light coffee- colored, limpid fluid were taken after death from a hydro-nephrotic kidney of a young woman. The mother stated that the child was born dropsical. The other kidney was healthy. In a case at Bellevue Hospital, which occurred some years since, the collection was so large as to resemble ascites, and after death several calculi were found in the pelvis of the kidney, one of which projected into the ureter, completely occluding it. 1 "Deutsche Klinik," 1870. ' Boonhuysen, quoted by Rayer. ' " PhiloaopWcal Transactions." HTDEO-NEPHROSIS— CAUSES. 371 Sometimes the cyst is smaller than the healthy kidney (atrophy). Absorption of the secreting structure is usually partial, but may be complete. One or both kidneys may be affected, and, what is remark- able, both kidneys may be largely dilated, and display, on autopsy, not a trace of true renal structure, and yet the urine present nothing abnor- mal, and the patient live in this condition for a variable length of time. In such cases the urine is usually of low specific gravity, and very abundant, and death may occur at any time with ursemic symptoms. Infants with congenital double hydro-nephrosis do not live (Rayer), but, where the aifection comes on gradually, life is possible to a far greater limit than would seem possible a priori. It is possible that the skin and bowels do the work vicariously in these cases for the kidneys. The cysts usually contain a fluid, clear or more or less colored by blood, pus, or debris. The constituents of the urine are found in it. Sometimes the cysts contain a colloid substance. Causes. — ^Hydro-nephrosis is often congenital, depending upon an impervious ureter, or some valvular obstruction of the same. Impervi- ous (congenital) urethra may be the cause; later in life, calculus impacted in the ureter, stricture of the ureter from previous ulceration, pelvic tumors, ovarian cysts, or other body (gravid uterus) compressing the ureter. Sometimes no mechanical cause can be assigned, except a valvular fold of mucous membrane, or great obliquity of entrance of ureter into pelvis of kidney, acting like a valve. Symptoms. — The symptoms of h3'dro-nephrosis depend mainly upon the size acquired by the cyst, and the compression exerted by it upon the surrounding organs. If the tumor be smaU, and the other kidney healthy, no symptom during life may lead to the suspicion of disease, and old age may be attained. When the tumor reaches considerable size, it usually presents itself in the flank, extending backward into the lumbar region, and forward, upward, and downward, to a greater or less extent, into the abdomen. The colon usuilly lies in front, the small intestines being pushed to the opposite side. The tumor is flat on percussion, feels soft, perhaps lobulated, and is evidently fluctuating. Sometimes the tumor suddenly disappears coinoidently with a free dis- charge of urina This symptom, when present, is of the highest diag- nostic value. Pain is usually absent, unless there be at the same time impacted calculus in the ureter. The action of the bowels may be irregular, dysenteric or diarrhoeal, from compression of the large intes- tine. The urine presents no characters pathognomonic of the disease. It may be absolutely healthv, and isnot necessarily increased in quantity. Course. — The obstacle (possibly calculus) perhaps becomes dislodged in time, and the cyst evacuated. - The latter may not refill ; its sac may shrivel up. Finally, urtemic symptoms may carry off the patient, but many die of intercurrent disorders. Spontaneous rupture of the cyst very rarely occurs. 372 DISEASES OF THE KIDNET. The diagnosis in man is with ascites, hydatid cysts, and pyonephro- sis. In hydro-nephrosis the colon lies in front of the tumor, there is no resonant percussion in the lumbar region of the affected side, but it exists on the other side, unless the disease be double. No change in the patient's position affects the sounds. In ascites, the lumbar dullness is double, but the sounds change with the position of the patient. In hydatid cyst there is escape of hydatid vesicles with the urine, or the presence of hydatid fremitus. Hydatid cyst is less often double than hydro-nephrosis. In pyo-nephrosis there is or has been pus in the urine ; the symptoms are more severe, pain is prominent, rigors are common. Treatment. — The disease, not being as a rule very dangerous to Hfe, does not call for officious surgery. If it be presumed that there is a calculus impacted in the ureter, precautions should be taken to prevent a similar accident on the opposite side. Roberts believes that he was successful in one case in overcoming the obstruction permanently by manipulation. A little girl of eight, under his care, had a soft, fluctu- ating tumor, on the left side of the abdomen, about the size of a child's head, which was believed to be hydro-nephrosis. This was carefully manipulated in every direction by the aid of a lubricating ointment on alternate mornings. After the third manipulation a large quantity of urine was suddenly discharged through the natural channels, the tumor disappeared, and did not return while the patient was under ob- servation. If the tumor become excessively troublesome, from its size, especially if it be telling upon the general health by interfering with the func- tions of the intestines, or show signs of inflaming (the occurrence of chills, etc.), recourse may be had to tapping, which might be cautiously repeated as the sac lefilled. Such tappings have been practised through the abdomen, between the last two ribs, near their free extrem- ities, and in other positions. If the tumor bulge considerably in the flank, or lumbar region, behind the colon, the tapping should be per- formed preferably here, or a point behind between the two floating ribs may be selected, as chosen by Mr. J. Thompson, in an interesting case quoted by Roberts.' In Mr. Thompson's case recovery followed. A year afterward the same operation was repeated. Eight years afterward it was done again. Eighteen months afterward the sac ruptured, discharging into the peritonseum. For the purposes of tapping, the aspirator is the best instrument. It must be remembered that tapping may occasion inflammation of the sac. There is always hope, in acquired cases of the disease, that tha fluid may escape by the natural passages. ' Op. cit. CYSTS— SYMPTOMS. 373 KIDNEY-CYSTS. Several forms of cysts are found in the kidneys. Simple cysts by occlusion in the healthy, or more often the granular kidney, rarely large enough to occasion appreciable symptoms during life. Complete cystic degeneration of the kidneys, congenital, and oc- curring very rarely in adult life, almost invariably affecting both kid- neys, and necessarily fatal.' Of the entozoa found in the kidney, hydatid cysts only come undex the surgeon's notice. They are not as common as hydatids of the liver or lungs, but are more frequent than hydatids of other parts of the body. Space will not allow a description here of the history and habits of this interesting entozoon. Both kidneys are rarely involved in hydatid disease ; the left seems to suffer more frequently than the right. The cyst may be primarily lodged in any portion of the kidney-substance, which it gradually de- stroys by pressure as it grows. It forms a rounded, elastic tumor, and may reach the size of an adult head. The cyst tends to point inward, and burst into the pelvis of the kidney, but may grow to a large size without so doing, and eventually discharge into the intestines or the lungs. Kidney hydatid cysts have not been known to discharge into the peritoneal cavity, or externally through the integument. The cyst may inflame, or excite abscess in its vicinity ; the echinococci may die, and the cyst shrink and be transformed into a calcareous mass, either before or after bursting. The cyst may be ruptured by external violence. Symi^toms. — Until the cyst grows large enough to be felt or seen in the flank, there are usually no symptoms. Febrile attacks, with rigors and pain, are occasioned, if the cyst or its neighborhood inflame or suppurate. The only pathognomonic symptoms are the hydatid fremitus on palpation, and the appearance of the characteristic vesicles, laminated shreds, or booklets, in the urine. The hydatid fremitus is rarely per- ceived. It may sometimes be obtained by grasping the tumor with one hand and tapping the fingers sharply with the other hand ; or by apply- ino" a stethoscope over the tumor while the latter is tapped smartly with the fingers. The sensation is a sort of a creaking vibration or thrill communicated to the fingers, and has been compared to the vibrations of a repeater-watch held in the hand. The discharge of characteristic vesicles by the urethra, when a cyst has burst, is usually spread over a considerable length of time, the discharges occurring in paroxysms, occasionally with an interval of years ; if there is only one small cyst, it may empty itself in one paroxysm. These paroxysms usually begin with pain in the ' In a practical work covering as much ground as does the present, it is impossible to more than indicate the existence of this rare form of disease, although it naturally falls within the domain of surgery. It is very rarely encountered, and totally unamenable to treatment. For its study the reader is referred to text-books on renal disease, and patho- logical works, in which it forms interesting chapters. 374 DISEASES OF THE KIDNEY. back, followed by nephritic colic, as the vesicles pass into the bladder, and perhaps retention of urine, and considerable pain, as the larger vesicles traverse the urethra. The urine usually, at such times, con- tains blood and pus, and there are symptoms of mild cystitis of the neck of the bladder. The tumor in the flank may become smaller after such an attack, from a discharge of some of its contents, or increase in size by distention with urine, if a vesicle be retained for a time in the ureter. The disease is most liable to be confounded with hydro-ne- phrosis, in case no vesicles appear in the urine. Prognosis. — ^The natural tendency of the disease is to get well by a discharge of the echinococci through the ureter. The mortality is lower than for hydatids of any other internal organ except the uterus. Where the cysts discharge by other routes, or become inflamed and suppurate, a fatal result is to be feared, although even in such cases re- covery is possible. Treatment. — Medicines are of no avail before the cyst has opened into the pelvis of the kidney. Nitre, coffee, white wine, spirits, and, in general, diuretics, have sometimes been found to increase the quantity of hydatids appearing in the urine after the opening of a cyst. If the cyst attain a large size, and do not burst into the pelvis of the kidney, operative procedure should not be undertaken, unless there seem to be imminent danger of its bursting in some undesirable direction, or unless it be pressing dangerously upon the pleural cavity, or causing consider- able disturbance by pressure on the intestine. If it be decided to open the cyst, such opening should be made pos- teriorly, in the loins if there be any bulging there, preceded preferably by an exploratory tapping. When the bulging is in front, the opening should not be made until the skin and abdominal tissues have been de- stroyed by caustic, and inflammatory adhesions excited between the two layers of peritonaeum covering the tumor. Then a puncture may be made with a trocar, the opening afterward enlarged with a bistoury, the contents of the tumor allowed to escape, and daily injections of the sac practised with mild, warm solutions of carbolic acid, or chlorinated soda, with an occasional injection of a solution of iodine. In this way desperate cases have been occasionally brought to a happy termination. TUBERCLE OP THE KIDNEY. This is a disease, on account of its comparative rarity, more interest- ing to the pathologist than to the practical surgeon. It occurs in two forms : 1. As small miliary granulations of true tubercle deposited rapidly in acute general tuberculosis occupying the secreting structure and pyra- mids. The little nodules are deposited mainly along the course of the smaller vessels. This species is only apart of acute miliary tuberculosis. TUBERCLE. 375 It rarely furnishes local symptoms, and is usually discovered after death. As a kidney-disease it is unimportant. 2. The kidney tuberculosis which constitutes a disease to be diagnosed and treated during life, is a more chronic form, which generally com-, mences by a deposit of gray tubercular matter upon the papillae, thence passing to the mucous membrane of the cahces. The gray nodules first infiltrate a portion of tissue, then undergo a cheesy degeneration, and break down into tubercular ulcers, which advance inwardly, destroying every thing in their course. The pelvis and ureter participate in the disease, perhaps primarily, but certainly in the course of time. The disease is comparatively rare, and not infrequently coincides with the deposit of tubercle elsewhere, especially in some other portion of the genito-urinary apparatus (prostate, epididymes, seminal vesicles). All ages are liable to it, but it is most common in early manhood. It comes on usually in an insidious manner. The little tubercular masses unite to form large patches. Kidney-substance is absorbed, to be replaced by the lowly-vitalized tubercular matter. After a while the masses soften centrally, break down into a puriform matter, and leave ragged ulcers in the kidney-substance, or in the walls of the pelvis. Rarely these ulcers or abscesses heal, leaving a depressed cicatrix. Some ulcerations may cicatrize, while others progress. The fibrous structures of the ureters and pelves of the kidneys become greatly thickened and indurated by chronic inflammation, so that the calibre of the ureter may be nearly or quite obliterated. The ureter so constricted may become blocked up bv some softened tubercular matter or tissue debris, coming down from above, in which case pyo-nephrosis would in all probability result, with symptoms of nephritic colic at the beginning. A stone formed in ihe kidney may be unable to pass the contracted ureter, or, from decompo- sition of the urine retained in the kidney in contact with the tubercular ulcerations, phosphatic stone may be formed there. Under any of these contingencies the symptoms would resemble those of chronic calculous pyelitis. The disease is more frequently double.than single. Sometimes however, it is found on one side only, and then it not unusually hap- pens that the testicle or epididymis of the same side also suffers. There is an undoubted connection in the male sex between tuberculization of the genital organs and that of the kidney. The attack of the former usually precedes that of the latter, and seems to hold a certain causal relation to it. Symptoms.— ThQ symptoms are identical with, and in fact are, those of chronic pyelitis, with or without severe nephralgia or nephritic colic. It is rare that much or any pain is felt at first, the disease most often coming on insidiouslj-. There are exceptions to this rule, when, for in- stance, a large, acute deposit is attended by great local pain, fever, bloody urine, etc. If pyo-nephrosis comes on, the tumor or sacculated abscesses may be 376 DISEASES OF THE KIDNEY. felt in the flank. As the disease progresses the nephralgia becomes more marked, as do also the accompanying symptoms of cystitis. Great emaciation, with rigors and hectic fever, supervenes, and the patient dies exhausted, or, from the bursting of kidney-abscess, possibly with urjemic symptoms, or, from tubercular disease elsewhere, wasted by hectic. There is rarely any profuse hematuria with kidney tuberculosis. The urine is almost uniformly over-acid. The disease may prove rapidly fatal in a few months, or may drag along several years. Diagnosis. — The most reliable diagnostic marks of this affection are chronic pyelitis coming on in a tubercular subject, or one of tubercular antecedents, or living in bad hygienic surroundings, where no other cause (stone, etc.) for the pyelitis is evident. Where the epididymis is the seat of cheesy degeneration, or the seminal vesicles knotty with chronic, cheesy deposit, or the prostate affected by similar disease, and symptoms of chronic pyelitis come on, a diagnosis of tubercular pyelitis may be safely ventured. The urine usually contains a large amount of debris besides its pus, but, taken by itself without the co-relation of other symptoms, this sign is absolutely valueless. Treatment. — Tubercular disease of the kidney is very rarely recov- ered from ; it is even more fatal than tubercle of other vital organs. Its treatment is that of chronic pyehtis, and that of chronic tuberculosis — fatty medicines and food, proper hygiene in air, clothing, and diet, with quinine, iron, astringents, and, if the pain be great, a small amount of anodyne. Renal and extra-renal accumulations of pus may require ex- ternal incision. Extirpation is not to be thought of, unless there is pretty positive evidence that one kidney is sound, which is rarely the case. CANCEE OP THE KIDNEY. Cancer of the kidney is not a common disease. It occurs primarily in the kidney or in general cancerous cachexia as a secondary deposit, especially secondary to cancerous disease of other parts of the genito- urinary apparatus, in which case it often fails to furnish any symptoms, and is to be detected only by autopsy. Again, secondary cancer of the kidney may assume primary rank, and lead to the fatal issue by its rapid growth. Secondary deposits occurring in connection with cancer, other than of the genito-urinary organs, usually affect both kidneys in the shape of numerous nodules, from the smallest imaginable size up to that of a nut or larger. These nodules as a rule occasion no renal or vesical symptom, there being enough tissue left to perform the function of the kidney. Their softening and ulceration may not have time to take place, on account of the more advanced condition of the primary cancerous deposit, which carries off the patient by cachexia or otherwise. Cancer of the kidney is almost without exception encephaloid (soft) ; epithelial and other forms being mentioned as curiosities in surgery. CANCEE. 377 No time of life is exempt from an attack of primary cancer of the kid- ney. Children under four years seem especially liable, and old age the next most frequent epoch for its appearance. As a rule only one kid- ney is aifected. The disease may advance until the mass has reached a size large enough to fill the whole abdomen, and a weight of twenty to thirty pounds. It always seems to begin in the cortical substance, ex- tending thence to the pyramids. The kidney-substance as such becomes absolutely obliterated, no trace of it being left in the large cancerous mass, which, like other specimens of soft cancer, is usually lobulated, harder in some parts than others, of different consistence in different specimens, giving obscure or real fluctuation in parts, often containing large cavities filled with clots, fluid blood, or cancer debris, possibly pus, " a strange, distempered mass " (Hey). Cancer of the kidney, like that of the liver and testis, is commonly filled with numerous, large, thin-walled vessels which readily break, forming blood cysts and clots of large size. Kidney-cancer sometimes grows out through the renal vein and advances into the ascending cava. Here portions of it may be broken off and be carried along in the general circulation to form infarc- tions in the lungs. When the cancerous mass sprouts out into the pel- vis of the kidney, its large, thin-walled vessels are apt to give way and occasion that symptom so characteristic of cancer — ^profuse, sponta- neously-recurring hiemorrhage, often filling the bladder to distention with clots. The disease may commence as a single cancerous nodule, or as an infiltration. When the tumor reaches large size, it usually forms inflam- matory adhesions with all the surrounding viscera. The colon lies in front of it, the other viscera are crowded aside. The pressure of the cancerous mass may cause caries of the vertebrse. The ureter is often occluded. When the disease in the kidney is primary, secondary de- posits are apt to occur in the rest of the body. The lymphatic glands in the hilum of the kidney, and the vertebral and mesenteric glands, are often involved, sometimes forming a considerable tumor of themselves. Symptoms. — The most constant symptom of primary renal cancer is a tumor, often in adults, and, as a rule, in children attaining enormous proportions before death. This tumor is first noticed in the flank above the crest of the ilium, growing forward and upward. It usually feels irreg. ular but smooth (lobulated), and generally gives the sensation of deep fluctuation at points. It may be entirely painless to pressure. The reso- nance of the colon passing in front of it may often be made out. Pain in the back and hypochondrium, in the region of the kidney, of the nephral- gic character, is usually complained of before the tumor appears, per- haps not till later. The pain is usually intermittent in character, and not often very intense. It may be wholly absent. Htematuria is a sign of great value, when present, but its absence has not the signification which has been given to it. It may be absent throughout the disease, 378 DISEASES OF THE KIDNEY. or appear for a time only at the beginning or at the end. It is rarely continuous throughout, tending, as it does, to be irregularly intermittent without appreciable cause. Often during the paroxysms it is very pro- fuse, perhaps clotting in the ureter or bladder, and causing considerable inconvenience and pain. If distressing feelings have been present, some alleviation of them is apt to follow profuse bleeding. When haematuria is abundant and paroxysmal without provocation, in the case of renal tumor, cancer is pretty certain to be the cause. Among other symptoms there may be ascites, anasarca, and great development of the cutaneous abdominal veins, from pressure of the tu- mor upon the large venous trunks within the abdomen. The size of the Fia. 124— (iJoScrts.) tumor may cause functional derangements of the stomach and bowels. Vomiting sometimes appears early. The urine presents no character- istic diagnostic features. It is idle to place any reliance upon the ap- pearance of so-called cancer-cells in the urine, or upon the hope of find- ing a shred of cancer-tissue, since such a shred, starting at the kidney, already softened and partly decomposed by the ulcerative process which CANCER. 379 loosened it, would become wliolly indistinguishable as a portion of can- cer after traversing the ureter and remaining soaked in urine in the blad- der for even a short time. In children the disease is more rapidly fatal than in the adult. It rarely lasts over a year. The tumor grows to an immense size, not infrequently fills the whole abdomen. The patient emaciates rapidly and dies. Fig. 124 is an excellent representation of a child with advanced can- cer of the kidney. Adults with cancerous kidney usually die in two or three years, but many drag out more than double that length of time (Roberts). Can- cerous cachexia is more liable to be marked in the adult than in the chDd. The diagnosis in the male is with ascites, hepatic or splenic tumor, or renal tumor of other nature (hydro-nephrosis, pyo-nephrosis, hydatid). In ascites fluctuation is distinct, both loins are flat, the dullness may be made to change by position. A kidney-tumor is immovable, feels solid in parts, only one flank is flat on percussion. A tumor in connection with the liver does not have the colon in front of it. A kidney-tumor can usually be separated from the liver unless adhesions have formed ; perhaps a line of resonance wiU exist between them. A splenic tumor does not have the colon in front ; it grows more upward than downward ; resonance may be heard in the flank behind it ; its border may be felt stiff and thinnish ; deep percussion wUl elicit the bowel-sound beneath (for the spleen is not a very thick organ) ; the history will show previ- ous malarial poisoning. For diagnosis with other renal tumors, the previous history, pres- ence or absence of cachexia, existence of pus or hydatids in the urine, sudden decrease of the tumor after free urination, etc., form the distin- guishing points. Treatment, — The hematuria, if excessive, calls for treatment, as may also the nephralgia. As the disease is so often confined to one kidney for a length of time, without infecting neighboring glands or other parts, it belongs to the surgery of the future to decide whether, in a case recognized very early, ablation of the kidney might be a justifiable operation, ABLATION OP THE KIDNEY. The successful case of removal of the kidney by G. Simon,' of Hei- delberg, has been followed by other operations, but as yet by none of fortunate issue. Simon's case was that of a woman, aged twenty-six, whose kidney was healthy, but the ureter had been diwded in ovarioto- my. To cure the resulting urinary fistula, the kidney was removed and the woman recovered. G. A. Peters," of New York, removed a kidney five and three-quarter ' " Deutsche Klinik," 1870. » Nem York Medical Journal, November, 1872. 380 DISEASES OF THE KIDNEY. inches long by three broad. The patient failed to recover. Dr. Peters's paper upon the subject is interesting and full, and contains a report of certain cases (three in number) where a similar operation had been per- formed previous to the date of his own. The operators were Simon, Linser, and Durham. Dr. Peters's method of reaching the kidney was simple and effective. An incision six and three-quarter inches long was made from the twelfth rib to the crest of the ilium, three inches from, and parallel to, the vertebral spines. The outer border of the quadra- tus lumborum was thus easih- reached, and, through the fat beneath it, the kidney. This was gradually enucleated and removed, after tying the vessels. SYPHILIS OF THE KIDNEY. The kidney is occasionally the seat of syphilis. Lancereaux,' in twenty autopsies of patients with visceral syphilis, only found the kid- ney affected in five cases ; four with interstitial nephritis, and one with gummy tumor ; several with cicatrices. Yirchow ' believes that amyloid degeneration of the kidneys may depend directly upon syphilitic ca- chexia. Kidneys affected by syphilitic disease do not furnish any symptoms which can distinguish the malady from other forms of slow nephritis ; more or less albumen, in a fluid of low specific gravity, with usually a few pale casts. There are no distinctive, subjective symptoms. Such patients are liable to slight morning nausea. Sometimes recoveries occur, under treatment. An occasional case of albumen in the urine, which has disappeared under anti-syphilitic treatment, may be found recorded in the journals." But, on the other hand, it wiU occasionally happen that patients with visceral syphilis, under protracted treatment, by large doses of iodide of potassium, will gradually show morning nau- sea, and upon examination their lu'ine will be found light, slightly albu- minous, and containing pale casts. In such cases the kidney-trouble is probably due to the irritation produced by the large amount of iodide of potassium passing through them, and the albumen and casts may be made to disappear, together with the morning nausea, by reducing the activity of the treatment. Several such cases have fallen under the authors' observation. The pathological appearances of syphilitic kidney, besides amyloid degeneration, which may be found, perhaps due to the disease, are those of interstitial chronic inflammation (usually circumscribed), local cir- rhosis (rarely general), thickening of the parenchyma and capsule, per- haps local fatty degeneration, with atrophy, the tough adherent capsule being depressed in deep seams, the kidney stroma compressed, atrophied, and degenerated between portions of contracted connective tissue. ' Op. eit. 2 "Die krankhaften Gesehwaste," vol. ii., p. ill. ' Oilier, quoted by EoUet, p. 278. SYPHILITIC KIDNEY. 381 These appearances may be found alone or combined with one or more vellow gummy nodules, of varying size, solid, or more or less softened. Such nodules are usually connected to white bands of hypertrophied connective tissue, running through the kidney. The gummy nodule is pathognomonic; the chronic interstitial nephritis is distinguished from the ustal form by being generally confined to circumscribed portions of the gland. The treatment of cases suspected to be syphilitic is that of tertiary syphilis. CHAPTEK XXI. DISEASES OF THE SCROTUM. Anatomy.— iBJuries.— (Edema.— Emphysema.— Eczema.— Intertrigo.— Pityriasis.— Eczema Marginatum. —Pruritus Genitalium.— Pedicull Pubis.— rhlegmouous Erysipelas.-Elephantiasis.— Tumors and Cancer of Scrotum. — Epithelioma. The scrotum is a pouch formed of skin, muscular and connective tissue. Its function is to contain and support the testicles. It is developed from two lateral halves which unite centrally in the raphe (paTTTU, I sew), a raised line continuous with the raphe of the penis and that of the perinseum. The lateral halves sometimes remain separated and resemble labia majora, giving rise to an appearance sug- gestive of hermaphrodism. The healthy scrotum in the young man is thrown into rugae at right angles to the raphe on either side, by the contractions of the dartos. Tbe integument of the scrotum is delicate in structure, covered with a few hairs, and apt to become pigmented at pubertj'. The sebaceous glands are very large. The dartos is a layer of unstriped muscle. It lies beneath and firmly attached to the integument, and is reflected on either side inward from the raphe, to form the septum scroti. Each testicle has thus a dartos of its own. On exposing the scrotum to the air, the vermicular contractions of this muscle can be readily seen. They occur under the influence of cold or fright, and during the venereal orgasm. In youth, especially in winter, the dartos is habitually contracted and holds the testicles well up under the pubes. The ancient sculptors did not fail to notice that contraction of the scrotum was a mark of general as well as of sexual vigor. In the aged and infirm, on the other hand, especially during summer, the muscle relaxes, allowing the testicles to hang low, supported mainly by the cord. The connective tissue of the scrotum is peculiarly loose, and con- tains no appreciable amount of fat. The septum scroti is pervious to 383 DISEASES OF THE SCROTUM. fluids, so that serum or infiltrated urine can find its way readily from one side to the other. The lymphatics of the scrotum are large and numerous, and lead to the inguinal glands. The scrotum develops in- dependently of the testicles, but, if the latter fail to descend, it is always rudimentary. rNJTJUrES OF THE SCROTXTM. In contusions, extensive ecchymosis is liable to occur, on account of the laxity of the connective tissue. These should not be incised. The parts should be supported and covered with cool lead-water, to which a little spirit has been added, or laudanum, if there is pain. Absorption may be pretty confidently expected. In wounds of the scrotum there is usually a great deal of bleeding. In uniting such woimds, many sutures are required, to overcome the ten- dency of the dartos to pull the edges apart. Abscess of the scrotum after injury requires no comment. An early opening is advisable. CTJTAlIEOTrS APPECTIONS OF THE SCEOTXTH. Xearly aU of the numerous diseases, syphilitic or otherwise, of the general integument, may occur also upon the scrotum. Certain of them are modified by their position, and require a passing notice. .Extensive oedema is liable to complicate any inflammatory affection of the scrotum — on account of the laxity of its tissue, and its dependent position. Scrotal oedema may also be due to any obstruction to the return of its blood, as occasionally to the hard inflammatory induration aroimd inflamed lymphatic glands in the groin, or it may come on in connection with general prostration and anasarca. Where oedema is excessive, and the tension is so great that injury to the skin seems imminent from pressure, a few punctures may be made on either side of the raphe, at the most depending point of the scrotum. These incisions, however, should be practised with caution, as there is danger of their being followed by gangrenous erysipelas. Emphysema of the scrotum is occasionally met with. It is easily distinguished by the crackUng under the fingers, and resonance on per- cussion. It occurs with general subcutaneous emphysema, and with scrotal gangrene. Eczema. — Eczema attacking the scrotum, perinseum, and thighs around the root of the scrotum, is apt to be excessively obstinate, and prone to relapse. (For treatment, see text-books on dermatology.) Intertrigo occurs in children, and often in fat men of rheumatic habit who perspire a good deal. This affection is apt to be troublesome. Much can be done to prevent it, by scrupulous cleanliness, and the use of a suspensory bandage, to keep the cutaneous surfaces apart. To over- come the hjrpersBmia, when it exists, rest, cleanliness, and exposm« of PITrRIASIS— ECZEMA MARGINATUM. 383 the parts to the air, are speedily effective in mild cases. If the surface is moist, and excoriated, it should be dusted with equal parts of iinely- powdered oxide of zinc, camphor, and starch, or with simple rice- powder, or may be dressed with the oxide-of-zinc ointment. A strip of old thin linen should be used to sling up the scrotum, and keep the cutaneous surfaces apart. Later, when the parts are dry, tincture of iodine, locally, will hasten the cure. Avoidance of stimulating food and drink, to render the secretions less irritating, is advisable. Pityriasis. — In men with a delicate skin, especially in summer, there is often a slightly brown discoloration of the thigh, and of the scrotum, where the two surfaces lie habitually in contact, caused by a vegetable parasite in the upper layers of the epidermis. It is, in fact, a pityriasis versicolor, and sometimes gives rise to a mild local erythema, and consid- erable itching. A few applications of the compound tincture of iodine diluted to half strength, and painted on after the affected skin has been washed with soap, and dried (to remove the fat from the scales and spores), will cure the discoloration and the itching. Eczema Maeginatum. — This is another parasitic disease, affecting the scrotum, thighs, mons veneris, and buttocks. It is not an eczema, but a herpes tonsurans vesiculosis — a combination of herpes tonsurans and intertrigo, as proved by Pick,' in a written discussion with Hebra. The eruption commences in one or more small, round patches, red, ele- vated, and itchy, just where the scrotum lies habitually in contact with the thigh. It spreads circumferentiallj', healing in the centre. The border of the eruption is sharply defined, and forms the distinctive feature of the disease. It is composed of papules, vesicles, excoriations, and crusts. The parts within this festooned border, over which the disease has passed, are left of a brown color. Often, little heaps of dried- up scales lie here and there upon this surface. Patches of eruption break out in the neighborhood, or within the border, and behave exactly like the patches first constituting the disease. The affection is slow in getting well, and tends strongly to relapse. Friction and moisture of the parts, together with the parasite, are necessary for its production. Among the scales scraped from the margin, the microscope may detect the moniliform filaments and spores of the tricophyton of Malmster, the parasite of ordinary ring-worm. In certain stages of the disease, the parasite is difficult to find. Treatment. — Dilute lead-water, or oxide of zinc ; ointment may be used locally at first if there be much inflammation of the skin, to be fol- lowed by parasiticide lotions, or the latter may be commenced with at once. The best of these is a mild solution of corrosive sublimate in water, gr. j-jss to the | j, which should be kept constantly applied. If mercury be objectionable, tincture of iodine may be used, or an oint- ' " Zur Verstandigung iiber daa sogenannte Ekzema Marginatum," Archiv f. Derm. »nd Syph., 1, iii., p. 443. 38i DISEASES OP THE SCROTUM. ment of turpeth mineral (hydrarg. sulph. flav.) gr. x-xx to the |j. Treatment should be kept up for some time after apparent cure, as re- lapses are the rule, and can only be averted in this way. Peueitts GEXiTAinni. — This, like other purely pruriginous skin- affections without eruption, is excessively obstinate. Rheumatic and gouty subjects most often are the sufferers, and, with such, any dietetic or hygienic errors seem liable to induce or aggravate the disorder. After the exclusion of animal or vegetable parasites from the role of causality, the treatment consists in hygienic and dietetic precautions, with the internal exhibition of alkalies, and, if need be, tonics. Turkish and Russian baths are often very serviceable. The following are among the most generally useful local measures, what is suitable for one case often having no effect upon another. Hygiene and change of air are sometimes the only really curative agents. Hot water, tar, pure or in combination, yellow wash — Or— 5 . Chloroform., 3 j. Adipis, 5j. il. Keep corked in a wide-mouthed bottle. Or— 5 . Acid. hTdroeyanie. dil, 3 ss- 3 j. Glycerini, Aquae, aa 3 ss. M. Ft. lotio. Finally, local electricity, either the induced or the continued current, has decided curative power over some cases. Pedicuxt Pubis. — These parasites may be found upon the scrotum, as they may, in fact, upon any part of the body from which the hairs of puberty grow. Thej' exist in greatest abundance, however, about the geni- tals, and particularly on the mons veneris. They are plainly visible to the naked eye, as are their eggs attached to the hairs (Fig. 125, a). They may be destroyed by sprinkling the parts with calomel, or by ap- plying a lotion of gr. j-iij corrosive subli- mate to I j of Cologne-water, or a wash o fe^ made of equal parts of tincture delphinii and water, or of hyposulphite of soda and borax, each 3 j to 3 j. When they infest the whole body, some few usually escape the ordinary application of lotions, and these soon breed a new crop. Care and patience, however, will always finally dislodge them. Ueinaet Lstfilteation has been already described. Phlegmonous Erysipelas. — Upon the scrotum this is an exceeding- ly dangerous disease. It is most frequently observed in the aged or de- bilitated, chiefly as the result of cold. A method of acquiring it, which is almost classical, is for an old man to come out of a hot room into the PHLEGMONOUS ERYSIPELAS. 385 open air to urinate. The cold air strikes upon the part, chills it, and within twenty-four hours phlegmonous erysipelas of the scrotum com- mences. Injuries and operations may also be occasionally attended by it. The so-called metastatic inflammations occurring in typhus, variola, scarlet fever, mumps, etc., are in reality phlegmonous erysipelas, de- scribed by some English authors as acute oedema. Symptoms. — A sharp chill announces the disease. The scrotum be- comes at once the seat of increased heat and redness, with pain, and rapidly enlarges. Blood escapes into the subcutaneous connective tissue, so that the whole scrotum may be black and shining, or its color may be mottled. The scrotum may reach the size of a child's head, the integu- ment is put upon the stretch, the epidermis may crack or may be raised into vesicles or bullae. The general tendency of the disease is always toward gangrene. Pain is not very great, but the prostration is exces- sive. The pulse runs up to 120-160, is small, feeble, and irregular. The appetite fails, the tongue gets brown and dry, the patient breathes hurriedly, is depressed and overcome. The skin is hot and dry at first, but becomes subsequently moist from depression. The diagnosis is between infiltration of urine and hsematocele. From the former it may be distinguished by the greater severity of the attack, the rapid change of color of the parts, the fact that one side of the scrotum is more seriously involved than the other in phlegmonous erysipelas, and that the oedema does not so certainly extend to the penis and abdomen. The patient is more depressed, and no preexisting cause for infiltration is present. In true haematocele one side only of the scro- tum is enlarged, and there is not much thickening of the skin. The swell- ing may be often made out as involving the testicle. The general symp- toms in hsematocele are not formidable. The dangers in phlegmonous erysipelas of the scrotum are twofold: the life of the patient is in danger ; the integrity of the scrotum is at stake ; any portion or the whole of it may slough, leaving the testicles uncovered. Treatment. — The treatment should be energetic and supportive. Repeated small doses of brandy, whiskey, or wine, must be given, with milk, cream, and beef-tea. The quantity of stimulant varies in every case. Eight or ten ounces of brandy or whiskey in twenty-four hours, in small portions at a time, is a fair average quantity. A good effect of the stimulant will be noticed in the pulse, which will decrease in frequency and become more strong and regular. The tongue will get moist, and the patient rally from his depression. The local treatment is equally important. Hope of aborting the dis- ease need not be entertained. One long, free incision parallel to the raphe, on either side, should be made well down into the subcutaneous tissue of the oedematous discolored mass. Persulphate of iron may be used, if necessary, to check bleeding, and water-dressings, with one per cent, carbolic acid, applied. If gangrene has already commenced, and 25 386 DISEASES OF THE SCROTUM. sloughs begun to separate, or if the latter form in spite of the incision, they should be detached and remoyed as soon as possible. The testi- cles hang out uninjured in these cases, suspended by the cord, and if left to themselves and kept moist, or, perhaps better, mildly stimulated, granulations wiU sprout out upon them, and a cicatrix will form, bind- ing them up under the pubis in a manner not unsightly nor incon- venient. The patient is always agreeably disappointed in the final result. If the process of repair does not form a good scrotum, recourse may be had to oscheo-plasty (bax^ov, scrotum y "rrXdaaeLV, to form), as performed by Delpech, Dieffenbach, Dilrger, and others, by transplant- ing from neighboring parts flaps of skin large enough to cover in the testicles. Elephantiasis Scroti. — This disease, not uncommon in some por- tions of the globe, is rare in the United States. Hypertrophic over- growth may attack the scrotum or penis alone, but usually both are involved, the scrotum to the greater extent. The scrotum may enlarge until it touches the ground. It has been known to reach the weight of one hundred and sixty-five pounds ! A scrotum of this weight was re- moved by Wilkes.' The only remedy for the disease is the knife. Cur- ling ' advises a disregard of the penis and testicles in operating, if the tumor be very large. Patients are apt to die on the table, from haemor- rhage, which is always excessive. If the mass is not excessively large, the penis, testicles, and cords, may be dissected out, enough of the healthiest tissue being left to cover them. Many cases of successful operation are recorded, among others, one by Thebaud, of Xew York, the mass weighing, when removed, sixty-three pounds. Cystic, fatty, and fibrous tumors of the scrotum are found occasion- ally. Small steatomatous cysts are common. They may reach a large size. Cancer of the ScROTUir, in this country, is a rare disease. When it occurs, it is almost invariably epithelial. Scirrhous and medullary cancer, recurrent fibroid, and melanotic sarcoma, are encountered at long intervals, but not as differing in any way from the same growths else- where. Epithelioiia of the Scrotum has been denominated chimney- sweeps' cancer, since it is somewhat common in England upon chimney sweepers. Soot seems to be the exciting cause in England, although in other countries those whose occupation brings them into contact with this substance do not seem to suffer. On the contrary, our countryman, Warren,' states that he has seen it a few times in the United States, but never in chimnej'-sweepers. Coal-dust is entirely inoperative. The disease begins as one or more small, soft warts, or tubercles, usually at the lower fore-part of the scrotum. These remain unchanged ' Titley, "Diseases of the GenitaU," p. 317. ' "The Testig." ' " Surgical Observations on Tumors," p. 329. EPITHELIOMA. 387 for a timej but finally indurate slightly, become excoriated, scab over, and ulcerate, the ulcer extending backward, and destroying, with more or less rapidity, the whole scrotum. Sometimes the testicles are in- volved, sometimes they escape. The ulcer resembles an epithelial, can- cerous ulceration, wherever seen. It has the same hardened, irregular, purplish, everted, knotty borders; the same hard, uneven, unhealthy- looking base; the same ichorous discharge, now sanguinolent, now purulent. Death occurs by exhaustion, or by hsemorrhage, if a large vessel be severed by the advancing ulceration. The disease continues local for some time. It is only tardily that the inguinal glands become in- volved. Treatment. — Thorough removal with the knife offers the only chance for safety. If the inguinal glands have not become infected, the opera- tion is a simple one. If either testicle should be found involved, or even adherent to the diseased mass, it should be removed. If the glands in the groin are greatly enlarged and indurated, operation is unadvisable. If they are only slightly enlarged, they may be left ; but, if they are at all indurated, they too must be removed. The earlier the operation is undertaken the Ip-'s the chance of relapse, which is always to be feared. A second and thira operation may be advisable, if the patient's general condition be not seriously impaired. (For mucous patches of the scrotum, see Syphilis.) CHAPTEE XXII. DISEASES OP TEE TESTICLE. Anatomy. — Anomalies. — CryptorcMdism. — Hypertrophy. — Atropliy. — ^Injuries. — Haematocele. — ^Hsemato- cele of the Cord. — Free Bodies in the Tunica Vaginalis. The testicles, suspended each by its spermatic cord, lie loosely in the scrotum, surrounded by an atmosphere of connective tissue. The left is usually slightly larger than the right and hangs lower, evidently for the purpose of allowing these important organs the more readily to elude violence. It has been observed, in transposition of the viscera and blood-vessels, that the right testicle hangs the lower. The mean dimensions of the testicle, according to Curling, are one and three- fourths inch long, one and a fourth inch antero posteriorly, and one inch laterally. The average weight in the adult is about six drachms. The dimensions, weight, and consistence, vary considerably, according as the organ is in action or not. During venereal excitement it is turgescent, 388 DISEASES OF THE TESTICLE. firm, and elastic ; otherwise soft and yielding. Two of the envelope of the cord also cover the testicle, the cremaster muscle, and the tunic vaginalis communis, while the remains of the gubemaculum testis attac it to the bottom of the scrotum. The proper coverings of the testicle are two — the tunica vaginali testis and the tunica albuginea. The former is a shut serous sac, ir vesting all the secreting portion of the testicle, except where the ep: didymis is attached behind, and the remains of the gubernaculum below It dips down in the middle posteriorly, between the epididymis and th testicle, forming a cul-de-sac, at the bottom of which the sac on the tw sides comes into close contact, and sometimes there is a communicatio; at this point. On the outer side the tunica vaginalis covers am closely invests the epididymis. The reflected layer forms a shut sac and this extends up the cord to a greater or less extent. This tunic vaginalis represents a portion of the peritonaeum which was brough down by the testicle in its descent from the abdomen. Ordinarily, a birth, all connection between its cavity and that of the peritonaeum i closed, a white, fibrous line (habenula) alone marking the original con tinuity of membrane. Sometimes, however, the opening remains pei manent, in which case congenital hernia is likely to occur. The com munication may be a narrow canal, open only to the passage of fluid Again, partial obliteration may exist, isolated serous sacs being lef along the cord. Finally, as more often happens, the upper aperture i closed, and a considerable portion below remains unobliterated, so tha the tunica vaginalis extends for some distance upward in front of th cord. The cavity of the tunica vaginalis is lined by pavement epithe Hum, and normally contains only enough fluid to lubricate the surfaces The function of the sac is to allow the testicle to slip easily away whei in danger of being pinched. The tunica albuginea is the proper investing membrane of the se oreting portion of the testicle. In its substance the branches of thi spermatic artery ramify, and break up to be distributed to the semina tubules within. It is composed of dense, white, fibrous tissue, is onl; slightly extensible (whence the pain in orchitis), and sends trabecula into the substance of the testicle to break it up into compartment (about four hundred for each testicle), for the lodgment of the ultimati tubuli seminiferi. It forms the rete testis (corpus Highmori) above am behind, where blood-vessels and absorbents pass to and from the testicle and where the straight tubes come out to form the coni vasculosi — tc gether, the head of the epididymis. The glandular substance of the testicle consists of innumerable littli tubes (tubuli seminiferi) closely packed in conical segments between tb fine, fibrous septa thrown out by the tunica albuginea. The number oi these cones is computed to be from 250 to about 500, and their com bined length from 1,000 to 5,500 feet. The diameter of the tubules ha EPIDIDYMIS. 3g9 been variously estimated at from ^V of a line (Muller) to ^ of a line (Lauth). Their mean length is estimated by Lauth at 25 inches/ The tubes are all of the same size throughout, and anastomose fre- quently with their fellows of the same cone, and with those of neighbor- mg cones. They are lined with mucous membrane furnished with po- lygonal cells, containing spherical nuclei. These cells are the active agents in forming the spermatozoa, the ciliated cells (so-called animal- culse) always found in health after puberty, free in the tubes in greater or less number, according to circumstances. The epididymis {ini, upon ; 6i6vfiog, testicle) caps the testicle proper, and skirts its posterior border. It is large and spread out above, being composed of the ooni vasculosi or convoluted vasa efferentia. This por- tion is known as the globus major, or head of the epididymis. The coni vasculosi finally all empty into one canal — the canal of the epididymis, which forms by its convolutions the central part or body of the epididy- mis. This body is separated from the testicle proper by the cyl-de-sac of the tunica vaginalis already alluded to. Below, the canal of the epi- didymis exhibits further convolutions. At this point it is known as the globus minor, or the tail of the epididymis. Connective tissue unites it to the testicle at this point, and from here on the canal becomes more dense, and is known as the vas deferens. The little supernumerary diverticulum (or there may be several), known as the vasoulum aberrans of Haller, when present, usually empties into the canal of the epididymis at this point. The canal of the epididymis is furnished with ciliated epithelium, whose cilia sweep its contents along toward the vas deferens. The two constituent parts of the testicle, which have been briefly described above, are developed separately in the foetus. Each receives its blood in the main from a separate artery, although these arteries anas- tomose pretty freely at their extremities. This peculiarity of vascular supply may account for the fact that one portion of the organ is often diseased the other part remaining sound. The epididj'mis is formed from the lower part of the Wolffian body, and its duct is a continuation of the Wolffian duct to the lower and back part of the bladder. The deferential artery, a branch of the hypogastric, supplies it. The se- creting portion of the testicle, on the other hand, is formed from foetal tissue lying in front of, but seemingly independent of, the Wolffian body, and its artery, the spermatic, comes from the aorta just below the renal artery (KsUiker)." ANOMALIES OF THE TESTIS. Instances of supernumerary testicles have been reported, but in all the cases where dissection has been resorted to, to clear up the doubt, the extra organ has proved to be some cystic, fatty, fibrous, or other ' Curling, op. cit. ' Entwickelunga-Geschichte des Mensoben und der hoheren Thiere." 390 DISEASES OF THE TESTICLE. tumor, so that it is doubtful if the anomaly exists at all. Even in two cases of double penis (p. 4) there was no abnormality of the t€ cles. The opposite condition, however — absence of the testicle — d exist (Paget).' One or both testicles may be absent ; the vas defer and seminal vesicle in these cases being sometimes fully developed, ; traceable into the inguinal canal, or even to the bottom of the scrot (Curling). OEXFTOECHIDISM— MONOECHIDISm.^ A CETPTOEOHiD {KpvTTTSLv, to coficeccl / opxig, testicle) is an Individ whose scrotum contains no testicles. A MOJsroECHiD {jiovog, alone ; opxi-g, testicle) has only one testicle the scrotum. When a testicle is absent from the scrotum, the presumption is t] it has been arrested somewhere in its descent. The testicle is forn high up in the abdominal cavity, behind the peritonffium, in about i position occupied by the lower end of the kidney at birth. During i tal life, guided by the gubernaculum testis, it descends, carrying w it a portion of peritonaeum, which is to become the tunica vaginalis, passes through the inguinal canal, and by the end of the ninth montt usually in the scrotum. It may, however, be arrested at any point in descent, or may follow an abnormal direction, finding its way into t thigh through the femoral ring, or even into the perinseum, where may become inflamed, and has been mistaken for an abscess. One vf common point of detention is in the inguinal canal. In all of these siti tions it can be felt, and should be searched for in case the scrotum empty. In about one case in five (or ten — Wrisberg) the testicle is ii in the scrotum at birth. It descends, usually, during the first wee but is often retained for months, sometimes longer, and not very inf quently until puberty, or even later ; it has been known to descend late as thirty years afterbirth. When it descends after birth there great probability that a portion of intestine will follow it, constitutii congenital hernia. It is estimated that in about one case in a thousai the testicle is permanently retained in the abdomen, or inguinal cam The right testicle is a little more liable to this accident than the 1( (Petr^quin Quetelet). When the testicle is retained in an abnormal position, it is almost ui versally foimd imdeveloped, or in a state of fatty or fibrous degenei ' Medical CfazeUe,Yo\. xxix., p. 81*?. ' The literature on this subject is rich. The foUowing papers reay be consult with profit : EoUin, " M6m. sur lea Anomalies de Position du Testicule," Archiv. de M6d., 1881. Le Comte, " ThSse sur les Ectopies congenitales des Testicules," 1851. Roubaud, "Trait6 de I'lrapuissance," Paris, 1872, p. 607. Godard, "ifitudes sur I'Absence coug^niale du Testicule," Mem. de la Society Biologie, 18B6-'59. Godard, "Etude sur la ilouorchidie etla Cryptorchidie chez THomme," Paris, 1857 Godard, " :6tudes sur I'Absence congeniale du Testicule," 1858. CRYPTORCHIDISM. 39 tion. Under these circumstances no spermatozoa are discovered in i or in the seminal vesicle of the affected side. Exceptionally, howeve it has been found of full size. When one testicle only is retained th other undergoes conservative hypertrophy, and the deformity is A mattf of no consequence, as one large, healthy testicle is all-sufficient. Bu where both testicles are retained, it may become a very nice matter in medico-legal sense, or in regard to prospective matrimony, to decid whether the cryptorchid is sterile or not. According to Godard, tl cryptorchid is necessarily sterile, yet he may be, and usually is, tho oughly potent, and possessed of the full amount of sexual desire. A opinion of his ability to beget children can only be founded upon mien scopic examination of the spermatic fluid. The secretion may be naturi in consistence, quantity, and odor (it is liable to be brownish), but, if does not contain spermatozoa, impregnation cannot be effected. Tt least ofi^ensive way of obtaining a specimen for examination is to requei the patient, immediately after sexual congress, to cause the woman wil whom he has cohabited to urinate, and then to bring the urine for e: amination. When allowed to settle for a short time, spermatozoa ca always be recovered, with a pipette, from such a specimen, provided tl seminal fluid contained any. Several cases are recorded where crypto chids have married, whose wives have had children, but doubt has alwai been raised as to the paternity of the offspring. Authors are not of a cord as to the sterility or virility of cryptorchids. The majority take tl former ground, but, as these individuals are apparently never impoten the test of their sterility can be easily applied, if desirable. The retained testicle is apt to become diseased. When retained i the inguinal canal, it is often the seat of severe pain, especially at aboi the age of puberty, from pressure by the tendons of the abdominal mu cles. It may be painful enough to impede motion, in which case an o] eration should be undertaken for its removal. A testicle in this si uation is liable to become the seat of malignant disease, due parti according to Virchow,' to the injuries inflicted upon it by the contra fcions of the abdominal muscles, and partly to a predisposition from i incomplete development. A testicle in this situation, which becom( inflamed, as it may in connection with gonorrhoea, is not able to swel and consequently is doubly painful. Testicles retained in the inguin; canal may be mistaken for hernia. Operations to replace a testicle when found in an abnormal positic have been undertaken, but without much success. If it can be felt, it always worth while to make an effort to get it into the scrotum, i insure its development, to guard against future disease, and to allow truss to be worn above to close the inguinal canal, and prevent the poss bility of hernia. In two (personal) unpublished cases this was effecte by careful manipulation extending over a length of time. If the testicl • " Die krankhaften Geschwiilate." 392 DISEASES OF THE TESTICLE. cannot be brought into its place, it may be left alone, unless it become painful or diseased. The pad of a truss should not be placed upon it. Occasionally monorchidism is acquired. One case has been reported ' ■\Yhere the right testicle was suddenly and violently drawn up into the inguinal canal during masturbation, and did not come down again. Later in life, when the patient died, this testicle was found soft, atro- phied, pulpy, about one-fifth the size of its fellow. ' HYPERTROPHY AND ATROPHY. The testicle becomes hypertrophied conservatively when its fellow is defective, or wanting, and in certain lusty individuals the testicles are abnormally large. Atrophy of the organ may result from a variety of conditions. The retained testicle in a monorchid does not develop fully, and may atrophy. In hot climates the organ is said to atrophy (Larrey), as it does normally in old age. Atrophy may come on, usually attended by neuralgia, after prolonged sexual excesses, or may succeed sudden pain after fatigue. Probably some inflammatory element is at the bottom of this cause. True orchitis, or the form complicating mumps, is liable to be followed by atrophy. Any tumor or morbid growth pressing on the testicle, or obstructing its vascular supply, may cause atrophy, e. g., ligation of spermatic artery, aneurism of aorta involving the spermatic arteries (Wardrop's case) ; in certain rare cases, hydrocele, large congenital hemise, varicocele, may act in this way. A section of the nerves of the testicle will cause atrophy, as may also certain injuries of the head, back, or spinal cord. Ligation of all the veins of the cord produces atrophy. Atrophy sometimes attends severe neuralgia, especially the form ac- companying large varicocele. Non-use of the testicle for any length of time does not cause it to atrophy. The somewhat common belief that the long-continued use of iodine wiU occasion atrophy of the healthy testicle is incorrect. Occasionally in children the testicles will cease to develop, or even atrophy, without any apparent cause. Syphilis may occasion atrophy, without any gummy deposit. Treatment. — For atrophy of the testicle there can be but little done. The causes are usually beyond the surgeon's control. In certain cases tlie cause (neighboring tumor, sj-philis) may be removed. CONTUSIONS OF THE TESTICLE. Contusions of the testicle are rare, owing to the peculiar anatomical surroundings of the organ, notwithstanding its exposed position. In jgygre contusions there is usually more or less ecchymosis, and perhaps hiEmatocele, or orchitis, and subsequent atrophy may result. One of the modes formerly adopted in the East for emasculating the attendants of tlie harem was that of squeezing the testis, and a similar plan has been ' Medical Times and Gazette, vol. xviii., p. 67. WOUNDS— HEMATOCELE. 3 resorted to upon animals instead of castration, in England and Frai) (Curling). The inflammation after injury may be sufficiently severe lead to the formation of abscess or to gangrene. Treatment. — The patient must be placed at once upon his back, the contusion be severe, with the testicle elevated and covered with cooling application ; if subsequent inflammation occur, it must be n appropriately (orchitis). WOUNDS OP TESTICLE. Punctured wounds, if small, are of no importance. They give ri to no inconvenience and heal without trouble. Penetrating wounds any size, however, allow some of the tubular structure of the testis escape. This, projecting outside and covered with pus, is very apt be mistaken for a core of pus, and to be pulled out as such. Malgaig mentions a case where he saw the whole pulp of the organ pulled out this way. Incised wounds are followed by suppuration, partial exuloe: tion, and recovery, with more or less atrophy. Injuries to the testi( (contusions or wounds) are usually very painful in sensitive subjects, a are liable to be complicated at the time with faintness, nausea, vomitii convulsions, or tonic spasms. Treatinent. — In wounds of the testicle, if there be any true hen of the secreting substance, it should be reduced if possible, and retain by pressure, or by a suture through the tunica albuginea. If it canr be reduced, it may be snipped off with the scissors, or allowed to sej rate by the natural inflammatory process, but should in no case be pull upon. Large incisions should be cleaned, united by suture, and t parts carefully supported. Even if a large part of the testicle has be destroyed by the accident, an effort should be made to preserve what left. Dorsal decubitus must be preserved, and the testicle properly sr ported. Cool water-dressing is as good as any that can be employe perhaps mingled with a little alcohol or carbolic acid. HEMATOCELE. The term hsematocele is applied to a tumor caused by the effusion blood into the sheath of the testicle and cord (sometimes into the c lular tissue of the scrotum as well), into the tunica vaginalis, or into preexisting cyst of the cord. It is usually of traumatic origin, or is secondary affection occurring where hj'drocele has preceded it by mingling of blood with the serous contents of the tumor. The most common cause is violence, associated with crushing tissue and injury of blood-vessels. An operation upon a hydrocele m; wound a vessel, or the testicle itself, and, if the hasmorrhage takes pla internally, an hematocele results. The disease may exceptionally have spontaneous origin from active or passive hypersemia ; varicose scrotal seminal veins connected with great laxity of the scrotum ; or, rarel 334 DISEASES OF THE TESTICLE. from a hsemorrhagio secretion in scorbutic individuals. Sir Benjamin Brodie ' mentions as a cause a diseased (calcareous) condition of the arteries distributed upon the tunica albuginea, similar to the degenera- tion of the arteries of the brain, which often precedes apoplexy. One of them may rupture into the tunica vaginalis. There are, consequently, two varieties. The one coming on rapidly, usually after injury, and attended by effusion of blood into the scrotum, where the latter suddenly swells, becomes blue, black, or violet-colored, with a more or less evident feeling of fluctuation, or where a preexist- ing cyst or hydrocele, after violence, becomes suddenly larger, more tense, and painful. There is more or less high symptomatic fever, and the inflammation may possibly go on to suppuration. In the other, or spontaneous variety, the tumor increases slowly in size and simulates hydrocele, except in regard to translucency. This latter form is diflScult to diagnose from hydrocele in proportion as the blood is thin, and confined to the tunica vaginalis propria. The blood in hsematocele may be found red and fluid, but it is usually black or brown, and may be mixed with pus, if severe inflammation has followed its effusion. Its fibrinous portions may be more or less strati- fied, as in aneurism. The walls of the tunica vaginalis, or of a cyst in contact with blood (unlike what occurs when their contents are serous) tend to thicken and become adherent to the surrounding connective tissue, while the inner sur- face becomes rough and uneven, resem- bling any thing more than a serous sur- face (Fig. 126). The walls of hsemato- cele have been found an inch thick. The diagnosis of hsematocele of the second or spontaneous variety presents many difficulties. Here there is no guide in any discoloration of the scrotum, or any suddenness of growth of the tumor. The records of surgery possess many cases where perfectly healthy testes, sur- rounded by an hsematocele inside of a thickened tunica vaginalis, have been extirpated, under the idea that they were cancerous. Often, there exists no positive means of diagnosis short of an exploratory operation with the knife, which is the proper course to follow in such cases. There are, however, characteristics of hasmatocele which may serve to distinguish it from hydrocele and malignant growths. The pyriform shape of hydrocele exists, but there is no translucency of the tumor. This, however, would also be the case in an old hydro- 1 London Medical Gazette, vol. ix., p. 927. Fig. m.— (Curling.) HEMATOCELE— TREATMENT. 395 cele, with thickened walls. The mass feels unusually heavy when bal- anced in the hand. If it has been attentively watched, it will be found to have decreased a little in size at some period of its growth, which does not occur in malignant disease. The peculiar sensibility produced by pressure on the testicle can often be called out by pressing upon the mass behind, at about the middle portion. Exploration with an explor- ing-needle wiU, perhaps, give a negative result, but, with a trocar, the diagnosis may often be cleared up. The amount of pain is variable. The general health does not, as a rule, suEer much. In a doubtful case an exploratory incision is demanded, In the traumatic variety, when the blood has been effused into the connective tissue of the scrotum, the diagnosis is made at once, by the history, size, heat, and color of the tumor. This is more strictly contu- sion, -with effusion of blood, and not true hasmatocele ; but it may accom pany the latter condition when due to violence. Treatment. — In acute cases all that can be done is to keep the patient upon his back, with the testicle supported and covered with cold lotions, administering perhaps an occasional laxative and an anodyne if the pain be severe. If the quantity of blood effused is not too great, the pain will soon begin to subside, and the patient may be allawed to go about with a suspensory bandage. The blood will gradually be absorbed. If, in spite of these means, which will rarely he found to fail, blood continues to be poured out into the cavity so that the pain becomes ex- cessive, and the tension of the parts very great, a trocar may be intro- duced to draw off the blood, and cold and pressure applied to prevent refilling of the sac. If it fill again, a second tapping, delayed as long as possible, will probably afford a more serous fluid than the first, and a third, a fluid stiU less tinged, after which iodine may be injected. (^See Teeatment of Htdeocelb.) When, however, the blood is in clots, it will not flow through a trocar, and then an incision may be required, as it is also when the inflammation is imminent from tension. All the clots should be turned out, the cavity thoroughly washed with a m.ild, warm solution of carbolic acid, one-half of one per cent. ; bleeding-points should be looked for and secured by ligature. The dressing consists of a little lint, position, and cool (or warm) applications, whichever give more comfort to the patient. The cavity wiU heal slowly by granula- tions. In incising the tunica vaginalis an opening should first be made above and in front, and this should be continued on a director, or be- tween two fingers, fairly to the bottom of the sac, to secure good drainage. If the incision be made at one stroke, the testicle, which is sometimes misplaced, and lies in front, may be laid open, an accident which has happened in the most experienced hands. If the tunica vaginalis in an old case be found much thickened, it is better to cut it away — invariably if its walls contain calcareous plates. 396 DISEASES OF THE TESTICLE. The reaction following operation is rapid and severe, aind, in the case of old patients, it may sometimes be preferable to perform castration, as the milder alternative. With the young and middle-aged, however, this course is not to be thought of, as the testicle is seldom injured, although in long-standing cases it is occasionally atrophied. Erysipelas or gangrene may follow the laying open of hematocele. An haematocele produced by the effusion of blood into a preexisting hydrocele may usually be treated like uncomplicated hydrocele. Any systemic state predisposing to haemorrhage requires special management, and all opera- tive interference should be delayed until such blood-dyscrasise have been removed. HEMATOCELE OP THE COBD. Pott has described a diffused hematocele of the cord coming on during straining at lifting, or at stool, and confined within the tunica vaginalis communis. This form is exceedingly rare. It may occur, also, in connection with general ecchymosis of the scrotum from injury, and calls for the same treatment. The blood will be reabsorbed in time. It has been confounded with hernia, and operated on as such. If the tumor continue to enlarge in spite of position, rest, and cooling apphca- tions, a free incision should be made, the clots turned out, the wound washed, and the bleeding vessel sought for and secured. When an encysted hydrocele of the cord, by accident or dyscrasial disease, becomes an hsematocele, the same changes take place in the walls of the sac and surrounding tissue as have been described in hsematocele of the tunica vaginaUs. The treatment is also the same, care being always taken to treat the dyscrasial causative condition. FREE BODIES HT THE TTJNICA VAGHTAXIS. Occasionally little excrescences spring up from the surface of the testicle within the cavity of the tunica vaginalis. They may grow any- where within the tunica vaginalis, but are more common on the epdidy- mis or around the so-called hydatid of Morgagni. These excrescences have an inherent tendency to grow large at the summit by a deposition of concentric layers of very dense connective tissue, and thus become pediculated. New excrescences may form upon an old one constituting a sort of dentritic vegetation. There is a tendency to a central deposit of calcareous salts early in the formation of these little pediculated balls, which causes an arrest in their growth. After this the pedicle becomes more and more thin, and finally breaks and disappears in some motion given to the testicle. In this way are the free bodies formed. They are found of all sizes, from the head of a pin to a large hazel-nut. They aie not encountered in connection with very large hydroceles, although some fluid in the tunica vaginalis usually accompanies them. They may often be felt from the outside, and be liberated at once by an HYDROCELE. gg^ incision if they cause pain or inconvenience; which, however they sel- dom do. Occasionally after tapping a hydrocele great pain has been complained of, which has been found to be connected with the existence of a loose body in the sac. In structure these bodies consist of con- centric layers of very dense fibrous tissue, cartUaginous to the feel, sur- rounding a central nucleus of calcareous matter. An attentive inspec- tion of the surface of the testicle will often show prominences or de- pressions corresponding to the points where the free bodies had been attached by their pedicles. CHAPTER XXIII. DISEASES OF THE TESTICLE. Hydrocele, acute, chronic— Diagnostic Table of Chronic Hydrocele with Incarcerated Hernia.— PaUiatiya Treatment.— Eadical Treatment.- Congenital Hydrocele.— Diagnostic Table of Congenital Hydrocele and Hernial Tnmor.— True and Spurions Hydrocele of Hernial Sac— Encysted Hydrocele of Testis.— Spermatocele.— Spermatic Congestion.— Origin of Spermatocele.— Hydrocele of Cord, diffuse, encysted. Htdeocele,' or dropsy of the testicle, consists in an accumulation of serous fluid within the cavity of the tunica vaginalis (simple hydrocele), or within a cyst connected with the testicle (encysted hydrocele). This fluid is usually highly albuminous and of a pale-yellow color, but it may vary through shades of red, brown, green, and black, by the admixture of more or less blood, or blood-pigment, and in old cases the fluid may contain fatty matter and plates of cholesterine, granular bodies, pus, epithelium, and occasionally spermatozoa (spermatic hydrocele). The fluid difi'ers, both in its nature and mode of production, from that of general anasarca. In anasarca the scrotum may be full and the tunica vaginalis empty. The liquid of hydrocele often contains a substance simUar to fibrine. On exposure to the air under these circumstances, it wiU generally deposit in one or several layers. Buchanan, of Glasgow, found that if blood were mingled with the fluid it coagulated, when by contact of air alone it would not do so. Alexander Schmidt produced the same coagulation by adding blood-globules or hfemato-crystalline. The fluid sometimes contains salts and albuminates in a proportion analogous to that of lymph — which never obtains in the fluids of simple dropsies (Virchow)." Causes. — In the aged, anaemic, weak, and badly-nourished, there may, be a chronic dropsy of the tunica vaginalis, whose cause is simply general hydrssmia ; there are usually other serous effusions existing at the same time. This condition is a general one, and no special atten- • All forms of hydrocele, including those of the cord, will be considered in this chap- ter, since they appropriately fall together. * Op. cit. 398 DISEASES OF THE TESTICLE. tion need be paid to the hydrocele, except the wearing of a suspensory bandage, until the general health is restored, after which it would be proper to undertake a radical cure, if the hydrocele did not spontaneously subside. In exceptional cases when the collection of fluid becomes excessive, palliative puncture may be resorted to. A slight amount of hydrocele exists, as a rule, in conjunction with aU diseases of the testicle, especially of the inflammatory sort (orchitis, epididymitis), and not infrequently with syphilitic and tubercular disease of the organ. But in these cases again the hydrocele is only a symptom, and a radical cure should not be attempted. When the disease of the testicle subsides, the hydrocele will get well. True hydrocele is the result of a secretory irritation of the tunica vaginalis testis, produced usually by mechanical violence, or in sympathy with some irritation of the testicle, cord, or urethra. The mechanical violence most apt to produce it is such as is slight, irritative, and long continued ; rubbing, jolting, crushing. In warm climates it is very fre- quent, on account of the relaxed condition of the scrotum, which exposes the testicle to injury. In Brazil one man in every ten is said to suffer from hydrocele (Hyrtl). Hydrocele may be left behind after an acute inflammation of the testis, and, in those exceptional cases where the communication of the tunica vaginalis with the peritoneal cavity has not been closed after birth, a hydrocele is known as congenital. ACTJTB HYDROCELE. This is an acute peripheral orchitis, coming on in connection with acute epididymitis or orchitis, and needs no detailed account. The con- dition is analogous to pleurisy. The effusion is rapid, sero-plastic, or sero-haemorrhagic. The fluid is absorbed, as a rule, while the inflam- mation of the testicle is subsiding, and no treatment is of any service before that time, unless, possibly, puncture, if the effusion be very large. It is always caused in a mild degree by the stimulating injections, or other treatment used for the cure of chronic hydrocele, and may occur idiopathically without necessar\' connection with other inflam- matory disease of the testicle, but this is exceedingly rare. Rest with cooling lotions, and acupuncture, if necessary, constitute the treat- ment. CHBONTC HYDKOCELE. In chronic hydrocele, the effusion takes place slowly, and without pain. The swelling is often only discovered by accident. It commences in ^ the lower part of the testicle in front. It has no tendency to spontaneous subsidence. The accumulation of fluid tends to go on indefinitely, with occasional periods of quiet, until, in some cases, an enormous size is reached. The amount of fluid may be only a few drachms. It seldom exceeds a pint. Curling ' met with one case which contained forty-eight > " Oa the Testis." HYDROCELE. 399 ounces. Sixty-four ounces were taken from one (personal) case. Mr. Clinc is said to have removed as much as six quarts from the historian Gibbon (Sir Astley Cooper). Out of a thousand cases reported by Dr. Dujat, from the Hospital of Calcutta, in eighteen, the quantity drawn off varied from fifty to one hundred and twenty ounces for each case. The mechanical inconvenience of such a tumor in such a position is at once apparent. When a hydrocele has lasted for a length of time, its walls are liable to a fibrous thickening, which greatly obscures the diagnosis, or they may undergo cartilaginous, or, more rarely, calcareous degeneration. If subjected to irritation, or repeated injury, which can hardly be avoided, these changes are all the more apt to occur. The contents of hydrocele may be mixed with blood, or even become purulent. Secondary cysts may form in or upon the surface of the testicle, surrounded by thd fluid of the hydrocele, but this is rare. Long-continued pressure of the fluid, especially when the tunic is thickened and covered with lymph, occa- sionally, but very rarely, leads to atrophy of the testicle. Points of ad- herence may exist between the two surfaces of the tunica vaginalis, dividing the cavity into compartments. Symptoms. — Hydrocele is usually pear-shaped, larger below than above ; or it may be oval, and, if very large, almost spherical. It can- not be reduced by pressure. Fluctuation can usually be made out. The tumor is generally very tense, the scrotum often stretched and shining. The cord, of natu- ral size and feel, can be grasped above the tumor. The weight is slight com- pared with the size of the mass. The tes- ticle is usually situated behind, a little below the centre (Fig. 127), and press- ure on this point gives rise to the pecul- iar sensation experienced when the tes- ticle is squeezed. Occasionally the tes- ticle is found below and in front, more rarely in the centre, in front, from plas- tic adhesion. Its position should always be ascertained before operating on a hy- drocele. Dupuytren mentions several cases where this precaution was over- looked, the testicle was wounded and the diagnosis unconfirmed. If the testicle be punctured, as a rule no serious inflammation results. Pressure on a hydrocele does not produce pain ; there is no heat or redness of the skin, unless the tumor be large enough to keep it constantly on the stretch. There is flatness on per- cussion, difTering from hernia, and there is no subjective symptom ex- Fio. 111.— {Pott.) 4:00 DISEASES OF THE TESTICLE. cept a little dragging sensation in the groin and lower part of the abdo- men, running up to the back, caused by the weight of the tumor. Diagnosis. — The infallible diagnostic sign is translucency. This is obtained by making the skin tense over the tumor, and viewing a lighted candle, held as near the tumor as possible, through the upper part of the swelling, shading the eye with the hand, or, better still, looking through a cjlindrical roll of paper, or a stethoscope. If the room be darkened, translucencj- may be detected where otherwise the test might fail. Of- ten translucency may be made out by simply making the tumor tense with one hand, shading the eye with the other, and holding the hydro cele between the eye and the window, in the dajtime. Translucency is greater in proportion to the slowness of the accumulation, the thinness and whiteness of the walls, and the limpidity of the fluid. If the contents of the tumor are dark-colored, or its walls very dense and thick, there will be no translucency. In such a case exploratory puncture will decide on the nature of the tumor. A fine exploring trocar should be used, and not an exploring needle, as the fluid will not always run when the latter is used, if the walls of the sac are dense and elastic. Few diseases are easier of detec- tion than simple, uncomplicated hydrocele ; few more difiScult where many complications exist. Varicocele may complicate hydrocele. To recapitulate — the symptoms of simple hydrocele are pyriform shape, slow growth, commencing at the bottom of the scrotum, fluctua- tion, translucency — all with absence of pain. DIAGNOSTIC TABLE— HYDROCELE— INCAECERATED HERNIA. Hydrocele. Incarcerated Semia. 1. Largest below. 1. Largest above. 2. Commences gradually. 2. Comes on suddenly. 3. Commences at the bottom of the scro- 3. Commences at the external ring and turn, and grows up. grows down. 4. Is tense or fluctuating. 4. Usually doughy. 5. Cord can be made out (normal) aboTe 5. Cord cannot be distmguished, or is tumor. felt as distinct from tumor. 6. Testicle cannot be found. 6. Testicle cau usually be separated from tumor posteriorly. 1. Dullness on percussion. 7. Resonance on percussion (unless her- nia be omental). 8. Tumor heavy, but movable. 8. Tumor unwieldy. 9. Reduction impossible. 9. Reduction impossible. 10. Size usually constant. 10. Size varies at short intervals. Simple hydrocele may be complicated with incarcerated or simple hernia (Fig. 128). For true or false hydrocele of a hernial sac, and congenital hernia with hydrocele, see p. 405, et seq. Absence of pain makes diagnosis easy, with all inflammatory diseases. Smoothness of HYDROCELE— TREATMENT. 401 surface distinguishes it from cancer, cystic or tubercular disease, and translucency from syphilitic disease. Treatment of Simple Hydrocele.— Ry&xocAe is cured by causing the fluid to be reabsorbed, or by exciting an inflammation within the sac leading to adhesion of the walls and obliteration of the cavity. Ab- sorption occurs occasionally in the young, and, as a rule, in acute hy- drocele spontaneously. The treatment is palliative or radical. Palliative treatment consists of tapping and acupuncture. Tapping. — First be satisfied of the position of the testicle. Then make the skin tense, and plunge in a well-oiled, fine trocar throuo-h the anterior part of the tumor, a little above the middle, holding the instru- ment with the index-finger placed firmly upon the canula at that point up to which it is desired to make it penetrate ; introducing it in a direction upward and outward, to avoid the testicle. The canula should fit tightly, else the tunica vaginalis may be pushed before its shoulder. A knowledge of the posi- tion of the testicle insures the operator from in- juring it. In withdrawing the trocar, push the canula a little farther into the cavity of the sac, and be sure that it is there by freely moving its extremity in every direction. If the end of the canula touch the testicle or cyst-wall, there will be no flow of fluid. This simple operation will always efface the tumor at once, but in the majority of instances the sac will begin to refill in a few days, and after some weeks, or at most months, will have regained its previous size. Sometimes the tumor never refills, and the palliative operation thus becomes radical. This rarely occurs except with children, and very recent hydroceles. The chances of obtaining this fortunate result are greatly increased if the inside of the sac be roughly scratched with the point of the exploring-needle or the trocar, after the fluid has been drawn off. If the patient is old, or greatly de- bilitated, he should always rest for a few days after tapping. The con- stant stretching of the skin by a large hydrocele renders it prone to take on gangrenous inflammation. Sir Astley Cooper mentions two cases of inflammation with sloughing, followed by death, in old men who took a long walk immediately after the operation. It is well also if the collection of fluid is very large, especially if the patient is old, not to draw it all ofi^ at one sitting. If the testicle has been wounded, the patient will complain of great pain, and blood will flow after the serum has been evacuated. Under these circumstances it is advisable to strap the testicle with adhesive plaster, immediately after the operation, to prevent the further effusion of blood into the sac, as this is favored by the removal of pressure. The 26 Fig. 12S.-(J/arf!Sf.) 402 DISEASES OF THE TESTICLE. pressure by strapping is said to favor adhesion of tlie sinfaces of the tunica vaginalis. Collodion is recommended by some authors to com- press the testicle in this and other conditions, but it ■will not do for all cases, as its application to the thin and sensitive integument of the scrotum sometimes gives rise to exquisite and prolonged torture. Acvpuncture. — This consists in making the skin tense over the tumor, and penetrating the sac rapidly a number of times with a needle, which should bs rotated as it is being withdrawn. The serum, in cases so operated upon, gradually escapes into the scrotum (in twenty-four to forty-eight hours), where it does no harm, and whence it is absorbed. The adult hydrocele will usually fiU up after this operation, as it will after tapping, but the hydroceles of children often remain radically cured, especially if the internal surface of the sac be scratched. If the cyst-wall be thick, and the tumor not translucent, neither tapping nor acupuncture wiU ever effect a cure. Healthy young patients can put on a suspensory bandage, and resume work at once, after tapping or acupuncture. Radical Treatment. — ^External irritation or stimulation of the skin will often suffice to cure a simple hydrocele in a young child. Tincture of iodine, at about half strength, may be used, or a lotion, recommended by Curling, of hydrochlorate of ammonia |j, distilled vinegar |iv, water § vj ; in fact, any mildly stimulating ointment or lotion will do. It is a waste of time to try this treatment upon the adult. Although chronic hydrocele has been known to subside spontane- ously in the adult, yet this termination is of so rare occurrence that practically it may be said never to happen. Sometimes the sac becomes ruptured by accident, inflammation follows, and the cure is permanent. That this is not an inevitable result is proved by a case reported by M. Serres,' of a Spaniard, who was accustomed to ride horseback, or per- form some other violent exercise, when his hydrocele became uncomfort- ably large. In this way he had ruptured it thirty times, remaining well for a considerable period after each application of this rather severe treatment. Of the many methods of treating simple hydrocele, only two need be detailed, as they are applicable to all cases, namelv, injection and incision, including excision of the tunica vaginalis. A small seton may sometimes be permitted in the case of a child, but for the adult it ranks with tent and caustic, as too severe. Subcutaneous scarifica- tion is equivalent to puncture and simultaneous scratching of the inside of the cyst. Of late years galvano-puncture has been greatly vaunted as a radical treatment for simple hydrocele. It is but little better than simple tapping, the advantage being that the puncture made by the negative needle tends to remain patulous for some time after the needle has been withdrawn, allowing the fluid to escape, and that the irritation starting from this point is sometimes sufiScient to induce ' Quoted by Curling, op. eU HYDROCELE— TEEATMENT. 403 enough adhesive inflammation to close the sac. The modus operandi is simple, and consists merely in introducing two needles at opposite points into the tumor, and passing a mild galvanic current, without causing too much pain, for about half an hour, being sure that the points of the needles do not come into contact with each other, or with the testicle. The number of cells used is regulated by the sensations of the patient. No after-treatment is required.' Injection. — All simple hydroceles which are translucent, no matter what their age or how great their size, are amenable to treatment and cure by injection. Injection is not appHcable to cases where the con- tents of the tumor are sero-purulent or sero-sanguinolent, or where the tunica vaginalis is extensively thickened, with or without calcareous deposit {see Case XXIX.) ; under these circumstances adhesion cannot be excited by injection ; suppuration is more apt to occur, and incision or excision should be resorted to. Hydrocele with syphilitic testis should not be injected. The following type case will illustrate the point : Cask XXTIII. — A middle-aged, apparently healthy man, presented himself for treat- ment of a moderately-sized hydrocele. The fluid had already been drawn off by a surgeon, and the cavity injected with iodine. The result had been purely negative. After the hydrocele had been tapped and the fluid evacuated, the testicle was found to be a little over-sized, hard, smooth, and to possess the general characteristics of a syphilitic testis. Further questions made out a syphilitic history. Consequently, no injection was made, but the sac was allowed to refill. A few months of anti-syphilitic treatment cured the hydrocele, as well as the disease of the testicle giving rise to it. Celsus alluded to injections as a method of treating hydrocele, but Munro, of Scotland, Sir James Earle, and Sir James Ranald Martin, of England, are the names most prominently connected with it. Inflation with air has been employed, and the most varied substances have been used in injec"tions, from distilled water to the strongest acids, hot and cold. Many substances have been employed successfully, such as spirits of wine, port wine, solutions of alum or sulphate of zinc, air, chlorine gas, lime-water (which Curling strongly recommends) ; but, better than all these, is the tincture of iodine, introduced by Martin. This is stimu- lating enough without being too irritating, and usually causes no harm if some of it escape into the connective tissue of the scrotum — an ad- vantage which most other injections do not possess. If a mild injection be required, the compound tincture may be employed, diluted one-half with water, otherwise the pure compound tincture should be used. A hydrocele should never be injected when first seen. Tapping ' To test this method, I selected two cases in young healthy subjects, one of spermato- cele, the other of simple hydrocele. The testicle was perfectly healthy in both cases, and the wall of the hydrocele very thin. Stohrer's battery was used, and as strong a current passed as the patients could bear— in the one ease sixteen, in the other, eight cells, the current was passed for nearly three-quarters of an hour in each case. In one, a slight, cutaneous slough appeared at the point of entrance of the negative pole. The result in both cases was entirely negative. The tumor subsided to a great extent m a lew hours, but refilled rapidly, no permanent benefit ensuing. — Ketes. i04 DISEASES OF THE TESTICLE. should be tried first, and perhaps the fluid will never reaccumulate. When the tumor contains more than ten or twelve ounces of fluid, injec- tion ought not to be practised until its size has been reduced by repeated tappings, assisted bj pressure to lessen the extent of the secreting surface. If this cannot be eSected, the patient will be vrise to submit to frequent tapping, and give up the idea of radical cure, for there is danger in ex- citing a very extensive serous surface to inflame, and it is not justifiable to perform an operation which may compromise life for a disease which is perfectly benign. If the hydrocele is found to contain more or less blood, injection should be postponed until some future tapping yields a comparatively limpid fluid. If syphilitic or tubercular disease be found, injection is inadmissible. To inject the tunica vaginalis, proceed as follows : Puncture with a trocar of suitable size. Be sure, by moving the end of the canula, that the instrument has penetrated well within the cavity. Allow all the fluid to run off. Examine the testicle thoroughly. If it be much larger and harder than natural, or in any way sensibly diseased, do not inject. Some hardening and thickening of the epididymis alone does not contra- indicate injection. The amount of tincture of iodine thrown in should equal about one-half the quantity of fluid drawn off. It should be thrown in gradually, retained several minutes, and worked around in such a way that every portion of the inner wall of the sac may come into contact with it. The fluid is then allowed to run off, and the canula withdrawn. Great pain, with nausea and sickness, is often experienced while the injection is within the sac. The pain may continue for several hours, ex- tending to the abdomen and thighs. Occasionally no pain is felt. The pulse sometimes falls, and there are evidences of shook. The amount of pain experienced is no criterion of success, but rather the reverse. Care should be exercised not to throw in any air ^^nth. the injection, as this would prevent contact of the fluid with the walls of the sac. The more concentrated the solution, the more plastic is the inflammation which follows. A healthy man may walk about until pain compels hiiii to keep quiet ; weak or feeKe patients should remain in Aed for twenty- four hours after the operation. At the end of this time the testicle will commence to get large and hard, the scrotum becomes oedematous, and there will be more or less reaccumulation of fluid. The patient will often consider himself more hurt than benefited by the operation at first. If the inflammatory reaction is not very painful, the patient may go about with a suspensory bandage ; if it should not come on at all, or is very slight, the testicle should be squeezed and manipulated daily for a week or ten days, so as to increase the grade of inflammation. If, on the contrarj', severe inflammatory reaction sets in, the patient should be confined to bed with the testicle supported, perhaps poulticed. After four or five days, or sooner, the pain and swelling begin to subside, the fluid is absorbed, a harsh friction-sound can be produced by rub- HYDROCELE— TREATMENT. 4Q5 bing together the two folds of the tunica vaginaHs, and a permanent cure is effected in from three to six weeks or longer. A second operation is rarely necessary. In double hydrocele both sides should not be injected at the same sitting. In using solutions of iodine, metallic instruments should be dipped in oil before use, and in a solution of potash after- ward, or they will soon corrode. If the quantity of fluid which reaccu- mulates after operation be very great, keeping the surfaces covered with the plastic exudation too far apart, Lisfranc advises that it should be drawn off with a fine trocar, as in the operation of simple tapping. Incision must be employed where there exists the least doubt as to whether or not the tumor be hernia, where the walls of the tumor are very thick or calcareous, where its contents are sero-purulent or sero- sanguinolent, and where injection has failed. Unless tlie position of the testicle has been positively made out beforehand, the sac should be opened upon a director, otherwise a clean incision may be made from top to bottom anteriorly. If the walls of the sac are very thick, and especially if they contain calcareous plates, they should be cut away. A type case of the sort is the following : Case SXIX. — A healthy man of advanced middle age applied for treatment of hydro- cele. The fluid drawn by exploratory puncture was pellucid. Enough study was not bestowed upon the testicle afterward, and an injection of iodine was practised. Nothing peculiar occurred until the fourth or fifth day, when inflammation of a bad sort came on attended by high fever and depression. The scrotum became purple, the testicle large, hard, and tender. This excessive inflammatory reaction, -with general depression, was met at once by laying open the tunica vaginalis from top to bottom. Now, upon intro- ducing the finger through the wound, the sharp edges and spicule of the calcareous plates could be distinctly felt. The parts were dressed with warm water, and allowed to digest for several days, after which, when the general condition had improved, the thick- ened calcified walls of the tunica vaginalis were cut away, and a cure followed, without other bad symptoms. The wound is to be dressed looselj' with lint or oakum, and the pa- tient kept in bed with the testicle supported. Suppuration will be estab- lished by the fourth or fifth day, when the dressing should be removed by syringing with warm water, and reapplied daily. The wound now be- comes a simple granulating cavity, and is to be treated as such. The patient is confined to bed from two to eight weeks. Incision is the most ancient of all the methods of treating hydrocele. It is too severe an operation for general application, and should not be resorted to ex- cept to meet the conditions above enumerated. CONGENITAL HYDEOCELE. In congenital hydrocele there has been only a partial obliteration ot the peritoneal prolongation at its neck, and, instead of the usual solid, thin, fibro-oeUular cord (Scarpa's habenula),we have an open canal mak- ing the cavity of the tunica vaginalis continuous with that of the peri' 406 DISEASES OF THE TESTICLE. tonEBum. The abdominal serum gravitates into this cavity, and hydro- cele is the result. The diagnosis is usually easy, but in certain cases there is some chance of confusion with hernia. Congenital Hydrocele. 1. Appears soon after birth. 2. Tumor continues into inguinal canal. 3. Receives impulse on coughing. 4. Flatness on percussion. 5. Always reducible at an even rate, more or less rapidly according to size of opening; no jerk. 6. Testicle, entirely obscured by the tu- mor, reappears on reduction of the latter. 1. Feel soft, not doughy. 8. Always translucent. Hernial Tumor. 1. May appear at any time. 2. Same. 3. Same. 4. Eesonance on percussion. 5. If reducible, goes back suddenly, with a gurgling sound. 6. Testicle can usually be made out as a distinct lump. 1. Doughy feel — perhaps gurgling, on manipulation. 8. Never translucent. A simple hydrocele may coexist with hernia, at any time of life, and it is not uncommon for congenital hydrocele to be complicated by congenital hernia (Fig. 129). Congenital hy- drocele may be found in adults, but is rare. Treatment of Congenital Hydrocele. — The fluid need not be reduced, but a well-fitting truss must be applied. This wiU usually ob- literate the neck of the sac, and is Nature's method of accomplishing cure. The fluid will be absorbed in from two to eight months after closure of the neck of the sac. If not ab- sorbed, the case, after the neck is closed, may be treated as simple hydrocele. Complication with hernia does not call for any modification of treatment. Congenital hydrocele should never be injected. Desault and Dupuytren did inject congenital hydrocele with a stimulating fluid, making, at the same time, firm pressure at the ring. This treatment, sometimes suc- cessful, has also been followed by fatal peritonitis. Fig. 129.— (Jfaciise.) HYDROCELE OP HERNIAL SAC. An old hernial sac may become obliterated at its neck by wearing a truss, or by becoming plugged up by a portion of small intestine, or a piece of omentum. This old sac may fill with fluid, and thus become hydrocele of the hernial sac. The diagnosis is made mainly by a study of the history of the case. Treatment. — Injection is not allowable. A careful incision is to be SPERMATOCELE. 4.07 made, the fluid evacuated, and any portion of intestine or omentum blocking up the neck returned into the abdomen. Dress with lint. SPTTRIOTJS HTDROCELE OP HERNIAL SAC. This is a considerable accumulation of fluid around an incarcerated hernia. Treatment. — Incision and operation for reduction of hernia. The fluid in true and in spurious hydrocele of the hernial sac is usu- ally dark colored. ENCYSTED HTDROCELE OE THE TESTICLE. Simple cysts, developed out of the pedioulated or non-pediculated hydatids (so called), sometimes containing spermatozoa, are found about the head of the testicle. They may be found within simple hydrocele, and it is by the bursting of one of these cysts into the cavity of an already-distended tunica vaginalis (or its puncture during operation) that the contents of hydi-ocele contain spermatozoa (spermatic hydro- cele). On this point Virchow and Gosselin are in accord. Suoh cysts may be treated by incision or injection. SPERMATOCELE. Spermatocele is a collection of serous fluid, containing spermatic elemelits, either in the tunica vaginalis or in a cj'st situated near the head of the testicle. The title has been inappropriately bestowed upon another condition, which may be briefly disposed of. When the sexual appetite has been kindled and kept excited for some time without being gratified, seminal fluid, which has been produced and is collected in the testicle, vas deferens, and seminal vesicles, will usually be discharged in an involun- tary emission at night, and no inconvenience will be felt beyond slight aching, and increase of size of the testicle. Sometimes, however, Nature fails to relieve herself, and then the testicle becomes large, hot, and excessively tender, the epididymis is distended and knotty, the whole cord tender and tense, the scrotum red, the sufi^ering very considerable, and the testicle, apparently, about to become acutely inflamed. The origin of the mischief can always be ascertained. A cure follows a natural discharge of the excess of semen, or may be brought about by rest, elevation of the testicle, and cooling lotions. This derangement does not deserve the name of spermatocele. It might be called spermatic congestion. Listen (1843) and Lloyd (1849) first found spermatozoa in the fluid of hydrocele. Spermatic hydrocele does not exist, except in an encysted form, or secondary to it. Although a tumor may resemble hydrocele 108 DISEASES OF THE TESTICLE. n all respects, yet it may yield, on puncture, a milky fluid containing spermatozoa. In such cases one of two accidents has occurred : 1. An encysted spermatocele, jutting out within the tunica vaginalis, md obscured by its fluid, has been punctured during tapping of the atter, and thus allowed a mingling of spermatic elements with the other ;ontents of the hydrocele. 2. The cystic spermatocele has ruptured early in its formation, dis- ;harged its contents into the tunica vaginalis, and continued on furnish- ng spermatozoa mixed -with the fluid of the hydrocele (Virchow, Gos- ielin). There exist iiormally upon the head of the epididymis several little prominences,' solid and cystic, known as the hydatid of Morgagni or pediculated hydatid, corpus innominatum of Giraldes, and non-pedicu- ated hydatids. They are the remains of the WoliBan body, and of the luct of M-Qller. From one of the non-pediculated hydatids, undoubtedly spermatocele is formed." " KosenmiUler, " Qufedam de ovariis Embryonum et Foetuum humauorum," Lipsias, 1802. Sobelt, "Der Neben-Eierstock des AVeibes," Heidelberg, 1847. Muller's "Physiology," )y Baly. Yirchow, "Die Krankhaften Geschwiilste." Strieker, " Manual of Histology," imerican edition ; and "Todd's Cyclopaedia," toI. v., Supplement, Art. "Parovarium." 2 The testicle is developed in the foetus, near the AVolffian body, but independent of it. This Wolffian body consists of a set of tubes, all of which open into the duct of the Wolffian )ody. The duct terminates in the uro-genital canal. This duct becomes finally the vas ieferens in the male (in the female it atrophies). Of the tubes forming the Wolffian body he central ones unite by open ends (vasa recta) with the testicle. They become the coni rasculosi, and connect the testicle with the canal of the epididymis. Of the lower CEecal lUbes of the Wolffian body, not connecting with the testicle, some atrophy, and others one or more) become developed into the vasa aberrantia of Haller, while the upper tubes itrophy, or become converted into non-pediculated hydatids (so called) ; in other words, limple little cysts at the head of the epididymis. The corpus innominatum of Giraldes, t convolution of small tubes, shut at both ends, is another remnant of the Wolffian body, 'n the female, all the tubes of the Wolffian body continue cjecal. They constitute the )arovarium of Eosenmiiller, and furnish the little cysts so often existing normally in the iroad ligament, near the outer border of the ovary. Besides the duct of the Wolffian body, there is found in the foetus another tube, begin- ling in a blind extremity running over the tubes of the Wolffian body, but not connected vith them or with their duct, to which it runs parallel, and emptying by a separate orifice Eto the uro-genital canal. This is the duct of MuUer. In the female it forms the Fallo- )ian tube. Its extremity becomes fimbriated, and its blind end atrophies or remains as a imall, pediculated hydatid. In the male it atrophies, its blind extremity often persist- . ng as the hydatid of Morgagni (so called), a pediculated cyst at the head of the epididy- nis. Its length lies along the border of the epididymis, as an atrophied thread, som'e- itnes showing hydatidiform swellings, whiie its other extremity is represented by the pros- atie utricle. This insight into the origin of the little cysts found normally at the head of the epdidy- nis explains why we sometimes have developed there a simple cyst, and sometimes'a ipermatic cyst. If the hydatid of Morgagni or one of the hydatidiform swellings of the itrophied duct of Miiller should become enlarged into a cyst, we should have a simple cyst, or the duct of Miiller never possessed any connection either with the testicle or with the iVolffian body. If, on the other hand, one of the far more numerous cysts, the remains of he upper blind tubes of the Wolffian body, should enlarge, it is easy to see how the connec- ion which originally existed between this blind pouch and the duct of the Wolffian body now canal of the epididymis and vas deferens) might be reestablished (ornevefhave )een closed), and seminal elements find their way into the cyst, especially if there were ome stricture of the canal of the epididymis or of the vas deferens. In the same way, f one of the vasa aberrantia should enlarge, we might readily have spermatocele. It has )een supposed that some of the tubuU of the testis itself may become enlarged into a permatocele, but this has never been demonstrated. HYDROCELE OF THE COED. 409 It tends to increase in size indefinitely. It may coexist with hydro- cele, and be masked by it. It may be broken early by accident, and, continuing to secrete, form spermatic hydrocele, or it may be punctured with the trocar, when a supposed simple hydrocele is tapped. Symptoms of Spermatocele. — "When complicating simple hydrocele and jutting into the cavity of the latter, there are no symptoms by which spermatocele can be distinguished. Uncomplicated, it has peculiar features. Usually a slight uneasy sensation is experienced near the head of the epididymis, not amounting to pain, often entirely unnoticed, or at least forgotten by a patient who may afterward find the little tumor by accident. If seen early, an undefined sense of thickening with extra resistance is distinguishable by the finger, in the region of the top of the testicle. This goes on increasing, usually, at so slow a rate that the patient soothes himself with the idea that it will become no larger. It grows, however, constantly, and may attain a large size. There is no pain, except a slight dragging on the cord. The cyst keeps its position at the upper end of the testicle, and becomes gradually heart-shaped, the testicle lying belpw at the point, the cyst sometimes notched above. The walls are usually thin and tense, so that fluctuation cannot be always distinguished, but translucency is usually present. The fluid may be dark colored or very milky, somewhat masking translucency. The patient is very apt to become hypochondriacal, and to imagine that his sexual appetite and power are failing. On tapping such a cyst, the fluid will usually be found milky or dark colored, and the microscope readily detects spermatic elements, often exhibiting lively movements, with others more or less decomposed, many oval heads without the tails, blood, granular and fatty matter, and some granular pigment and epithelial cells. The diagnosis can never be pro- nounced with absolute certainty until the microscope has detected sper- matic elements in the fluid. Treatment. — After tapping, a spermatocele will invariable refill. The proper mode of treatment is by injection or by incision, as in hydrocele. HYDROCELE OF THE SPEEMATIC COBD. Hydrocele of 'the cord is either difi^use (infiltrated) or encysted. The spermatic cord is enveloped in a loose layer of connective tissue, which is continuous with the external and internal connective-tissue envelope (perimysium) of the abdominal muscles, starts at the external abdominal ring and surrounds the whole cord, the epididymis and the testicle, being firmly attached to the latter at its lower end, and inseparable from the refleerted tunica vaginalis propria. The cremaster muscle is spread out upon its external surface. This loose connective tissue is described by anatomists as a separate fascia, and is called tunica vaginalis commrmis. The meshes of this tunic sometimes become the seat of a diffuse :10 DISEASES or THE TESTICLE. erous infiltration (first described by Pott) constituting infiltrated hydro- ele. Scarpa has described it as a simple oedema. Boyers recognizes t as a special form of hydrocele. Vidal doubts its existence, and Pitha lever saw it. It is very rare. Curling believes it may occur in general nasarca, and saw it once complicating acute orchitis. It is mainly in- eresting from its liability to be confounded with omental hernia. The ymptoms readily differentiate it from ordinary hydrocele. Symptoms. — The swelling is uniform, round, and smooth, the infil- ration occupying the meshes of the connective tissue ; toward the base here may be one large cavity. There is no communication with the avity of the tunica vaginalis propria. Enlarged inguinal glands or -ny obstruction to the return of blood from the testis, may act as lauses. The swelling ceases, according to Pott, just where the vessels inter the testicle, the latter organ being isolated from the general iweUing. The tumor becomes more cylindrical in shape in the supine )osition, but it does not disappear. Pressure makes it recede upward lUghtly, but it returns in any position of the patient. The penis never ippears so much retracted as in simple hydrocele of equal size. Diagnosis is with omental hernia. The latter, however, when re- luced, will remain in the abdomen until the patient stands up, while the lydrocele will return ia any position (Pott). The surface is firmer in ipiplocele, and the swelling larger above than below. Hydrocele is not o entirely reducible, and receives no impulse on coughing. In irredu- lible epiplocele the diagnosis is difiBcult, at times impossible. Fluctua- ion can be felt at the bottom, but not at the top, of diffuse hydrocele, rhe enlargement extends to the ring. The shape is rather pyramidal, )ut can be somewhat altered by pressure. Treatment. — Palliative punctures may be made at the bottom of the iwelling. Large incisions are dangerous. Pott lost a case in this way. iVlien a diagnosis with omental hernia is impossible, and an operation leems advisable, an exploratory incision may be practised. ENCYSTED HYDROCELE OP THE CORD. Cysts may form along the cord in the habenula (remains of peritoneal Drocess from the abdomen to the tunica vaginalis) when its occlusion has )een imperfect at certain points. The " hydrocele en chapelet " of Cloquet s so formed. Again, cysts may be developed at any point along the ;ord, in its connective tissue, or in the meshes of the txmica vaginalis ;ommunis. They vary in size from a pea to a hen's-egg, or larger, rhey are usually tense, smooth, oval, the long diameter parallel to the axis )f the cord, translucent, sometimes fluctuating, although the tension of ;he cyst usually makes this sign valueless. Pain is absent or insignificant. The cysts usually occur between the external abdominal ring and the «stic]e, but may also be found in the inguinal canal. In the latter situ- INFLAMMATION. ^jj »tion it is sometimes impossible to distinguish such a tumor from in complete inguinal hernia, without an exploratory herniotomy. When the cyst occupies this position, whether in the male on the cord, or in the female on the round ligament, unnecessary fear and anxiety are' often excited in regard to hernia, and a truss or some other retaining bandage- is usually applied. This always gives rise to pain, and considerably ag- gravates the trouble. Treatment—For large encysted hydrocele of the cord, injection, as in simple hydrocele, is the best treatment. Injection is inadmissible when the cysts are strung out and communicate, as the result would be necessarily imperfect. For small cysts, whether single or multiple, in- cision is the best treatment, care being taken to avoid wounding the constituents of the cord. Incision is indispensable for cysts situated within the inguinal canal, or where there is any doubt as to hernia. A fine seton may be used successfully in most cases external to the ring, where the cyst is small, the thread being left in till inflammation has consolidated the tumor. The patient need not keep his bed, but should wear a suspensory bandage. HEMATOCELE of the cord is rare, but may occur in the same way as hsematocele of the tunica vaginalis, usually after injury. Indications for treatment are the same. CHAPTEE XXIV. DISEASES OF TEE TESTICLE. Inflammation, — Orchitis. — Causes.— Symptoms. — Pathological Clianges. — Prognosis. — Treatment. — ^Epi- didymitis. — Frequency and Date of Appearance in Gonorrhcea. — Causes. — Symptoms. — Sterility as a Result of Epididymitis, — ^Diagnostic Table of Orcliitis and Epididymitis. — Treatment of Epididymitis. Inplammation' of the testicle may be limited to the epididymis (epi- didymitis), or may attack the secreting structure alone (orchitis). This has been explained by the fact that the arterial supply is diiferent for the different constitutents of the testicle. Sometimes both parts inflame simultaneously — as after injury. The secreting structure may become secondarily involved by a simple inflammation commencing in the epi- didymis, but the latter rarely suffers in connection with primary, true orchitis. The sub-serous connective tissue of the tunica vaginalis being in direct continuation with the connective tissue of the epididymis, in the vast majority of cases of epididymitis also becomes inflamed, con- stituting peri-orchitis, or acute hydrocele. Peri-orchitis, on the other hand, is rarer with inflammatory orchitis, since the dense structure of the tunica albuginea keeps an inflammation originating on one side of it from being rapidly transmitted to the other. 12 DISEASES OF THE TESTICLES. OBCHITIS. Causes. — True orchitis is very uncommon. As complicating mumps io-called metastatic orchitis) no rational theory has been advanced to 3count for it. Observation abundantly proves that it occurs in at least ve per cent, as a complication of mumps in young adults, and the fact lust be accepted without explanation. It has been noticed, indeed, uring the prevalence of an epidemic of mumps, that cases of orchitis ocur spontaneously in some patients vchose parotids escape.' Orchitis ue to mumps is most often observed at about the age of puberty. It 3mes on near the end of the first vreek of the mumps, and is usually anfined to a single testicle. The epididymis is perhaps also involved, ut may escape. The affection runs a quick course of about a week or ;n days, very rarely terminates in suppuration, usually subsides without saving any impairment of the organ behind, but is sometimes followed y atrophy. Orchitis, after severe injury to the testis, is not uncom- lon. It tends to terminate in abscess or gangrene, and to be followed y atrophy, with loss of function of the organ. Orchitis as a result of aid is possible. Case XXS. — A young gentleman, in perfect health, one summer evening sat out upon is door-step, and felt the cold stone through his pantaloons as his testicles rested upon . The following day acute true orchitis of the right side set in, and passed through its ^lar stages without suppuration. Complete atrophy followed. The swellmg continued I decrease in size, until nothing but the stump of the epididymis was left attached to the )rd. The other testicle escaped. Afterward the remaining healthy testis became the ;at of epididymitis during the course of a gonorrhoea, greatly to the patient's alarm, but lis swelling subsided in due course, and got well without harming the testicle in any ay. The patient afterward married, and impregnated his wife. Sometimes orchitis comes on in children, and even in adults, where o sufficient cause can be assigned. Excessive sexual excitement has een adduced as a cause. Very rarely orchitis complicates variola or y^phoid fever. A low grade of true orchitis, located in the fibrous cov- ring of the organ, is liable to attack gouty individuals. Orchitis may ome on secondarily during epididymitis. Occasionally, especially in le old or enfeebled, true orchitis originates spontaneously in patients aving chronic inflammatory urethral or prostatic disease. Case X5XI. — In 1868, a gentleman of seTenty-five, with an enormous prostate, who id been obliged to employ the catheter constantly, for many years, in order to empty is bladder, failing in health during the cold of winter, was suddenly seized with a swell- ig of the right testicle, which became exceedingly painful, but not very large. The veiling remained stationary for a number of days, when the patient had a sharp chill, fter a few days more the organ began to grow larger, the scrotum adhered in front, actuation became apparent, and an incision gave exit to a large collection of matter from le substance of the testicle. In 1872, the testicle was considerably atrophied, and a fis- ila remained. The patient died of apoplexy in 1873. Case yxXTT . — In 1870, a gentleman of very gouty habit, who also had enlarged pros. ' Medical Times and QazMe, voL xix., p. 512. ORCHITIS— SYMPTOMS. 413 tate, -was attacked by a subacute cystitis of the neck of tlie bladder, and ran down in health. He was obliged to continue the use of his catheter. Both testicles swelled, one shortly after the other, and, after much pain and suffering, abscesses formed in the sub- stance of each. The epididymes and tunicse vaginales were also, in this case, simultane ously affected with the secreting structure of the testis. Symptoms. — la true orchitis the increase in size of the testis gener- ally advances rather slowly, and seldom becomes considerable until the affection has lasted a length of time. This is accounted for by the un- yielding nature of the albuginea, and the fact that there is usually no effusion into the tunica vaginalis. The pain is explained in the same manner. It is often excruciating, and always out of proportion to the amount of swelling. It has been compared to that of nephritic or he- patic colic. No position gives rest, and any handling of the organ is liable to induce syncope. The irritated cremaster contracts upon the sensitive testis, and draws it up toward the groin. The pain continues high for several days, and then gradually becomes more bearable, or it may suddenly cease altogether. This last circumstance is gratifying only to the patient. The surgeon learns it with regret, for he knows that it means mortification of the organ. The shape of the testicle is rarely altered in orchitis ; it is smoothly, regularly ovoid. The epididymis is not distinguishable from the rest of the tumor. The organ feels peculiarly indurated, the natural elastic feel having entirely disappeared. The scrotal tissues are often red, swollen, cedematous, inflamed. There is a strong tendency to suppuration or mor- tification, the latter marked by a sudden cessation of pain. The former is often announced by the occurrence of chill. After the chill the testicle commences to enlarge more rapidly, the scrotal tissues adhere to its sur- face, and, after a period longer or shorter, according to the depth at which the matter forms, a soft, fluctuating spot, surrounded by indurated borders, indicates clearly the position of the purulent collection. After the pus has escaped, all the severity of the symptoms abates, unless a second purulent collection exists in some other part of the gland. The flow of pus gradually diminishes. As it decreases, the swelling subsides, and partial or total atrophy of the testicle ensues, with perhaps a fistula remaining open for years. Sometimes exuberant granulations grow up out of the opening, forming a cauliflower excrescence (hernia testis), which may reach considerable size, and, growing as it does out of an enlarged, hardened testicle, perhaps at this stage irregularly lumpy, and containing some softer spots, while at the same time the glands in the groin may become enlarged, hardened, and tender, and the general health decline — all this array of symptoms is very liable to give rise to a sus- picion of cancer — a suspicion which the result does not justify. Sometimes an abscess forms centrally in true orchitis, and never comes to the surface. In such a case the symptoms run a despairingly slow course, but the hard and tender organ gradually reduces in size, undergoes chronic inflammatory induration, while the purulent collection Hi DISEASES OF THE TESTICLE. gradually becomes solidified, surrounded by a tough capsule ; perhaps cretifies and so remains indefinitely, the function of the testicle being destroyed, unless the purulent collections have been very smaU. A somewhat similar state of affairs may succeed deep abscess, which has discharged and remained fistulous for a considerable time. These testi- cles remain long the seat of chronic pain, and are liable to repeated out- breaks of inflammation. Pathologicai Changes. — On section, it is usual to find a concrete mass of more or less solidified pus in some portion of the organ, sur- rounded by a distinct fibrous capsule, while the contiguous structure of the testicle is modified by chronic inflammation, perhaps degenerated into a fibrous mass. Concrete pus is distinguishable from cheesy tubercle in that the latter usually lies not encapsulated in direct contact with the seminal tubules, which, though atrophied by pressure, are in other re- spects sound. The yellowish, gummy (syphilitic) tumor is distinguishable from concrete pus in not being (strictly) encapsulated, being usually ho- mogeneous, consistent, tough (not friable, like concrete pus), and being infiltrated through the convoluted tubes. Teemhtations. — When orchitis terminates in gangrene, after adhe- sion of the scrotum, the slough makes its way through the skin, and is found to be not black, or brown and fetid, like an ordinary slough, but yellowish, dry, and soft. It is a sort of dry gangrene, a necrosis, as Ri- cord calls it, and the slough may be pulled away in long filaments, con- stituted by the dead seminal tubules. Finally, two other terminations of orchitis are encovmtered : 1. Resolution, with a return of the organ to its full functional power. 2. Atrophy, without either necrosis or suppuration. The general symptoms in true orchitis are marked, often severe : slight chills, pretty high fever, anorexia, nausea, vomiting, hiccough, constipation, sleeplessness, anxiety, great nervous irritation. The gen- eral symptoms have been compared to those of strangulated hernia, and, indeed, there is strangulation of the testicle within its tight, fibrous sheath. Prognosis is always grave ; the most energetic treatment is called for, to keep off impending destruction of the organ. Treatment. — Rest on the back in bed, with the testicle supported in a sling, is essential to even moderate comfort. The patient needs no urging to keep him lying down. If the case is seen early, some of the large scrotal veins should be opened, and the bleeding encouraged, by causing the patient to sit in a hot bath, or ten to fifteen leeches may be applied in the neighborhood of the abdominal ring. If seen at the very commencement, it might be allowable to try the constant application of ice-water in bladders, but this expedient has little or no influence over inflammation once under way in the testicle. The constipation which always exists should be combated. The testicle may be enveloped in EPIDIDYMITIS. 415 strong belladonna-ointment, or a paste composed of powdered opium and glycerine, or, if the pain be not too excruciating, in a light tobacco poultice. In short, the organ must be narcotized and held suspended by an appropriate sling, so that the venous blood may be assisted in draining out of it. The diet should be low, non-stimulating, easily digestible. The early employment of these means gives the testicle its best chance. If in spite of them the symptoms fail to abate, in short, on the slightest suspicion of impending gangrene, or in any case where the symptoms run very high, it is wise to resort without delay to sub- cutaneous section of the tunica albuginea, to take off tension from the strangulated parts within. This simple operation is readily performed with a sharp tenotomy-knife introduced through the skin, and then made to cut the tense fibrous capsule, while the testicle is steadied in the other hand. The incisions should be carried fairly through the tunica albuginea, several short cuts being made at different points on the sur- face of the testicle (three to six), not over two or four lines long. In this way the tension being relieved, the pain will usually cease, and a continuance of the means above enumerated will probably lead to reso- lution. If abscess form, puncture should be made on the first appearance of fluctuation. In sphacelus, carbolized water-dressings are advisable. Nature and time alone are able in many cases to close a fistula of the testicle, left behind by the opening of an abscess. All that art can do is to make the opening a depending one, slit up sinuses, keep the parts clean, apply some stimulating lotion or injection to the sinus, and build up and maintain the patient's general health. In benign fungus (hernia testis), besides the above means applied to the opening from which it grows, the mass itself may be cauterized, cut or tied off, subjected to pressure by adhesive straps, or, preferably, after other diseased conditions have been subdued, the edges of the wound may be incised, freshened, and united by suture after the fungus has been replaced (Syme). Fungus should never be pulled upon, for fear of draw- ing out the entire contents of the testicle. In severe, long-standing cases, where a testicle is the seat of chronic induration full of fistulsB, or with large, obstinate fungus, castration is advisable, sometimes necessary, in order to remove from the patient a source of physical irritation, and to save him from serious injury to the general health. EPIDIDYMITIS. Epididymitis is the most common of all the diseases of the testicle. It occurs at all ages, most frequently during early adult life, and middle age, since its chief cause — urethral inflammation or irritation— most commonly exists during these periods of life. It has an acute form, but is very prone to run into the chronic state, and may be subacute from the first. It habitually terminates in resolution, rarely in abscess. One attack predisposes to another. It is often double, but the two testicles 416 DISEAIiES OF THE TESTICLE. are verj^ rarely simultaneously iavolved, one usually precedes the other by a number of days, or weeks, after which the disease sometimes returns to the testicle first invaded, chiefly in badly-managed cases. Foumier ' has never seen double simultaneous epididymitis, but that it may occur is proved by the following (personal) case : Case XXXm. — An old gentleman with retention from enlarged prostate, in the fall of 1871, shortly after beginning the habitual use of the catheter, was attacked with mild double epididymitis, both inflammations commencing, running their course, and terminat- ing simultaneously. Although the epididymis bears the brunt of the disease, it rarely suffers alone, except in very mild or chronic cases. In all acute attacks the tunica vaginalis is more or less involved, giving rise to acute hydro- cele, and sometimes the secreting structure of the testis takes fire as well. One particularly interesting feature of the disease is the fact, mainly brought out of late years by Gosselin, that the chronic indura- tion so often left behind in the epididymis by inflammation sometimes blocks up the tubes sufficiently to prevent the passage of the spermatic elements, thus entailing temporary and sometimes permanent sterility, without an accompanying loss of sexual power. Feeqtjexct of Epididymitis axd Date of its Appeaean-ce in GoNOEEHCEA, — Fournier states that epididymitis occurs about once for every eight or nine cases of gonorrhoea. In some individuals there seems to be a predisposition, so that every attack of the latter, not- withstanding the utmost care, is invariably attended by swelled tes- ticles ; while others, regardless of all hygienic precautions, go around with a raging gonorrhoea, employing perhaps no treatment, continuing sexual intercourse, and the abuse of alcohol, not even supporting the testicle with a suspender, and yet they escape. Foumier saw it de- velop, on the other hand, in a gonorrhoeal patient with typhoid fever, who had not put his foot to the ground for six weeks. Here the gen- erally shattered condition of the patient, brought about by typhoid fever, probably acted as a predisposing cause. It may, however, be stated dogmatically, that while a gonorrhoea of itself will sometimes, in spite of all precautions, occasion swelled testicle, yet this complication is not apt to ensue if the patient wear a suspensory bandage, abstain from violent or jolting exercise (horseback, dancing), and avoid bodily fatigue and efforts at lifting. Above all, sexual excitement or indul- gence, and the use of alcohol in any shape, must be interdicted. The passage of instruments through a canal subject at the time to gonoi^ rhoea is a sufficient cause for epididymitis. The power of the suppres- sive treatment of gonorrhoea by strong injections early in the disease, although somewhat active, has been overrated. It should, however, be borne in mind. Balsams and terebinthinates internally cannot give rise to the affection. ' Art. "Blennonhagie," " Diet, de Mdd. et de Chir. prat.," p. 211. EPIDIDYMITIS. 417 The remarks already made concerning the liability to epididymitis in gonorricea apply with about equal force to cases of stricture. Some patients suffer from the worst of the inflammatory sequences of strict- ure, but the testis escapes ; while in other oases, perhaps of mild type, one or the other epididymis will be constantly falling into trouble on the slightest provocation, until the normal condition of the urethra has been restored. The treatment of stricture by instrument may itself originate epididymitis. As to the date of occurrence of gonorrhoeal epididymitis, Fournier has a personal tabulation of 323 cases, of which there ocorured — In the first week Making in the first month .... 86 second C( 22 " second a .... 78 " third (( 34 " third " fourth .... 22 " fourth " fifth tt 30 .... 6 IL 29 fifth " sixth " seventh a 6 " sixth " seventh " eighth U 19 (( 4 (( . . 9 (( 3 il 21 " eighth " ninth (. 3 (( 4 later 10, of which in the seventh year 1 ; most of the latter cases depend evidently upon stricture. De Castelnau's exhibit,' derived from the statistics of four surgeons, shows a total of 239 cases, of which there occurred— 16 In the fourth 34 " fifth 24 « sixth 39 64 and later 72 In the first week. 16 In the fourth week. " second " " third " Unfortunately, this "and later" is deceptive, since it includes all cases of epididymitis due to stricture. It is probable tliat, as a rule, the time for the occurrence of epididy- mitis in gonorrhoea has been set down a little too late. In every-day practice it is perhaps nearly as common to find this complication before as after the sixth week. In a general way it may be laid down that epididymitis is to be looked for mainly from the third to the eighth week of gonorrhoea. Cawses.— Nearly all the causes enumerated as capable of producing orchitis may also exceptionally give rise to epididymitis: traumatic violence, cold. Case XSXIT.— In 1869, a coachman, driving during a cold rain, sat for some hours in a pool of cold water, which collected upon the leather cushion under him On the following day he was attacked by a perfectly characteristic epididymitis, which ran the usual course, without affecting the secreting portion of the testicle, and terminated m resolution. Prolonged sexual excitement has been enumerated, and gout, but ' Quoted by Bumstead. 27 il8 DISEASES OF THE TESTICLE. urethral inflammatiou or irritation is by far the most active cause. The most common form of this irritation is gonorrhoea, or urethritis, then stricture, finally any prostatic or urethral irritation, the passage of in- struments, especially through a urethra abeady affected by mild chronic inflammation or stricture, but occasionally where no appreciable disease exists, the use of the lithotrite, cutting operations for stone, retention of a smaU calculus or stone fragment in the prostatic urethra ; in short, any inflammatory affection of the prostatic sinus around the orifices of the ejaculatory ducts. It is probable, with all this last series of causes, that the mechanism of the cause is identical ; namely, that the prostatic sinus in the neigh- borhood of the orifices of the ejaculatory ducts first becomes inflamed, if only slightly, and that the inflammation, starting there, travels rapidly down the continuous mucous membrane of the vas deferens to the epi- didymis, where it locates itself. That this is son;ietimes the method of propagation is demonstrable by the course of the symptoms, and by the traces of inflammation occasionally found in the vas deferens after death; but in the vast majority of instances the inflammation, passing rapidly through the vas deferens, announces its course by no symptoms, and leaves no vestige of its presence behind. This has induced Brown- S^quard to deny that epididymitis is a transmitted inflammation, and to claim that it is a reflected irritation. He draws a comparison between the passing of a sound through a seemingly healthy urethra, or an in- flammation existing in the canal, and the subsequent epididymal swell- ing, and idceration of the small intestine after extensive peripheral bums. Fournier has cautiously emitted the theory that epididymitis may be a specific gonorrhoeal affection of the rheximatic type, like the gonorrhoeal (rheumatic) affections of the eye ; still this would fail to ac- count for epididymitis from the passage of an instrument or the lodgment of a stone fragment. To sum up briefly, the theory most plausible and best borne out by observed facts is, that epididymitis from urethral in- flammation or irritation is a direct but sudden transmission of inflamma- tion over a continuous membrane, from the orifice of an ejaculatory duct to the epididymis. This is further supported by the following facts: Epididymitis from gonorrhoea rarely comes on early in the disease, \m- less instruments or irritating injections have been used, but occtu-s tow- ard the end of the causing malady, just when the latter occupies the lower end of the urethra. The mucous membrane behind a tight strict- ure is always more or less inflamed, and this inflammation is liable at times, in bad cases, to run backward and affect the neck of the bladder. Under these circumstances, mild, continuous forms of epididj'mitis are not uncommon. The deeper down the urethra the stricture lies, the more apt is epididymitis to complicate it. Instrumental interference, or the retention of a stone fragment in the forward parts of the urethra, is very rarely attended by epididymitis, while this complication is not uncom- EPIDIDYMITIS— SYMPTOMS. 419 mon when the same irritation is applied to the prostatic portion of the canal. Si/mptoms.— Epididymitis may come on in an acute or a subacute form, the latter where the epididymis has previously suffered from a similar attack. First attacks, like first attacks of gonorrhoea, are usually the most severe. Epididymitis is ushered in by premonitory symptoms which precede the swelling by some hours. Gonorrhceal or gleety dis- charge is usually not visibly modified until after the testicle begins to swell. Then it becomes lessened, perhaps stops, to return again as soon as the inflammation of the epididymis is fairly on the decline. A vague uneasiness is felt in the testicle, and along the cord up into the back, as if the cord were being pulled upon. Attentive patients will frequently aver that the pain was noticeable in the groin for some hours before any uneasiness was experienced in the testicle. This fore- running inguinal pain is rarely absent where the epididymitis is of ure- thral origin — except in hospital patients, who are unintelligent observers. There is usually only a slight painful tension in the groin, but some- times it is very severe, extending around to the lumbar region, and up the back. Sometimes there is a sense of weight in the perinaeum, fre- quent desire to urinate, with perhaps pain and diflBculty in the act. Occasionally a chill, with febrile action, will usher in the afiection, but these symptoms are far more constant with orchitis. Whether any of the foregoing symptoms have attracted attention or not, within a few hours decided pain is felt in the testicle, attended by a rapid increase in size. The amount of pain and swelling varies in dif- ferent cases. In the subacute form of patients with strictm'e, the swell- ing is moderate, comes on rather slowly, palpation at once distinguishes the heat, sensibility, and hardness of the epididymis, and that the tes- ticle itself is less affected. Peri-orchitis is absent, or not marked. There is but little, if any, fluid in the tunica vaginalis, or it may be felt loosely in the sac, not causing any considerable distention. With such mild cases there are no general constitutional symptoms, and the pain is not excruciating. It is aggravated by the erect posture, but wholly disap- pears after the patient has been on his back, with the testicle elevated, for a few moments. The scrotal structures escape implication. But the picture changes vastly for the onset of an acute attack. The swelling commences promptly, and increases with rapidity. First it is localized posteriorly, but soon the subserous connective tissue of the tunica vaginalis carries the inflammation to the latter structure, which rapidly inflames, pouring out a plastic material upon its surface, and a sero-sanguinolent fluid into its cavity, which becomes rapidly tense and distended, greatly adding to the pain. The secreting structure of the testicle is often distended fully with blood, but is not the seat of any pathological changes. The scrotal tissues inflame and become oedema- tous, large veins sometimes appearing on its surface. Yet, even under 420 DISEASES OF THE TESTICLE. all these disadvantageous surroundings with an oedematous scrotum, and a tenselj-fiUed tunica vaginalis, careful examination will rarely fail to localize all the hardness and most of the pain in the epididymis. The inflamed mass rapidly reaches the size of the first, but its shape is not so evenlj' oval as in orchitis. The cord becomes swollen, and painful on pressure. Occasionally so much inflammatory swelling exists here, that the cord becomes partly strangulated in the inguinal canal, since it is impossible for it to swell much there, surrounded as it is by firm fibrous structures. This gives rise to all the well-known symptoms of inflam- matory strangulation — excessive local pain, great prostration, anxiety, vomiting, perhaps hiccough. Pain in acute epididymitis is great, increasing from the first propor- tionally with the rapidity of growth of the swelling. . The pain, how- ever, is not so severe as in true orchitis. It is of the sickening variety, making patients feel faint. Locomotion is almost (sometimes quite) im- possible, the motions of the patient are very deliberate as he changes his position, and, if necessitated to stand, he carefully supports and shields his swollen scrotum with his hand. Rest on the back, with the testicle raised, while it modifies, does not allay the pain, but in this posi- tion the torture is more bearable. If strangulation of the cord at the ring occurs, the pain is greatly intensified, resembling that described for acute inflammatory true orchitis, being, in fact, dependent on the same cause — inflamed tissues strangulated within unyielding fibrous coverings. If some inflammation of the body of the testis exist, the pain wiU be proportionally heightened. As the disease advances, pain increases in intensity for several days (three to six), remains stationary for several days after the organ has reached its full size, and finally begins to decrease, and, even in desper- ate cases, by the end of the second week has usually disappeared, or be- come reduced to the slight dragging uneasiness which constitutes the only pain of mild cases. This relief from pain is often experienced while the organ is yet large, the epididymis thickened, the scrotum oedematous, and some fluid still left in the tunica vaginalis. For several daj^s after the pain has ceased, a few moments in the erect posture, with the testicle hanging, wiU recall it. The form and size of the swelling vary greatly. In the mildest cases the tail of the epididymis alone suffers. All the inflammation localizes itself there, forming a hard, sensitive lump, giving a little uneasiness unless supported, every thing else being normal. The head, together with the tail of the epididymis, may suffer, nothing else being involved, or the whole of the epididj-mis, while the gland proper may be felt normal in every respect in front of the inflamed mass. The vas deferens may be also involved in mild chronic cases, as in the tuberculoid varieties. It may, however, in anj- inflammation of the epi- didymis, be increased in size (perhaps greatly so), and painful on pressure. In very acute attacks the whole cord is sensitive and hypersemic. The EPIDIDYMITIS. ^21 Betninal vesicles are also occasionally inflamed at the same time. Very rarely peritonitis has been seen to come on, provoked by the last-named complications (Hunter, Velpeau, Ricord). If the disease be at all acute, the tunica vaginalis is sure to be in- volved, the degree of its inflammation usually, but not invariably, co- inciding with the intensity of the epididymitis. This peri-orchitis varies greatly. Fluid may be rapidly poured out, filling the sac to its utmost, giving rise to a tense svs^elling of considerable size, in which case it be- comes impossible to distinguish the constituent parts of the testicle. This form is often attended by excruciating pain, relieved, as if by magic, by puncture of the tunica vaginalis. Again, but little fluid may be effused. This, lying loosely in the sac, fluctuates freely, and does not in the least obscure the fact that the main disease is in the epididymis. The fluid may be absorbed speedily, allowing the plastic material effused with it to glue together the two surfaces of the vaginal tunic or perhaps only to form numerous bridled adhesions. Some fluid may remain throughout — the nucleus of future hydrocele. In acute cases the scrotum may be so inflamed and oedematous as to give a very exao-ger- ated idea of the size of the tumor. The constitutional symptoms, fever, loss of appetite, etc., are mild, with epididymitis, do not occur at all in chronic and subacute cases, and in acute cases, like the pain, vary with the intensity of the inflamma- tion. What fever there is disappears before the pain, and long before the swelling. Epididymitis may be said to have a natural limit for its acute symp- toms of about two weeks, but relapses are very common, and careless- ness may prolong the trouble to as many months. Hardness of the epididymis may remain behind for months, or even years ; such indiu-a- tions retain their sensitiveness on pressure for a long time. Relapses are always milder than first attacks. If the other testicle inflame before the first is well, the latter runs through its course more quickly. The gradual disappearance of the hardness from the epididymis may extend over many years, and in some cases is never accomplished entirely. The body first attains its natural feel, then the head, and, last of all, the tail. The absorption starts rapidly, but progresses more and more slowly, until in some cases it seems to rest stationary. In such cases the little hard lump at the bottom of the epididymis occasions the patient no uneasiness, is not sensitive to pressure, and is ignored. Sup- puration is very rare in true epididymitis, not tuberculoid in charac- ter ; atrophy never occurs unless the substance of the testicle has been in- volved. Sterility. — In connection with the sterility often following double epididymitis, the pathological changes seen on section are instructive, and fully explanatory. In the early stages, hyperemia, plastic, serous, and sanguinolent effusions occur. These plastic deposits take place in i22 DISEASES OE THE TESTICLE. tte Cavity of the epididymal tubules as well as around tliem, gluiug them firmly together, so that after a certain time, especially in the tail of the epididymis, nothing can be distinguished on section but a homogeneous mass, in which the eye seeks in vain to trace out the con- volutions of the epididymis or the course of its canal. In the case of a patient of Velpeau,' an examination of the specimen by Eobin disclosed the fact that the hard lump occupying the epididymis was homogeneous, resembling cheesy tubercle on section. The convoluted tubes inclosed in this mass were dilated to several times their ordinary size, but filled with the products of inflammation ; pus-corpuscles, fatty debris, granu- lation bodies — all of this being within and none without the tube, look- ing as if all the inflammatory action had expended itself in producing secretion in and upon the free mucous surface, not extensively involving the peritubular tissue. Gossehn" found in his interesting dissections that the canal in the lower part of the epididymis was often impermeable, the tubes beyond the obstruction being sometimes dilated, sometimes normaL Testicles in these cases of obstruction do not atrophy, nor do the seminal vesicles of the same side undergo any change. For purposes of prognosis, it is well to recall the anatomical fact that the head of the epididj'mis is formed of many tubes (coni vasculosi), all going to unite with and pour their secretion into the canal of the epididymis. Hence chronic induration here may have allowed one or more tubes to escape, and sterility is not so inevitable. The tail of the epididymis, on the other hand, as Gosselin sagely pointed out, is composed of the convolu- tions of one tube. This tail of the epididymis, too, is just the spot where the chronic induration left behind by epididymitis is apt to be- come localized. The tube obliterated here cuts off communication with the testicle, and, if both sides are affected, no spermatozoon can reach the urethra. Yet it is well to know that even in these cases afiairs are not always desperate. The patient is by no means impotent, his sexual power and appetite are unimpaired. He ejaculates semen resembling the healthy fluid in quantity, smell, and color, only it contains no spermatozoa, and consequently he is sterile. The same holds good usually of a monorchid, who has epididymitis on the sound side, for the retained testicle seldom furnishes spermatozoa. This sterility lasts from a few months to twenty years, perhaps indefinitely. It disappears with the induration, sometimes before. There is always hope that a well-directed treatment may cause the latter to disappear by absorption, and restore the patient ais fertility." A curious fact in connection with this subject (showing the bound- ' Reported in the Gazette des Sdpitavx, December, 1864. ' " Archives G^n^rales," Fourth Series, xiv., xv. * Langelbert, " Syphilis dans sa Relation avec le Mariage." EPIDIDYMITIS— DIAGNOSIS. 423 .ess kindness of Nature in doing every thing to preserve the genital functions uninjured) is, that the testicle does not atrophy, no matter hov^ long its duct may be occluded, and, if the latter finally become per- vious, the testicle is ready for use. Animals have been experimented upon by having their vasa deferentia cut, but the testicle does not atrophy. Healthy spermatozoa are found in it months afterward (Curling). Another curious fact is, that in man sexual intercourse may be practised -without (as might have been expected) causing painful, or inducing any, swelling of the testicle or upper portions of the epididy- mis from the accumulation of spermatic elements. In the vast majority of cases time alone will remove the indurations, and with them the sterility. Diagnosis. — The following table may be of service as bringing into contrast the most marked diagnostic differences between true orchitis and epididymitis. Of course when orchitis complicates epididymitis the symptoms will be mixed. Orchitis. 1. Very rarely encountered. 2. Causes usually, injury, mumps, gout, cold, etc. 3. Pain usually excruciating, and not relieved by position, while enlargement is still moderate. 4. Shape of tumor oval. 6. Epididymis not distinguishable from the rest of the tumor. 6. Testicle of peculiar hardness, very sensitive. I. Rarely any fluid in tunica vaginalis. 8. Constitutional symptoms usually present. 9. Termination in resolution, abscess, gangrene, chronic induration, or atrophy. 10. Never followed by sterility except as result of destruction of tissue, and then, if both sides have suffered, by impotence as well, II. Course often slow. Epididymitis. 1. A very common affection. 2. Cause almost invariably urethral in- flammation or irritation. 3. Pain usually bearable except with extreme enlargement, always modified by position, except in cases of strangulations of the cord. 4. Shape oval, roundish, oblong, often irregular — especially from scrotal oadema. 5. Epididymis distinguishable from the rest of the tumor, enlarged, indurated, and particularly tender ; testicle often percep- tible, of natural feel in front of it. These symptoms, perhaps obscure for a few days, at the height of the afiection, always hold good during the period of decline. 6. Testicle often normal in front of epididymis; perhaps hard from inflamma- tion of its tunics, but not as sensitive as in orchitis. I. Always fluid in tunica vaginaHs in acute cases. 8. Constitutional symptoms absent or unimportant. 9. Termination habitually in resolution, leaving slight chronic thickening of tail of the epididymis behmd. 10. Often followed by temporary, some- times indefinite, sterility if both sides have sufi'ered ; never by impotence. II. Course generally rapid. i24 DISEASES OP THE TESTICLE. Treatment. — The prophylactic treatment of epididymitis is the use of a suspensory bandage during the existence of urethral disease, together with a strict observance of the hygiene of the urethra (p. 40). When, late in gonorrhoea, or during treatment of stricture, complaint is made of a dragging, uneasy sensation in the groin, 'or testicle, the patient should be immediately placed upon his back, with the testicle elevated, and the threatened attack may thus be often averted. In mild cases, where rest on the back with elevation of the testicle is sufficient to quiet pain, these means alone are required to effect a cure, perhaps aided by a light, hot flaxseed-potiltice, and a laxative. In a few days the patient can stand, and, by supporting his testicle, walk without pain. In acute cases the treatment must be more active. Rest on the back and elevation of the testicle over the abdomen are indispensable. The latter cannot be secured by a suspensory bandage, since that sup- porter allows the testicle to hang down ; nor is it well to trust to pillows and compresses under the testicle, since they allow the patient no mo- tion. No improvement on Curling's method has yet been suggested. It consists simply in a handkerchief, or piece of bandage, around the waist, and a large (preferably silk) handkerchief, folded in triangle. The base of the triangle is placed under the scrotum ; one (acute) angle on each side is tied to the waistband, the other (right) angle is brought up over the testicles and penis, serving to retain dressings, and is pinned or tied to the waistband. If the testicle be not very large, or the patient move much, the sling tends to slip up in some cases. This may be easily obviated by sewing a tape to that portion of the sling immedi- ately under the scrotum, carrying it between the nates and attaching it at the back to the waistband. In all inflammatory diseases of the testicle this bandage is of the first importance. Having arranged it, the patient is put to bed with the tes- ticle enveloped from the start in a tobacco-poultice. In cases that re- quire any active treatment at all, and where pain and swelling are already present, any cold or astringent application is harmful. The ob- ject is to narcotize the testicle at once, and quiet pain, and this, in the vast majority of instances, tobacco, heat, and position, will do.' The poultice is made by mixing a paper of any fine-cut tobacco ( | j) in about § x of hot water, bringing the whole to a boil while stirring it briskly, and then adding ground flaxseed, with or without ground elm-bark, until the proper consistence of a poultice is obtained, stirring the tobacco well in with the meal. A poultice of this mass is made about a quarter of an inch thick, and large enough to envelop the whole testicle. A piece ol fine muslin is put on the surface of the poultice, which is perhaps sprin- kled with laudanum, and placed upon the testicle as hot as it can be ' The tobacco-poultice was subjected to the test of a thorough trial through many years at the New York Hospital. It proved itself more serviceable than any other agent. EPIDIDYMITIS— TREATMENT. ^25 borne, the wliole covered with a piece of oil-silk — for cleanliness' sake as well as to retain the heat — and supported in the handkerchief-sling above described. Ordinarily, the testicle will be narcotized, and nearly pain- less in a few hours, unless the patient attempt to stand upricht. The poultice is to be renewed every eight hours, and these applications con- tinued steadily until the indurated epididymis has quite or nearly lost its sensitiveness to pressure, when the patient may commence gradually going around, wearing a suspensory bandage containing some woolen batting. Ordinarily, the acute stage of the disease requires not a whit more of treatment than this to effect speedy resolution. A laxative, with a tempered regimen, is always appropriate where a healthy man is sud- denly confined to his back. In conditions, however, of extreme pain, where the disease is excep- tionally acute, we have at our command powerful means of relief. When the cord has become strangulated, and position does not brino- relief from ten to fifteen leeches above the groin, along the course of the cord will often calm the pain as by magic. The bleeding should be encour- aged by the use of hot water. This is much more efficient than the ex- traction of blood from the scrotum. Another cause of excessive pain in some cases, is extreme distention of the tunica vaginalis with fluid. A puncture to let this out is followed by striking and immediate relief. Some authors advocate puncture of the tunica vaginalis in all oases, whether it be tensely distended or not, stating that it moderates the pain and shortens the attack. It is often unnecessary, and need not be re- sorted to where position and local narcotism suffice to quiet pain, as they usually will. Patients with swelled testicle are sometimes unruly, and refuse to go to bed, taking narcotics and wearing a poultice while they continue at their work. Such a course is certain greatly to prolong the duration of the attack, and to be followed by chronic induration of the epididymis, which is very apt to be obstinate, and to entail sterility, as far at least as one testicle is concerned. Then, again, the impatience of restraint, felt by a man lying on his back and suffering no pain, often induces him to leave his bed too soon, and thus sometimes a relapse is provoked. Patients anxious about business or concealment should be advised from the start that they will save time and trouble, and perhaps avoid de- stroying the functional activity of the testicle, by yielding to the necessi- ties of the case at once and going to bed. They may be assured that often four or five days are enough, and that not more than a week, or, in the worst cases, ten or twelve days in bed will be required, if they will observe the horizontal position absolutely for that period. In such a case leeches to the cord, puncture of the tunica vaginalis, and diligent poulticing will bring the testicle in a week to a condition of comparative repose, not paining when let alone, but still, perhaps, several times larger i26 DISEASES OF THE TESTICLE. than its fellow, painful on manipulation, and in the erect posture. Un- der these circumstances, the patient may employ his time as he chooses, and go about at will if the testicle be strapped. Strapping a testicle to reduce swelling, first proposed by Fricke,' of Hamburg, has not met with the favor it deserves, for two reasons : 1. It takes time, trouble, and some experience to apply it so as to give comfort, and be of service. 2. If unsldllfuUy applied, it either does no good, or causes pain, and actually does harm. It has been known to occasion gangrene. In declining epididymitis, however, this agent, properly employed, is most valuable in abridging the duration of treatment. When the or- gan is stiU quite sensitive to pressm-e, some days before the patient can walk with comfort, even with his testicle suspended, if adhesive straps be carefully and snugly applied, locomotion without pain is at once possible (with a suspender), and there is no fear of a relapse. Strapping is performed as follows : The hairs are cut from the scrotum, and strips of adhesive plaster ' prepared from one-half to three-quarters of an inch broad (according to size of testicle), and six to eight inches long. The patient now sits on the edge of a chair in front of the surgeon, with his knees widely separated. The testicle is caught in the band, gently rolled and manipulated xmtil the scrotum relaxes, and the thumb and finger can encircle the cord easily above it. The position of the encircling finger upon the scrotum is accurately noted with the eye ; the patient is instructed to seize the testicle lightly, and hold it in position ; a piece of bandage long enough to encircle the testicle, and about two inches wide, is rapidly placed arovmd it, its centre correspond- ing to that portion of integument previously encircled by the thumb and finger, and a strip of warmed adhesive plaster is placed at once over the centre of the bandage behind and one end brought round to the front and secmred. The surgeon now seizes the top of the testicle, draws lightly upon it, at the same time producing constriction with his thmnb and finger above, and with the other hand pulls upon the free end of plaster, brings it rapidly around to the front following the cen- tral line of the bandage, and attaches it under tension to the back sur- face of the other end of the same strip. Now the testicle may be dropped. It will be seen to be covered by a tense, shining, perhaps purplish-looking integument, pretty tightly constricted above by a strip of plaster, the latter margined all around on both sides by about three- quarters of an inch of bandage. The object of the bandage (prepared lint is perhaps better) is to keep the sharp edge of the adhesive strip from cutting into the tender scrotum, an accident which always happens ' Fricke's proposition was to strap a commencing swelling, and thus prevent it. This is impossible. ' Bumstead's suggestion of two parts of adhesive plaster with one of extract of belladonna, spread on thin leather, is a good one. It does away with the necessity of any lint or bandage vinder the top strap. EPIDIDYMITIS— STEAPPING. 427 to a patient strapped without this precaution, who walks about and sometimes even in spite of it. The first strap is put on tight enough to cause a little uneasiness. It has to be snug, or the straps subsequently applied would push the testicle through it. The remaining straps are adjusted in circles, each one covering about half of its predecessor, and all applied with a certain degree of tension which can only be learned by personal experience. After a number of straps have been applied, it will be found that they will no longer adhere (in a circular direction) to the purple, tense, bulging extremity of the scrotum. This portion is consequently covered in from the sides, and from before backward, by attaching a strip of plaster at a given point, high up over the circular strips, bringing it down and tightly across the bulging end of the testicle, and attaching it high up over the circular straps at a point exactly opposite that from which it started. In this way, by starting at successive points, the whole of the exposed skin at the end of the testicle is covered tightly in. One or two more circular straps may now be applied to keep the lateral ones from slipping. The whole looks something like a large cartridge. A certain amount of soreness follows this apparently rough han- dling, and it is well for the patient to lie down again for half an hour, to find out whether the strapping feels comfortable or not. If properly applied, comfort wlU have returned by that time, and the patient may now place his testicle in a suspensory bandage to keep it from dragging upon the cord, and go around at will without fear of pain or a relapse. By the mechanical action of the evenly-adjusted pressure, the blood is kept as thoroughly out of his testicle as it was by his position in bed. If the straps cause pain after half an hour, they should be removed. Straps need to be reapplied every twenty-four or forty-eight hours, whenever they become loose. If they have been carelessly put on, any point where the pressure is uneven will become oedematous. There is habitually some oedema about the bottom of the scrotum on removing the straps, but it is of no importance. The straps may be detached by cutting each one separately, or they may be conveniently removed all at once in a hot bath. After removal, new straps should be applied im- mediately. Ordinarily after four or five strappings, extending over as many days, or perhaps a week, the testicle will be found to be reduced nearly to its natural size, a certain amount of hardness still remaining in the epididymis, perhaps confined to its tail. This hardness, as a rule, subsides spontaneously in a few weeks, in cases which have been judiciously managed ; sometimes, however, it remains for years. Its departure may be hastened by keeping the testicle constantly in a suspender, covered by oU-silk, so as to keep up slight constant heat and moisture, of course treating any urethral disease which may exist. Sometimes it seems as if the continued use of mild mercurial ointment i28 DISEASES OP THE TESTICLE. under the oil-silk hastened the absorption. No known medicine is of any proved service, iodine and iodide of potassium included. Tonics and cod-liver oil do good by improving the quality of the blood. Nothing has been said of internal medication in the treatment of epididymitis. No medicine has any specific power over it. Gonorrhoea! treatment may be continued, as it does no harm. Injections into the urethra are best intermitted. CHAPTER XXY. DISEASES OF TEE TESTICLE. Pseudo-tnbercular Epididymitis. — ^Tutercular Testis. — Symptoms. — Pathology. — Treatment. — SypMitic Epididymitis. — Sypliilitic Orchitis ; Interstitial ; Gummy. — Cancer. — Sarcoma. — Diagnostic Table of Syphihtic Testis, Tubercular Testis, Cancer, Sarcoma, including Diagnostic Features of Different ITungi. — Castration. — ^Dermoid Cyst — Irritable Testis. — ^Neuralgia Testis. PsEUDO-TuBEECUxAE EpiDiDTMins is very rare. It is simple, slow, chronic inflammation. D6sormaux and Fournier ' seem alone to have called especial attention to it. It is peculiar in being observed, as a rule only in the course of chronic urethral discharges, and because it simu- lates tubercularization with the most absolute accuracy, so as to be usu- ally mistaken for it. It comes on during chronic urethral discharge, often without appreci- able, immediate exciting cause, either as a subacute epididymitis, very indolent and not yielding to ordinary treatment, or, even more insidiously, it commences in an absolutely indolent chronic form, simply character- ized by knobbed, irregular points of induration in the epididymis, slightly sensitive to pressure. The swelling increases slowly, but the pain ceases, until after a time we may have a large, knobbed, irregular epi- didymis, a healthy testicle, more or less fluid in the tunica vaginalis, and, perhaps, the vas deferens, which not infrequently participates in the disease, swollen to the size of a pipe-stem, hard, slightly sensitive to pressure, smooth, or knotty and irregular. • There is now a strong tendency to suppuration, and one or more ab- scesses may form in the epididymis, or possibly in the vas deferens, and discharge externally. Such abscesses long remain fistulous, and closing leave a nodosity which is slow to disappear. Sometimes matter forms near the taU of the epididymis, but the abscess finally dries up without discharging. This may leave a hard, insensitive shot or marble-like lump, freely movable in the scrotum, and connected with the tail of the epididymis by a pedicle. Such curiosities are occasionally encountered. Sometimes resolution is effected after many weeks, perhaps months, without suppuration. ' Art. " Diet, de ll^d. et de Chir. pratiques." TUBERCULAR TESTIS. 4.29 Case XXXT.— A young gentleman while undergoing treatment for stricture bad an attack of epididymitis, wiiioli ran its course and got well. Some mouths afterward in the early spring, after a winter's hard -work at an excitmg business, he commenced to run down perceptibly. His gleet, which had ceased, returned, although he continued to use a fuU-sized sound, and he suffered from an attacli of pseudo-tubercular epididymitis. The use of poultices, ointments, and all ordinary means, combined with tonics, failed to effect any improvement. Abscess formed, the vaa deferens became as thick as a, pipe- stem, the patient was pallid, and more than ever run down. He was now induced to give up business and go to the country, as the only means of safety. He was fortunately very fond of milk. On reaching the country he was directed to give up cod-liver oil and tonics, to stop all medication, general or local, and to Uve on milk, bread, meat, and fruit. A little abscess which had formed discharged, but general improvement set in at once. The patient gained in flesh and spirits. He continued to use the sound, and his urethral dis- charge ceased. His abscess closed, and after two months the epididymis and vas deferens had returned nearly to their origmal size. The following winter they became absolutely normal to the feel. During this winter, however, again the patient overworked himself, and appeared again in the spring with a precisely analogous condition of disease in the epididymis and vas deferens of the other testicle, but not so far advanced as the previous year. His gleet and general running down had also returned. He still used his sound regularly. The country was again resorted to as a means of treatment, the patient continuing to come to town to his business, wearing a suspensory bandage. No abscess formed, but complete recovery ensued after some months. He is now — three years after his last attack — perfectly well. No induration remains. Case XXXVI. — ^Another patient with this form of disease, occurring under precisely similar circumstances, could not be induced to leave town. No treatment seemed to benefit him materially, till after some months he was lost sight of. Tha above cases indicate the outline of treatment. It is doubtful if any local measures are of advantage, except the wearing of a suspensory bandage. The treatment is hygienic and tonic, in fact exactly the same as for tubercular epididymitis, but with more hopes of entire success. TUBEBCTJLAR TESTIS. Tubercular disease of the testis is usually described as occurring in two forms — one as a continuation and degeneration of chronic inflamma- tory thickening, left behind by previous disease ; the other spontaneous, tubercularization coming on without apparent local cause, and uncon- nected with any urethral disease. The first of these forms has been described above as pseudo-tubercle. It always affects the epididymis primarily, may extend thence to the vas deferens and seminal vesicles, and finally involve the testis proper as well. It is distinguished under a different head from tubercle proper. Its prognosis is much better. If not arrested, however, its advanced stages may be identical with those of true tubercular testis, and its terminations the same. The pathology of the affection is cheesy degeneration of inflammatory products effused inside of, as well as outside of, the seminal passages. Tubercular testis proper has certain peculiarities of its own. Its pathology is cell-proliferation, totally outside of the tubes and ducts i30 DISEASES OP THE TESTICLE. (Rindfleiscli).' Tubercle of the testis does not seem to occur in the mil- iary form.' It comes on without appreciable provoking cause in lym- phatic, strumous, or tubercular subjects, sometimes in young men ap- parently perfectly healthy. It is most liable to appear during early manhood just after puberty, when the physiological activity of the gland is most marked. It may appear in childhood. Symptoms. — ^The deposit takes place by preference in the epididy- mis, but the secreting structure usually also suffers later (Riudfleisch). There is no pain, so that it is usual for the disease to pass imnoticed until by accident the patient's attention is attracted by the fact that one testicle is larger than the other. Sometimes, where the deposit is rapid, slight pain is experienced. On examining such a testicle, it is usually found large, hard, and lumpy behind ; but the whole organ is often also hard, irregular, unevenly nodular. There is perhaps some fluid in the tunica vaginalis, obscuring the outline of the testis. The vas deferens is often knotty, enlarged, and hard as far as it can be felt, and a finger in the rectum may detect the seminal vesicle similarly affected. There may also be (more rarely) tubercular prostatitis or evidences of tubercu- lar kidney. The testicle feels heavy, the skin over it is unaltered, press- ure does not cause pain (unless abscess be forming), nor does it occasion the sensation felt when the healthy testis is squeezed. It is not uncom- mon for both testicles to be affected, the one in a more advanced stage than the other. If both are involved, the sexual appetite is usually re- duced or absent. The malady advances slowly, sometimes remaining stationary for many months ; finally the nodules soften into abscess ; the skin becomes oedematous, adheres over the epididymis, the patient has a little pain for a few days, when the abscess bursts and discharges a thick, cheesy material, containing, if the body of the testicle has ulcer- ated, portions of necrosed seminal tubules from time to time. These abscesses remain fistulous for a long time, sometimes indefi- nitely, the fistulous tract being marked by great induration from chronic inflammation. New abscesses tend to form, pointing by old or new routes. After abscess of the substance of the testis, hernia testis may come on, and, when the disease mounts the cord, the inguinal glands are not infrequently enlarged. These cases are often mistaken for cancer, and as such extirpated and recorded as fortimate cases of removal of cancer, with no return of the disease. A patient may have both testicles indurated, knobbed, full of fistuljB for years, and still seem to be enjoying excellent health, with the exception of more or less loss of sexual desire and power, but usually he is pale, thin, aniBtnic, weak, perhaps with tubercular deposits in his lungs or elsewhere. For dififerential diagnosis, see table after Saecosia. As to prognosis, a tubercular testicle is not necessarily lost. Pseudo-tubercular disease also is often indistinguishable from it. ' " Histological Pathology," second edition. ' Virchow, however, admits it. TXIBERCULAR TESTIS— TREATMENT. 431 Pathology. — Tubercular nodules are developed in the connective tissue (or lymph canals) around the seminal tubes and ducts. These partly organize into fibrous tubercles. The tubercles coalesce into large masses, dirty yeUow on section, in direct connection with healthy tissue, not encysted ; and then, their vitality being low, cheesy degeneration of the centre takes place. After a variable period the mass breaks down, and is partly eliminated by abscess. Rindfleisoh,' following Langhans and Klebs, believes tubercle to be the result of endothelial proliferation in the lymphatic spaces surround- ing the seminal tubules. Treatment. — In tubercular disease of the testis the treatment applied may save not the patient's life, for that is rarely implicated, but his sexual power, his peace of mind, and may give life to his children. It is hard to convince such patients that medicine is not the best thing for them, and they suffer so little pain that they are slow to see the necessity of giving up their business and living an easy out-door life in the country. Some patients, unfortunately, cannot foUow this course, and their case is sad indeed. Others can, but will not recognize the neces- sity of it. The chances are not encouraging or the hope very great, but in all cases where there is a hope that the disease may be pseudo-tubercular, where only the epididymis is involved, the testicle being healthy, where only one organ is affected or even where both suffer, but the disease has not advanced far, the surgeon's duty is plaiijly to throw the whole weight of his influence into the scale, to induce the patient to flee into the country, to change his air and his surroundings, preferably to go to the sea-side, or to some southern climate, and to observe all the condi- tions of physical hygiene suitable to tubercular cases. A suspensory bandage is useful, with the testicle enveloped in oil-silk. These means exhaust cur best resources. Local dressings to the tes- ticle are of no avail, except to amuse and satisfy the patient. If abscess form, it should be poulticed, and induced to point quickly, the other treat- ment being followed unremittingly. Cod-liver oil, the hypophosphites. phosphate of lime, iron — especially the iodide — quinine, cinchona, and to the end of the chapter, are of service as general tonics. Arsenic has value, and possibly iodide of potassium a little. The latter has been greatly overrated. Mercury is of no service. Both mercury and iodine have undoubtedly derived their reputation from curing cases where a syphilitic testicle has been believed to be tubercular, a mistake some- times not easy to avoid in obscure cases. The rule of treatment in tubercular testis is imperative. Do not lose time by trying drugs. Let the patient get a change of air at any sacrifice to himself, and let him take his medicine while he is using the stronger agents, intelligent hygiene and dietetics. » Op. cit. 432 DISEASES OF THE TESTICLE. Case XXXVII. — A gentleman, with commencing double tubercular testis, complicated by hydrocele requiring the use of the trocar, got entirely well during an expatriation of eighteen months, from New York to Syria. The patient afterward married and had a family. As a rare symptom, the patient lost blood from the urethra coincidently with the occurrence of the tubercular deposit, and the efiiision into the tunica vaginalis, thus es- tablishing a singular analogy wich pulmonary phthisis, and its haemoptysis and pleurisy. SYPHrLITIC TESTIS.' Syphilitic disease of the testicle has become of late years a well- recognized ajffection, and has, indeed, absorbed into itself, according to agreement by most modem authors, most of the cases which were formerly described as chronic inflammation of the secreting portion of the testicle.* It is not, indeed, too much to say that perhaps all cases of chronic enlargement of the testicle of a seemingly inflammatory origin, excepting such as are left behind by previous acute inflammation, when not due to cancer or tubercle, are syphihtic, although there may be at the time no other evidence of syphilis upon the patient, and may not have been for years. For distinguishing marks of these forms of enlargement, see diagnostic table. There are two forms of syphilitic testis : 1. Syphilitic epididymitis. 2. Syphilitic orchitis, diifuse and gummy. 1. Syphilitic EpiDrDXiuris. — An exhaustive description of this af- fection was first furnished to the profession by Dron,° who gives a num- ber of cases. Other authors have since described the disease. No autopsy has yet revealed its exact pathology, but an identity of lesion with other s}-philitic affections of the testicle is probable. It is of rare occurrence. It comes on usually in the early months, at a mean of about three or four months after chancre, during the period of the early erup- tions. Bassereau and Eollet have seen it coincide with roseola. The disease is confined to the epididymis, mainly to the globus major. The epididymis may suffer with the testicle in the later forms of syphilitic orchitis, but in this earlier form the testicle is only involved in a small proportion of cases. Lancereaux states, as a general rule, that the earlier syphilis attacks the testicle the more liable is the epididymis to suffer. This syphilitic epididymitis has been observed (very rarely) as late as several years after chancre. The disease usually involves both sides at the same time. In one such case, Dron examined the semen of a patient and found spermatozoa. This test might be of service in doubtful cases to differentiate the disease from ordinary chronic epididymitis, although in the latter it is the tail and not the head of the epididymis which is generally involved, and there has been almost invariably some urethral discharge preceding the attack. Furthermore, this syphilitic induration ' The testicle, in inherited disease, also may suffer. A well-marked case has fallen under the author's observation, cured by iodide of potassium. ' " De I'Epididymite syphilitique," Archives G^n., Sixth Series, vol. ii., November and December, 1863. SYPHILITIC ORCHITIS. 433 of the globus major stands out clearly defined as a hard tumor, entirely distinct from the testicle, and not capped over it as is usually the case in chronic epididymitis. The swelling is indolent, accompanied by an insignificant amount of pain. All reported cases have ended in resolu- tion, it never suppurates, but declines rapidly under the appropriate treatment of early syphilitic lesions (mercurial). RoUet puts the limits of treatment necessary at from fifteen days to two months. Local means are not necessary. No functional alteration or organic lesion is left behind. 2. Syphilitic Oechitis.— This ajBfection appears under two forms : a. Diffuse, chronic, parenchymatous inflammation of the organ, of a peculiar sort. 5. Gummy nodules ; the latter being an intensification of the former process, often accompanied by it, but of the two forms the more rare. a. The diffuse form, like parenchymatous hepatitis, or nephritis, is an interstitial orchitis, a peculiar sort of chronic inflammation attacking the fibrous envelope and the parenchyma of the organ. Ricord named it albuginitis. The process begins by hyperaemia ; young cells appear in the connective tissue of the organ, many of them developing into fibres which go on to contract. These young cells press upon, and gradually cause atrophy of, the tubular structure. The tunica albuginea becomes thickened, as does also the tunica vaginalis. More or less fluid occupies the cavity of the latter, while many adhesions commonly take place be- tween the free surfaces. In this way the organ reaches double its nat- ural size, perhaps more, but rarely becomes very large, unless from a considerable collection of fluid in the tunica vaginalis. Often only a portion of the gland is involved in these changes. Both testicles may be affected simultaneously, but usually consecutively. After a time the newly-formed connective tissue contracts, the septa between the lobes of seminal tubules become greatly thickened, composed of dense, fibrous tissue, showing white on section, while the clusters of tubules interven- ing between them, after first undergoing a brown pigmentation, become atrophied by pressure, and finally may disappear, lost in the general fibrous metamorphosis of the gland. The contraction may continue, much of the newly-formed material being absorbed, and the process go- ing on to wasting of the organ, until only a stump is left behind. If the gland has only been partially invaded, a depression may be left marking the site of the disease. In this form there is no tendency to suppuration, ulceration, or formation of fungus. This is the slower variety of disease. h. The gummy form, which is believed to be an intensification of the foregoing process, sometimes coexists with it. It is marked by the formation of nodules, usually multiple, which seem often to take their origin in the external tunic of a vessel, or the wall of a spermatic tubule (Lanoereaux). They may be found of all sizes, from a mere point to that of an &gg, and consist of an agglomeration of cells, with more or 28 i34 DISEASES OF THE TESTICLE. less fatty, granular matter, tougHy united by fibrous elements into a lump, presenting, on section, a grayisb-yellow or distinct dark-yeUow color. As they get larger these nodules tend to soften at the centre. They are surrounded by a grayish areola, traversed by vessels, and later are often enveloped by a condensation of tissue somewhat resembling a capsule. These tumors may form near the surface, or deep in the gland. They may occur iu the epididymis. The latter, however, usually es- capes, while the vas deferens is very rarely involved. The tunica vagi- nalis is usually more or less distended with fluid. In gummy orchitis the testicle may acquire a very large size. The gummy tumors once formed may cease to grow, soften, degenerate, and calcify, or be entirely absorbed, leading to atrophy, perhaps, of the whole organ, or only of a portion. .Again, the integument over them may ulcerate, after adhesion has taken place, and syphilitic fungus result. The mechanism of the formation of fungus is as follows : The gummy matter infiltrates the ttmica albuginea, and undergoes degeneration, caus- ing softening of that structure, with bulging of the contents of the tes- ticle. The superjacent skin and intervening tissues now inflame and adhere, finally ulcerating and allowing the continuous growth of gummy matter within the testis to extrude through the opening, together with the tubular structure, which may be found lying m. little clusters amid the yellow material. The fungus continues to grow, the dartos and skin contract about its pedicle, and the extruded mass becomes covered with some granulation tissue, and bathed in pus. These syphilitic fungi are rather firm to the feel, painless, and do not bleed very easily. If cut off they continue to grow, or, if the disease be not arrested, the sprouting may continue until the whole tubular structure of the testis has been pushed out from the inside, after which it may wither and dry up, the testicle going into complete atrophy. The seminal tubes lq the fungus retain some of their activity, as shown by the fact that spermatozoa may be found in the discharge. The fungus differs from other fungi of the testis. After injury some of the tubules may protrude as a slough, but whatever fungus there is is simple granulation, soft, bright, pink, bleed- ing easily. (For differential diagnosis of fungi of testicle, see Diagnos- tic Table.) Symptoms. — True syphilitic orchitis, affecting the body of the testis, rarely appears until after at least a year, rarel}' before the third year has elapsed from the date of chancre. It may be very rarely more preco- cious. Ricord and Bumstead have seen it as early as the fourth or fifth month. It may coincide with iritis, with groups of tubercles, with ul- cers, or deeper lesions of bone or cartilage. Not infrequently, how- ever, it comes on long after the patient has ceased to show any evi- dence of specific disease. The enlargement of the testis takes place gradually and without pain. It is usually first discovered by accident, already quite large, so that the patient affirms that the swelling came SYPHILITIC ORCHITIS— TREATMENT. 435 on very rapidly, in a day or more. There may be, however, some slight paia at first, especially along the cord, and in the groin, with an uneasy feeling in the testicle itself. When iirst seen, the size of the testicle is usually not more than twice or three times as large as natural. It may be perfectly smooth, and hard as wood, the epididy- mis not distinguishable. Usually the body of the testis is irregular and nodular, very hard, or there may be one or more prominent lumps of gummy exudation. Only a portion of the testicle may be involved, the rest feeling natural. In such a case" the healthy portion may be normally sensitive, giving, when pressed, the natural sensation of squeezing the testicle. Often, however, the swelling is wholly insen- sitive, and may be squeezed at will, without evoking the least uneasy feeling. The outlines of the testicles may be obscured by a considerable col- lection of fluid in the tunica vaginahs. After drawing this off, the hard, Bodular, uneven outline of the insensitive, syphilitic testis becomes ap- parent. The vas deferens is always healthy, and the scrotal tissues rarely involved, so that the hard mass can be freely moved and exam- ined under the thin skin of the scrotum. The general health may appear excellent, but, if both testicles are involved, sexual appetite and power are almost invariably absent. There are no erections, and func- tion is temporarily abolished. The same impairment of sexual function exists in a less degree where one gland only is involved. There may be, very rarely, a syphilitic fungus, as described above. The glands in the groin are not affected. (For differential notice, see Diagnostic Table.) The duration of the disease may extend over several years. The ter- minations are resolution, degeneration (fibrous, fatty, calcific), atrophy. Prognosis. — The prognosis is good. The seminal tubules do not become occluded. They only perish by degeneration and atrophy, from pressure, and some of the canaUculi have usually escaped. The sooner treatment is commenced, the better the prognosis. The gummy mate- rial melts away under appropriate measures, liberating from pressure such of the tubules as have escaped atrophy, and, with a return of the organ to its natural size, erections and sexual appetite reappear. Gosselin has found spermatozoa in the semen of patients who had had double syphilitic orchitis after the same had been cured by treatment. Relapse is always to be feared, especially if the treatment be not per- sisted in long enough, or if the testicle be subjected to mechanical violence when nearly cured. Treatment. — All three forms of syphilitic testis are amenable to treatment. Early syphilitic epididymitis gets well promptly under mercury, employed as for the earlier syphihdes. Of the other two forms, the purely gummy may be more promptly relieved ; but, in any case, the earlier an intelligent treatment is instituted the more speedily does the disease respond. The mixed treatment is most commonly ap- ^36 DISEASES OF THE TESTICLE. plicable — mercury and iodide of potassium ; but, as a general rule, the later the attack after the chancre the more reliance is to be placed upon the iodide, and the less upon mercury. With distinct, large knobbed, gummy tumors, and always with syphilitic fungus, and in connection ■ivith other marked evidences of tertiary disease, the iodide should be used alone, carried rapidly to a high dose. {See Teeatment of Syphi- lis.) A suspensory bandage should be worn, and all hygienic means employed. Local treatment is unnecessary. Fungus may be touched with nitrate of siver, and strapped after any constriction at its neck b\' the scrotal tissues has been divided ; but re- liance can only be placed on internal treatment, which will cause it to shrink back into its place. It is unwise to cut away any portion of it, for healthy seminal tubules may thus be sacrificed. It is needless to add that no attempt should be made to cure the accompanying hydro- cele by local means. The fluid will disappear as the tesicle reduces in size (Case XXVIIL), and no injections or other local measures can cause its subsidence before that time. As often as the tunica vagi- nalis becomes distended a palliative puncture may be resorted to. If occasionally the hydrocele persist after the testicle has returned to a state of health, it may then be treated successfully by the ordinary methods. Sometimes a syphilitic testicle is first suspected, after the evacuation of a hydrocele, by the characteristic feel of the gland. Ex- tirpation is not to be thought of. Before syphilitic disease of the tes- ticle was understood, the older surgeons were in the habit of extirpating many large, chronic, indolent swellings of the organ (called sarcooele, or hydro-sarcocele), which an appropriate treatment might have restored. Sir Astley Cooper at one time gave it as a general rule that no testicle should be removed for chronic enlargement and induration until " the gums had been touched by mercury." Modern progress has altered the rule. We no longer " touch the gums," but it may now be safely laid down as a proper rule to follow, in all cases of doubt, with enlargement of the testicle, never to operate until a thorough anti-syphilitic treatment has been tried faithfully, including large doses of the iodide of potassium. A final caution must be given, namely, not to remit treatment too soon. It should be kept up for many months after the testicle has resumed its natural size, and only given up gradually, for fear of relapse. CANCER OF THE TESTICLE. Soft carcinoma is the only variety of cancer occurring primarily in the testis. Scirrhus lacks the " strict requirements of anatomical proof." ' Pigmented cancers are said to have been seen as metastases. But even soft cancer is very rare. It does occur, however, and is found at all ages, from the cradle to the grave. Pitha saw it in a new-bom infant, ' Rindfleisch, loc. cit., p. 351. Curling, Pitha, Foerster, Vemeuil, and others, admit Bcirrhus. Nepveu reports a case, "Tumeurs du Testicule," Paris, 18'72, p. 35. CANCER. .i,^ij After sixty it is very uncommon. It is met with mainly in early man- hood, when the function of the testicle is most active. It rarely occurs on both sides. An injury seems sometimes to be the immediate excit- ing cause. Sarcomatous tumors of the testis are very liable to degenerate after a time, and become carcinomatous. Symptoms. — Gradually, sometimes rapidly, induration and enlarge- ment come on. The oval shape is preserved, there is only slight pain (worse on pressure throughout the disease), and there is eifusion into the tunica vaginalis. As the testis grows, it becomes uneven on its surface, elastic in portions, perhaps so soft as to give the idea of true fluctuation. The pain now increases in the testicle and cord, the latter becomes engorged, the pelvic and abdominal glands, as also often the inguinal, swell and become cancerous. The tumor formed by these glands may usually be felt in the loins. There is generally constant pain in this region. Venous circulation is impeded by pressure of the cancerous masses upon the great abdominal veins, the veins of the scrotum stand out varicose and prominent, the leg becomes oedematous. The pains become intense, sharp, shooting, often burning in paroxysms, between which a constant ache is felt in the testicle and cord. The testicle during this period has been constantly growing, it has burst the bounds of the tunica albuginea involved the epididymis and cord, but the scrotum expands and the tumor may reach the size of a^hild's head. Boyer removed a cancerous testis weighing nine pounds.' During its growth it may experience periods of rest when there seems to be little or no advance made, or when it may become smaller for a time, by the absorption of some fluid portions, as of fluid in the tunica vaginalis. The pain is aggravated by pressure, and the normal feeling on pressiue is absent. After a time, if death or an operation do not remove the tumor, the scrotum will adhere to it at some one or more prominent portions, the skin will ulcerate and the cancerous mass will spread to the outside, forming fungus hema- todes, the true cancerous fungus. This is bathed in a thin bloody ichor, grows rapidly, portions of it slough away, and it often bleeds profusely. Meantime the general health, perfect at first, sufi"ers proportionally with the advance of the disease, until finally well-marked cancerous cachexia is reached, attended by its usual sallowness, and tendency to waste away. The pain so characteristic of this disease is sometimes very slight in the testicle, but particularly so in connection with the cancerous growths from the pelvic and lumbar glands, where there may be no pain at all with advanced disease (Brodie). Pathology.— 'Y\\Q disease commences at different points, which co- alesce. It is rarely a general infiltration. On section it is impossible with the naked eye to distinguish between soft carcinoma and soft sarcoma, but the soft "medullary" sarcoma is also malignant, afi'eots '■Beone Medicale November, 1839. i38 DISEASES OF THE TESTICLE. the retro-peritoneal glands, and is finally fatal. They both exhibit the same soft spots, perhaps fiUed with pultaceous matter, the same white or pink-white colors. The microscope shows the cancer to be a stroma, richly permeated by young cells, inclosing " epitheloid cell-aggregations " which owe their origin (Birch — Hirschfeld) to the proliferation of epithe- lial cells of the glandular tubuh ; the medullary sarcoma, also malignant, shows a broad trabecular work of spindle-shaped cells, with often nests of epithelial cells, showing that it is partly carcinomatous, or a roxmd- celled stroma, with elements of other histoid formations (mucous car- tilaginous tissue, Eindfleisch). The large soft spaces yield a plentiful juice when pressed, and, if water be run over them, the softer parts may be washed away, leaving a delicate stroma behind. The stroma, again, may be thickened and fibrous. Cysts are not infrequently found, sometimes blood-cysts, or large blood-clots, as in kidney-cancer. Cancerous degeneration may have attacked a testicle already sar- comatous, when we should find, besides the conditions above described, perhaps cartilage more or less calcified, or mucous tissue, or unstriped muscle. The enlarged abdominal glands press upon the vena cava. The cavity of the latter has been found obliterated, filled with cancer-growth ; the bones of the spine become involved, while secondary cancer may be found in the kidneys, liver, and lungs. A- few instances have been cited of cancer of the testicle, beginning in the tunica vaginalis. One or two cases of colloid and melanotic cancer are recorded, as well as a few of scirrhus. Diagnosis. — In the early stages of the disease, especially if its course be slow, diagnosis is often exceedingly difficult. The diagnosis is with sarcoma, syphilis, tubercle (for which see Diagnostic Table), hydrocele, and hematocele, with dense walls. Hydrocele or hgematocele may be diagnosed, if all other symptoms fail, by exploratory puncture with trocar. If a trocar be used and thrust into a soft part of a car- cinomatous testicle, enough blood may escape to encourage the idea of haematocele, but it wiU be noticed that the volume of the tumor does not decrease proportionally to the amount of blood which has escaped. Prognosis is even worse than for cancer elsewhere. Two years is a fair average duration for the disease, and the Kability for secondary can- cer to appear in the loins or elsewhere after operation is very great. But few cases, and they could be counted on the 'fingers, are reported of a continuance of health a number of years after extirpation, and in these cases the operation was always done very early, and perhaps the disease was sarcoma. Treatment. — Medicine is of no service. Puncture of tunica vaginalis will often relieve pain immediately. A very early operation offers the only hope, but hope departs when the cord and glands become involved SARCOMA. 439 SARCOMA. Cystic Sakcoma, Enchohdeoma, Myoma, Myxoma. — This affection is even more rare than cancer. Its cause is unknown. It occurs most frequently between eighteen and twenty-five. It is rarely bilateral The body of the testis is involved, the epididymis sometimes secondarily. When the morbid mass is made up largely of cysts, it is called cystic sarcoma ; when there are but few cysts, and much solid matter, it has been customary to call it fibro-cystic sarcoma. Symptoms. — The growth of sarcoma is slow, and usually painless, so that considerable size may be attained before the disease is noticed. There may exceptionally be some pain or dragging in loin, groin, or testicle, especially after the mass has become bulkj'. The tumor may attain a weight of several pounds. The shape is oval, and the surface smooth, unless some large-sized cysts happen to be superficial. A healthy epididymis can be felt at first distinct from the testicle ; finally it is lost in the general swelling. The tumor may remain many years of a certain size, and then take on malignant degeneration, after which symptoms of cancer supervene. Sarcoma is liable to be confounded with cancer, tubercle, sj'philis (see Diagnostic Table), hydrocele, or hsematocele, but the tumor is elastic, not fluctuating, and a trocar distinguishes it from the latter affections. Severe pressure often produces a sensation of faintness. Pathology. — On section the tunica vaginahs and tunica albuginea are found thickened. There may be but a few cysts, or vast numbers con- stituting nearly the entire tumor, varying in size from a point to a pigeon's-egg. The smaller cysts contain a gelatinous fluid which gets thinner afterward, and may contain cholesterine, fatty d'ebris, etc. The fluid is often colored with blood. A pure, watery serum is rare. Some- times the fluid is synovial-like, sticky, stringy. The cyst-walls, especially the smaller, are lined by cylindrical epithelium. Papillary excrescences, covered also by cylindrical epithelium, are found growing into the larger cysts, which often become entirely filled up by them, as in cystic sar- coma of the breast, and as in the latter disease, so also in this, it is not uncommon to iind in the cysts Uttle, yellow, hard spherules of condensed epithelium.' As to the mass of the tumor, fibrous tissue is found in greater or less proportion, and as the tumor is nearly always a compli- cated one, it is not unusual to discover portions of muscular tissue (of both kinds, Senftleben, Billroth, Nepveu), masses of raucous and even of adipose tissue, and hyaline cartilage, perhaps partly calcified. This cartilage, which may be found in all sorts of curious, branched shapes, has been made out by Paget and Billroth to occupy the lymph-vessels. In Paget's case the cartilage extended up the lymphatics of the cord These little pearl-like clusters of epithelium are encountered in various pathological conditions of the testis. 440 DISEASES OF THE TESTICLE. into the abdomen, and a mass was found growing from one of them into the vena cava. Cartilaginous nodules were found in the lungs. Where there is much cartilage there are seldom many cysts. Indeed, the tumor may consist solely of hyaline cartUage at first. This grows slowly, pain- lessly, and may attain the size of a hen's-egg, when, possibly after several years, a sudden, rapid enlargement of the testis sets in, and we find that the cartilage has become surrounded by recently-formed masses of sarcomatous character. Cretification may be found in the testicle and its coverings, in connection with enohondroma or sarcoma (Rindfleisch). A pure mj'oma may occur in the testicle as a solid, painless lump. Eokitansky describes one as large as a goose-egg, of striped muscular tissue; Rindfleisch another, of unstriped fibres. Sarcoma may occupy only a portion of the testis, or the whole gland ; the tubular structure is then either found spread out upon the new deposit, or scattered through it. It eventually atrophies. The epididymis becomes flattened and wasted, or finally involved in the disease. According to Billroth, sar- coma commences in the sub-epithelial tissues of the seminal tubuli as a round-celled degeneration of the tunica propria, leading to occlusion of the tubule, and subsequent dilatation behind the occluded point. Com- mencing cancerous transformation may often be detected. Treatment. — The only treatment is extirpation. The disease may be indeed purely benign at first, and remain so perhaps indefinitely, but it may become cancerous, and, if the individual have one good testicle left, it is unwise to put off the operation. If the patient be a monorchid, strict justice would allow delay, so long as any of the secreting structure of the testis had been spared by the disease, and continued its functions. DIAGNOSTIC TABLE. Since it is so difiicult often to decide upon the nature of a given chronic enlargement of the testicle, it seems advisable to display the main diagnostic features of the four affections, tubercular testis, syphilitic testis, cancer, and sarcoma, side by side in tabular form, so as to bring out as clearly as possible, and emphasize, their most striking differences : Tuhermlar Testis. SyphUilic Testis. CaTicer. aarcoma. 1. Most common 1. Most common 1. Most common 1. Most common in early youth and manhood. in middle and later life. in youth. in early manhood. 2. No change in 2. Same. 2. Scrotal veins en- 2. No change. scrotal veins. larged and varicose after the disease has lasted some time ; due to the pressure of cancerous glands above. 3. Does not grow 3. Is usually com- 3. May reach an 3. May become to great size. paratively small. immense size. very large. DIAGNOSTIC TABLE. Ml Tubercular Testis. 4. Holds second place of frequency. 5. Primarily af- fects epididymis. 6. Form knotty, ir- regular, hard, espe- cially the epididymis. 1. Development Blow. 8. Pain absent or insignificant. Syphilitic Testis. 4. Most common of the four. 5. Primarily af- fects body of testis. 6. May be perfect- ly smooth and OTal, or more or less lumpy. 1. Same. 8. Often absolute- ly no pain. 9. Often discov- ered by accident. 10. Usually no sen- sation on pressure, neither pain nor the normal sensation. 11. Pluidin tunica vaginalis sometimes. 12. Tendency to suppurate, discharge, and leave fistula. 13. Both testes of- ten consecutively at- tacked. 14. Loss or impair- ment of sexual de- sire and power when both glands are in- volved. 15. Fungus not very common. If found, it is pale and soft, .bleeding rather easily, composed mainly of granula- tions. Pus thin, si- nuses leading into testicle, growth slow, usually painless. 16. No glandular Enlargement. 9. Same. 10, Same. 11. Fluid in tunica vaginalis nearly al- 12. Tendency to atrophy without ex- ternal opening, some- times there are a dis- charge and fungus. 13. Same. 14. Same, and more marked ; some- times exists when one gland only is dis- eased. 15. Mingus very rare. If found, it is hard, yellow, mainly composed of tubes and yellow syphilit- ic matter, does not bleed very easily, no sinuses, growth slow, painless. 16. Same. Cancer. 4. Holds third place. 5. Same. 6. Uneven ; prom- inent hard and soft spots; indefinite fluctuation. Y. Development rapid. 8. Pain liable to be severe soon af- ter commencement, sometimes excruciat- ing. 9. Recognized by pains from the start. 10. Darting, sharp, burning paroxysms and constant pains, aggravated by han- dling. 11. Fluid in tuni- ca vaginahs usually slight. 12. Tendency to open, and form fun- gus haematodes. 13. Usually only one testicle suffers. 14. Both glands not involved simul- taneously. 15. Fungus con- stant if testis remains long enough, grows rapidly, bleeds pro- fusely, sloughs read- ily, is covered with sanious, badly-smell- ing ichor, is formed mainly of cancer-tis- sue, is very painful. 16. Inguinal and pel- vic glands involved. Sarcoma. 4. Least common. 5. Same. 6. Slightly uneven, oval, perhaps with points of fluctuation. t. Tory slow, of- ten suddenly becom- ing rapid. 8. No pain. 9. Tumor grows slowly, and is usually discovered small. 10. No pain; squeezing testicle of- ten produces feeling of faintness. 11. Fluid in tunica vaginalis rarely. 12. No tendency to open or to form fungus. 13. Same. 14. Same. 15. 'So fungm. 16. Glands some- times involved. ii-2 DISEASES OF THE TESTICLE. Tubercular Testis. 17. Very rebel- lious to medical treatment. 18. Cord always affected erentually. 19. Yesiculse sem- inales liable to be- come involved. 20. Feel lumpy. 21. Duration, sev- eral years. 22. Prognosis not favorable. Progress always indolent, en- tire cure rare. Syphilitic Testis, 11. If taken early, quickly amenable to treatment. In any case always reduci- ble in size, by intel- ligent medication, to which all doubtful cases should be sub- jected, to give them a chance. 18. Cord never in- volved in a pure case. 19. Nothing of the sort. 20. Excessively hard. 21. Duration, sev- eral years — usually less than tubercle. 22. Prognosis good ; gets well, with functions restored if treated ; atrophies if not treated. Cancer. 17. Treatment in- effective. If cut out, returns elsewhere. 18. Cord affected in advanced disease. 19. Nothing. Sarcoma. 17. Medical treat, ment ineffective. If cut out, disease does not necessarily reap- pear; if left, can- cerous degenerations may occur. 1 8. Cord never af- fected. 19. Nothing. 20. Hard and soft. 20. Elastic. 21. Duration, av- erage two years. 22. Prognosis bad; kills by bleeding or cachexia if not re- moved ; by return of the disease if extir- pated. 21. Duration, many years, 22. Prognosis good. Does not re- turn if removed. If left, liable to become cancerous. CASTRATION. This is an operation not very often required since sarcocele (as any chronic fleshy enlargement of the testis used to be called) has been more closely studied and better understood. Still there are occasions when it is proper to remove the testicle. The operation is a simple one, and is best performed as follows : The pubes, perinseum, and scrotum, are first shaved, and any complication in the way of hernia is excluded if possible. An ansesthetio should always be administered. An incision is made, commencing a little below the external abdom- inal ring, and carried to the bottom of the scrotum along its anterior aspect. Even if such a length of incision were not required by the size of the gland to be removed, yet it is better to make it long, so that the lower angle may be depending, and thus to allow a free exit for the discharges. The spermatic cord is next exposed, and, if it must be U- gated very high up, it is better at once to put a stout ligature around it, and to tie the whole cord quickly and firmly. If enough of the cord is left to be seized, it may be held by the fingers of an assistant, but care must be taken not to let it slip, or it will disappear within the inguinal canal and a great deal of haemorrhage may occur before it can be re- covered by dissection. The cord being cut, the testicle is to be turned out more by tearing than by cutting. An oval piece of skin may be CASTRATION— DERMOID CYSTS. 443 removed with it if it is very large, and, if it adheres pretty tightly, care may be required to prevent wounding the urethra or the other testicle during the dissection. After the testicle is removed, the ar- teries of the cord (the spermatic, deferential, and the cremasteric) should be tied, and all the bleeding points in the scrotum secured. If a single ligature has been used for the whole cord tied high up, it may be left, and usually no bad symptoms will occur. Pain, however (and even tetanus), has been said to be produced in this way from including the nerves of the cord and the vas deferens in the ligature. The wound should not be united until all the bleeding points have been secured. There are few operations in surgery which are so liable to be complicated by troublesome bleeding after the wound is closed. This is due to the laxity of scrotal tissue. If hernia complicates the disease of the testis, care should be taken not to open into the peritoneal cavity. If the cord should slip into the inguinal canal after being divided, the tendon of the external oblique must be cut at the external pillar of the ring, and the dissection con- tinued up the canal until the cut end is reached and all its bleeding points secured. Several instances of death are recorded from neglect of this precaution. If haemorrhage comes on after the wound has been closed, it should be reopened and the bleeding vessels searched for. A few points of suture are necessary, otherwise the edges of the wound will be kept gaping by the contractions of the dartos. Some strips of adhesive plaster, a tent at the lower angle of the wound, and a T- bandage, complete the dressing. Self-castration has often been resorted to by lunatics, or by individuals, usually young men, laboring under some depression brought on by masturbation or other abuse of the organs. The bleeding is always excessive, but, in the cases reported, has usually been successfully arrested. DERMOID CYSTS OF THE TESTIS. The testicle, next to the ovary, is the most favorite site for the devel- opment of dermoid cysts. These cysts are cavities lined by integument, furnished with stunted papiUse, sebaceous and hair glands. Their con- tents are a sebaceous matter mixed with epithelium and rolls of long hair, usually reddish. Besides these there are often found fully-formed teeth, sometimes in great numbers, often embedded in portions of bone, bones with smaller bones articulated to them, cartilage, muscle, nerve. Case XXYVTTT. — In a personal case a dermoid cyst was taken from a boy who had been allowed to carry it for years, under the impression that it was cancerous. It was found to contain a portion of well-formed inferior maxillary bone, with several molars and a bicuspid tooth firmly fixed in it. Recovery followed. These cysts may be within or outside the testis, as in Velpeau's case.' These are the cysts sometimes known as foetal inclusions. ' Oaz. Med. de Paris, February 15, 1840. Andr«, " Mem. de I'Acad. Royale de M(5d.," [ii DISEASES OF THE TESTICLE. ilodern pathologists combat ttie views of Geoffiroy St.-Hilaire on this ubject, and the more poetical theory of fcetal inclusion is rapidly giving )lace to the common-sense one of simple, accidental, misplaced, formative .ctivity. The cysts are probably always congenital. They usually grow 'ery slowly at first, but may reach an inconvenient size in time. Gen- Tally they become very large, then suddenly begin to grow rapidly and ,re removed, or, becoming injured by a blow, they inflame, suppurate, .nd discharge their contents, remaining fistulous. The only treatment is removal with the knife. It should be remem- lered that the cyst sometimes lies outside the testicle, the latter adhering o it. The gland should be dissected off, and spared if possible. lEEITABLE TESTIS. This is a name given to a species of neuralgia of the gland. The rhole organ, or usually a particular spot, is extraordinarily sensitive to he lightest touch ; contact of the clothing alone is sometimes exqui- itely painful. In the recumbent postxu-e, with nothing in contact with he testicle, the pain usually disappears. Sometimes the organ is tense nd engorged ; but it is of full size, and seemingly normal. Again, it aay be decidedly flabby, the scrotal tissues being soft and lax. Irri- able testis occurs at all times, from early puberty to late middle life. It s met with chiefly in old bachelors and widowers. The patient other- nse may possess robust health, sometimes (especially with flabby tes- is) he is anemic, nervous, hypochondriacal, and dyspeptic. The causes of irritable testis are lack of use, or abuse, of the sexual lowers — perhaps most often ungratified sexual desire. Curling says,' ■ In a person of chaste habits, thus affected, I was informed that the aorbid sensibility disappeared on marriage." Temporary irritable testis day be produced in a healthy person, at any time, by prolonged sexual xcitement ungratified. Masturbators, who have suddenly reformed, nd recent widowers, and those who have abused their sexual powers ly over-use, are all liable to the affection under consideration. These patients are usually hypochondriacal, look upon their own ondition as a pitiable one, and ascribe it to loss of seminal fluid — per- laps to nocturnal emissions — ^to neither of which does it stand in any elation of effect. They often demand castration — a demand which hould be acceded to on no account. Curling quotes from Romberg an Qteresting case bearing on this point : A young man acquired irritable estis after becoming engaged to be married. It distressed him so seri- usly that he demanded extirpation of the organ, and would not yield mtU at last the operation was reluctantly performed. Eight days aftei^ rard the old pain returned in the other testicle. This being all he had ol. iii. Ollivier (d'Angers), " Mem. sur la Monstrosite par Inclusion," Archiv. G^n., toI. V. Yemeuil, 'Archiv. Gen.," June, 1855, who has collated nine cases besides oneof hia wn. ' " On the Testis." NEUEALGIA OF THE TESTICLE. 445 eft, the patient preferred to keep it He married, and "very soon re- covered completely." Treatme?U.—B.jgiejie, physical, moral, and sexual, is the proper treatment for irritable testis. As local means, a suspensory bandage and the cold douche are adjuncts. Drugs exert no specific power and cannot be relied upon. Marriage, with a proper sexual hygiene, is the natural antidote to any irritability of the sexual apparatus. NBURALGIA OF THE TESTICLE. An extreme degree of the condition just detailed constitutes neu- ralgia of the testicle, a disease which sometimes attains horrible inten- sity, and assumes the tic-douloureux type in paroxysms at irregular (oc- casionally regular) intervals. The pain in some cases is constant, and perhaps quite mild, but increased by walking and standing so as to occa- sion great discomfort. The character of the pain is acute, darting, stab- bing, sometimes dragging, heavy. The cremaster sometimes contracts spasmodically during the paroxysm, forcibly retracting the testicle, and a cold sweat, with nausea and vomiting, is not a rare accompaniment. Between the paroxysms the testicle is often entirely free from pain. Handling the organ is liable to induce a paroxysm. The testis, some- times swollen and tense, is usually unaltered. There is no febrile action. Neuralgia is usually confined to one testicle, unlike irritability, which is frequently double. Neuralgia must not be confounded with the sympathetic pain in the testis, and its retraction from spasm of the cremaster, accompanying certain morbid states of the bladder, ureter, and kidneys, and so often seen in kidney-colic. The cause of neuralgia of the testis is sometimes difficult of appre- ciation. It is often due to the same general influences which lead to the development of neuralgia elsewhere (gout, syphilis, malaria, etc.). It sometimes follows an attack of orchitis. It has been vaguely referred to the spinal cord, deranged digestion, etc. It has been seen to follow injury, and to attend a small, deep-seated, purulent collection. B. Brodie ' found it in one case always preceded by clay-colored evacua- tions and pain in the back of the head. He believed the cause in this case was situated in the liver. In another case, he found a small pro- jection on the epididymis, which, on pressure, gave the sensation of touching an exposed nerve in a tooth. The following is an analogous case: Case XXXIX. — ^A middle-aged healthy gentleman married to a sickly wife, with whom he had only occasional sexual relations, applied for treatment of a painful spot on the left epididymis, which could be felt as a little lump not larger than half a grain of rice, and which gave, when touched, the sensation of pressing upon an exposed nerve in a tooth. He had also " irritable bladder," depending on neuralgia of the vesical neck. There was no stricture. The systematic regular passage of a full-sized steel ' Iledical Gazette, vol. xiii., p. 621. y-G MALADIES INVOLVING THE GENITAL FUNCTION. sound, during several months, cured both the irritability of the bladder and the neuralgia of the testis. The little lump (probably a cyst) remained, but its sensitiveness on handling disappeared gradually as the bladder-symptoms got well. In neuralgia of the testis no nerve-lesion has been found. Sexual hygiene will be often found at fault. The affection may last for years and (possibly) then disappear spontaneously. Treatment. — Neuralgia depending on bladder, urethral, or kidney disease, disappears with its cause. In true neuralgia, a strict hygiene is all-important ; this involves marriage. Among drugs, arsenic, quinine, and iron, bear the best reputation internally ; belladonna, opium, and aconite, externally. But little reliance can be placed on them, however ; sexual and general hygiene outrank all remedies. If the testicle be extirpated, there is always danger of a return of the pain in the cord, or in the other gland. Diday ' recently very strongly advocates the con- tinued application of cold in all pure cases of neuralgia, and claims re- markable success with this agent. His method. consists in filling two bladders with large pieces of ice. One of these he places upon towels, so arranged as to underlie and support the testis, the patient being supine. The other bag is now placed upon the testis, so that the whole organ is sjarrounded by ice, or, rather, iced-water. This application is kept up night and day, for two to four days, after which (Diday states) the neuralgia does not return." CHAPTEE XXVI. MALADIES INVOLVING TEE GENITAL FUNCTION. Impotence. — True Impotence, its Causes and Treatment — False Impotence, its Causes and Treatment. Sterilty.— Masturbation.— Pollution, Nocturnal and DiumaL — Spermatorrlioea. — Erotomania. Saty- riasis. — Priapism. — Aspermatism. IiTPOTEsrcE is a symptom, usually, of some physical morbid condi- tion entailing inability to accomplish the sexual act. Its causes are very numerous. Most of them have been already considered ; the others will receive a few words of detail in this chapter. Impotence will only be considered as affecting the male. Impotence, from whatever cause, is a complaint not unfrequently submitted to the surgeon ; not always frankly and openly as such, but often by implication, as though it should be recognized and inquired about, in answer to remote indications which the patient has scantily ' " Annales de Derm, et de Svph.," 1869, No. 3, p. 182. * In weak subjects the possibility of sphacelus of the skin, or of at least impairing the vitality of the parts by a too rapid reaction on removal of the cold, should not be lost eight of, although these pomts are not mentioned by the high authority who suggests the practice. TRUE IMPOTENCE. 447 furnished. Indeed, the surgeon who would meet the daily wants of his fellow-men, in reference to troubles of this sort, must possess an accurate knowledge of the physiology of the sexual function, and of its various derangements, and be ready to anticipate the reticence of patients; otherwise he will fail to sound many of the depths of human nature, where suffering lurks — which suffering is for the most part preventable or relievable. Impotence signifies that an individual cannot beget children because he cannot perform the sexual act properly, no matter what the obstacle may be, whether he have spermatozoa or not. The term must be care- fully distinguished from sterility, which signifies inability to beget offspring on account of defect in the semen, whether the individual can have sexual intercourse properly or not. The two are undoubtedly often associated in the same individual, but they may be totally distinct, as the following examples will illustrate. Thus there are two methods of making eunuchs in the East : by one the penis is removed as well as the testicles, and such a eunuch is necessarily both impotent and sterile. By the other method the testicles alone are removed ; and a eunuch of this description, though sterile (having no spermatozoa), may be still partly potent, and does not bring so high a price as another eunuch who has no penis. It is a well-known fact that both animals and men, from whom the testicles have been removed after puberty, still retain sexual desires, and may have intercourse, with venereal orgasm and ejaculation of prostatic mucus, occasionally during a period of several j^ears. A cryptorchid is rarely at all impotent, but is very apt to be sterile, and so of a patient with double gonorrhoea! epididymitis ; while, as instances of impotence without any sterility, may be mentioned, deformities pre- venting sexual intercourse, where the spermatic fluid is normal (extrophy of the bladder), extreme incurvation of the penis, with or without hypospadias, aspermatism. The distinction between impotence and sterility being now plain, a few words regarding each of these complaints will perhaps serve to clear them of the mists of uncertainty which often surround them. Impotence may be considered as true and false. TRUE IBCPOTENCE. This is exceedingly rare in the male. Any one who can perform the sexual act is potent. This act imperatively involves two conditions, namely, sufficient erection to make intromission possible, and a mucous fluid leaving the body by ejaculation. Roubaud * has added two other factors as essential to the act of copulation ; namely, the existence of venereal desire and pleasure in the act ; and although both of these un- doubtedly exist in a state of health, nevertheless the absence of either of them by no means necessitates impotence, while the absence of either > "De I'Impuiasance et de la St(5rilit^," Paris, 1872, second edition. 448 MALADIES IXYOLVING THE GEXITAL FUKCTION. of tlie first-named conditions is impotence. An illustration of these points will bring out all that can be said practically concerning' true impotence. That lack of desire before the act, and pleasure during its ac- complishment, are not absolute essential's to sexual intercourse, is shown by the two conditions, priapism from cantharides, in which there is no desire, and yet intercourse is possible with perfect intromission and ejaculation, and certain diseases of the cord attended by more or less paraplegia, where intercourse may take place, followed by conception, and yet there be no pleasure in the act of ejaculation, the patient being unconscious at what moment it occurs. Conditions zntolting Teue Impotence: 1. Absence of penis, as in the cases already referred to (p. 5).^ In these cases, if there are healthy testicles, the patient cannot be called sterile. 2. Minute size of penis may involve impotence, as in Roubaud's case of a student whose penis was so small that, although he could practise masturbation, he was not able to reach the stage of ejaculation during sexual intercourse, on account of the minute size of his penis, between which and the vaginal walls there was little or no friction. Roubaud ^ rendered this man potent, and, he says, greatly increased the size of his penis by fitting him with an artificial one, into a depression in which his own would fit, and directing a series of copulative acts, anoiuting the penis, etc. That small size is only relatively a cause of impotence is evident, and that it by no means involves sterility is shown by Orfila,' in a case where an action for rape was brought against a man with only the stump of a glans in place of the full penis, by a woman who was impregnated by him. Orfila decides that impregnation may take place under these circumstances, but only through the consent of the woman, and that rape is consequently impossible. The numerous cases on record where impregnation has taken place without rupture of the hymen shows that a deposit of semen within the ostium vaginae may fertilize an ovum, and such a deposit of semen might be accomplished by the smallest possible penis. Intromission and ejaculation might take place, and im- potence, though possible (as in Roubaud's case), is not necessary. The patient is not sterile. 3. Extreme size of the penis is a (relative) cause of impotence Under the same head might be ranged double penis, with common cuta- neous sheath (Case I.). 4. Extreme epispadias and hypospadias, with or without extreme in- curvation (p. 38), involve impotence, without sterility. Extrophy of the bladder the same ; and, although, as in Huguier's * case, copulation might ' A case has been encountered by the authors. ' Op. cit., p. 160. ' "MiSdecine legale," vol. i., pp. Ill, 118. * Oaz. des H6p., 1840, p.46Y SYMPTOMATIC IMPOTENCE. 449 be possible with extrophy, yet intromission of semen would not take place, and impotence would be inevitable. The female with extrophy is neither impotent nor sterile. Slight hypospadias may, but does not necessarily, involve impotence. The semen is not properly ejaculated into the upper part of the vagina, and impregnation sometimes fails to take place — through the fault of the male. A very short frenum may act in the same way as slight hypospadias. 5. Large size of the prepuce, excessively tight and narrow orifice of the same, may involve impotence, as may also any tumors or growths upon or about the penis, elephantiasis, fatty tumor, hydrocele — or neigh- boring deformity, as faulty position of the thigh from anchylosis of hip, excess of abdominal fat, etc., all of which may mechanically interfere with copulation without in the least implying sterility. 6. Very tight stricture of the urethra, especially if there be large and multiple fistulse behind it, may involve impotence. The semen does not escape by ejaculation, but dribbles away after erection subsides. A similar cause of impotence exists in a vicious direction of the orifices of the ejaculatory ducts, by which the semen, during ejaculation, is turned backward into the bladder, and escapes afterward with tlie urine, as in Peyronie's case,' or from prostatic disease. According to Grimaud de Caux," such a condition of things may be caused by the action of a cer- tain class of Parisian prostitutes, who, fearing pregnane}', watch for the moment of ejaculation, and then press forcibly upon the urethra of their partner just in front of the prostate, by inserting a finger into his rec- tum. By this means the veru montanum, the natural dam to prevent reflux of semen into the bladder, is forcibly turned backward, and finally, by a repetition of the act, assumes a fixed, faulty position, and the in- dividual remains impotent, ejaculating his semen into his own bladder. 7. The peculiar affection called aspermatism is impotence. The patient is not sterile ; his copulation is perfect, except ejaculation. 8. Imperfect, irregular, bent erections, due to inflammation of (p. 34) or deposits of various kinds in the sheaths or substance of one of the erectile cylinders of the penis, may sometimes be extreme enough to prevent intromission, and entail impotence. 9. Eunuchs, and patients having atrophy of both testicles, are usu- ally impotent, always sterile. 10. Planque ° mentions a case where a blow on the head was followed by permanent loss of erection. The same may follow prolonged sper- matorrhoea, or excessive and continued masturbation. 11. Impotence may be symptomatic — not to speak of the physiologi- cal impotence of childhood and old age — and then is only conditional or temporary, and disappears usually with the removal of the cause. Im ' Quoted by Orfila, " Traits de M6d. legale," fourth edition, vol. i., p. 186. " "Pliysiologie de I'EspSce," Paris, 184 Y, p. 337. • " BibliothSque ohoisie de M^decine." i50 MALADIES INVOLVING THE GENITAL FUNCTION. potence depending upon most of the conditions already enumerated is, critically speaking, symptomatic, such as impotence from local deformity or overgrowth, or obesity, or stricture ; but the term " symptomatic" is used to make a class apart from idiopathic impotence, in both of which the entire sexual tract and. the penis are seemingly in good condition. A single example will illustrate the point : A. has double syphilitic or- chitis ; has no desire, no erections, has, in short, impotence symptomatic of syphilis. Prompt treatment is employed; his testicles return to a normal state, his erections reappear, and he is well. B. has the same condition of the testicles, the same impotence, but he employs no treat- ment ; both testicles go on to atrophy, and he passes from a condition of symptomatic into one of true impotence, with sterility as well. In symptomatic impotence there is always lack of erection, and of- ten also temporary sterility. Under the head of impotence symptom- atic of intoxication, Roubaud mentions, as causes, hashish, camphor, iodine, antimony, arsenic, lead ; and, although some of these have some influence over the sexual function, it is well not to over-estimate their power. The supposed efficiency of iodine in producing atrophy of the testicle is largely hypothetical, and evidently based, to a great extent, upon the influence of iodine over syphilitic enlargement of the testicle, and the coincidence of atrophy of the same after an ineflBcient course of iodine. Symptomatic impotence, broadly considered, is found in connection with all acute (general) febrile diseases, more or less marked with all cachexias, in connection with any advanced condition of disease of the testicle, especially with syphilitic testis, often depending on syphilis, without any appreciable afiection of the testicle. It is encountered with severe varicocele and neuralgia of the testis, with bad cases of sperma- torrhcea, and as a result of the lack of tone of the genitals, produced by long-continued excess — especially by masturbation — ^with severe diabetes and other advanced devitalizing diseases. Roubaud relates an exceed- ingly interesting case of S3-mptomatic impotence, where a patient ap- plied to him with large double hydrocele, and was entirely impotent. Roubaud supposed that the continued pressure of the hydroceles had caused atrophy of the testes. He punctured on both sides. The pa- tient recovered his potence, and impregnated his wife. He lost power again when the sacs refilled. The testicles were not atrophied. 12. Finally, impotence may come on without assignable cause ; but there are certain well-recognized causes which, acting upon certain sub- jects, are capable of producing impotence, more or less prolonged. Partial erection, attended by rapid ejaculation, is a not uncommon variety of impotence, due usually to continence, over-excitement, etc., and observed in animals as well as in men. In such cases also there will be found, not infrequently, a neuralgic condition of the prostatic sinus, and the treatment usually most effective is that of neuralgia of the vesi- FALSE IMPOTENCE. i51 cal neok, with, perhaps, the use of tannin, with the cupped sound, local external applications of cold water, and general hygienic measures. These means, aided by the confidence with which a physician should in- spire his patient, and the counsel to be deliberate in the sexual act, and to practise it in the early morning rather than the evening ; or even to trust to a second effort, rather than place all hope upon the first, will usually overcome this variety of impotence. Circumcision may some- times be necessary to diminish the sensitiveness of the glans penis, which is often over-acute. FALSE IirPOTBNCE. False impotence is an affection which the practical physician is often called upon to treat. True impotence involves the treatment of the phys- ical irregularity, deformity, disease, cachexia, etc., giving rise to it. False impotence requires a treatment of the individual, and not of any disease. In false impotence the cause is always nervous, or, it may be, a moral one ; and there is often no impotence at all, except in the mind of the individual. Here the surgeon requires all his delicacy, all his sym- pathy, in order to obtain the confidence of his patient, overcome his sus- picions, and gently lead him to a cure, which is always possible, if only the patient have faith. Among the causes of false impotence may be mentioned sexual in- difference, either temporary and spontaneous or more or less prolonged, as a result of sudden shock, grief, excessive joy, fright, repugnance, lack of affection for the individual with whom copulation is attempted. Under the two latter circumstances, the patient will sometimes think of another person than the one with whom he is Ij'ing, and thus main- tain erection and effect ejaculation. The sudden flooding of the vagina with warm mucus will sometimes cause erection to cease at once. Drunkenness, which is not habitual, may induce temporary impotence. Roubaud mentions a curious case where impotence came on with an indigestion, and remained long after its cause had disappeared. He speaks ' of another man who became impotent on drawing a prize of thirty thousand francs in a lottery. Another curious case of false impotence is related by the same author : ' A young man brought up in the country was, at the age of fourteen, initiated into the mysteries of Yenus by a young friend of the family, twenty-one years old Her hair was light, and worn in curls, and, for precaution's sake, she never had intercourse with the boy except when dressed — that is, wearing a corset, high boots, and a silk dress. The boy yielded for the sake of pleasure, but had no affec- tion for the lady. She was passionate, and drew largely upon his young powers during four years, after which he went to the military school. On entering garrison, he found that he had full sexual powers, * Op. cU., p. 186. ' Op. dt, p. 439. 452 MALADIES INVOLVING THE GEXiTAL FUXCTIOX. but that they were aroused only by certain -womeTi, and under certain circumstances. A dark beauty had no power over him, and a night- dress extinguished all his fire. In short, he found himself utterly im- potent except in the company of a light-haired woman, wearing curls, with high boots, a corset, and a silk dress. This false impotence had a powerful hold over him. Twenty-five years after having left his seducer it was still upon him, and that, too, in spite of his having meantime fallen desperately in love with a bru- nette, to whom he was afraid to offer himself on account of his inca- pacity " d'exercer le coit dans le neglige de la couche conjugale." In this case, the exercise of tact, aided by an aphrodisiac potion of cantharides and phosphorus, in time effected a complete cure. An equally instructive case, illustrative of false impotence, occurring in the practice of PeirUhe, is related by Grimaud de Caux,' of a cele- brated mathematician, who married a young and beautiful woman, whom he loved tenderly. He felt the power of her charms, and could commence the sexual act creditably, but, although they both ardently desired a child, before the moment of ejaculation arrived, the thoughts of the philosopher would unconsciously stray toward some favorite and engrossing mathematical problem, and erection would fail. A cure — at least to the extent of making Mr. father to several fine children — was effected by instructing his wife to get her husband partially intoxi- cated before accepting his approaches — ^the success of the expedient establishing the truth of the old adage : " Sine Cerere et Baccho friget Venus." Treatment. — This form of moral impotence requires special attention to all the agencies which may be active as causes, and the exercise of patient tact, and often of sympathy to acquire and retain the patient's confidence, a point of treatment most essential to success. The sur- rounding hygienic conditions must be made favorable, the advantages derived from change employed, all indications of deviation from health in any respect appropriately met. It is necessary to arouse the moral sentiment of carnal desire, as well as the power of the organs, locally, to respond. The first is attained by favorable relations to the sex — opera, theatre, etc. The second, by general dry frictions of the whole body, by massage and flesh-brush ; cold-bath ; sea-bathing ; generous diet, and the internal use of tonic medication; the mineral acids, strychnine, ergot, and especially phosphorus and cantharides, or the two combined, commencing at a fair dose, one-fortieth of a grain of the former to ten drops of the tincture of the latter, three or four hours before the desired erection, and increasing the dose carefully. Can- tharides produces erection without desire ; phosphorus is apt to in- crease desire directly. Cold and heat, by the douche, electricitv, and ' Op. at., p. 341. NERVOUS IMPOTENCE. 453 local applications o£ mustard, are sometimes serviceable in recallino- erection. In one case of syphilitic impotence, decided advantage was derived from the use of a quack-treatment, by an instrument called the equalizer, a large cell, in which the patient sits with his head out, and from which the air is exhausted. (A modification of the ventouse &norme of the French.) JVervous impotence, the most common form of false impotence, encountered frequently in young men, remains yet to be described. The patient is young and usually healthy. He has generally mastur- bated more or less, and has nocturnal pollutions. He has usually plentiful evidences of virile power. He has desires, which are some- times excessive. He awakes with erections. He can provoke erection or even emission, at will ; but, in presence of a woman, and when he desires to have sexual intercourse, his organs will not respond ; or if erection comes on, it lacks full energy, and is liable to fail at any mo- ment during the act. In short, the patient can do any thing he wishes, except that he cannot rely upon an erection at the critical moment. This form of impotence is the result of unnatural excitement of the sexual functions. It may come from protracted chastity, ungratified desire, or excessive erotic excitement at the moment. It is not infre- quently accompanied by involuntary emissions during sleep, and by the occasional escape from the urethra at any time of a semi-transparent, viscid fluid furnished by the urethra and prostatic follicles. The most persistent and obstinate mental dejection usually accompanies this form of impotence. Under the pressure of imperious desire, and after pro- longed chastity, the sufferer has probably approached some incongruous female, and at the portals of success his erection has failed him. The mental depression following an experience of this sort is of the most exaggerated nature, the existence of impotence is considered as demon- strated beyond cavil, and hope is obstinately banished from the horizon. The seminal fluid, it is assumed, is escaping in the urethral discharges, and with it manhood and vitality. These ideas are intensified by the cunningly conceived advertisements of charlatans, with which the swarm- ing newspapers abound, and the patient is still further enveloped by them in despair. False promises of cure often tempt him to a trial, and their failure relegates him to the surgeon sooner or later, more than ever deeply despondent. Such oases, which are unhappily not rare, require for their management all the ability and tact that can be brought to bear upon thera. Treatment. — ^The best treatment for a man with nervous impotence (who invariably awakes sooner or later with an erection) is to patiently instruct him in sexual physiology and hygiene, acquire his confidence by sympathy, and get him married, with the advice to attempt no inter- course, to be entirely frank and honest with his wife (who will more than equal him in timidity and ignorance), and, awaiting some morning 154 MALADIES INVOLYDfG THE GENITAL FUNCTION. when awaking with a vigorous erection, to accomplish coitus promptly, without delay or dalliance, as a matter of imperious duty. The act once accomplished, the charm is broken. The use of the steel sound and of local applications of tannin, with the cupped sound (p. 451), often of decided service where ejaculation is too rapid, is also sometimes use- ful here. STEEILITY. The consideration of sterility is so interwoven with that of impotence, that but little remains to be said. Sterility is ' an inability to beget children, on account of absence or imperfection of the semen, and in many such cases there is impotence as well. All eunuchs are sterile ; when both testicles are degenerated or destroyed by disease or atrophy, or retained as in cryptorchids, (usually), sterility results. In two special conditions there is sterility without impotence, namely, obliteration of the canal of the epididymis, after double gonorrhoeal epididymitis, and obliteration of the orifices of the ejaculatory ducts, after stone or opera- tions, from cauterization of the prostatic urethra with solid nitrate of sil- ver, after the process of Lallemand. Of the latter we see and hear little in this country at the present day, but, according to Grimaud de Caux, in his time the instrument of Lallemand made more eunuchs than did the demands of the harems of the East. Whenever the seminal duct is occluded on both sides at any part of its course, sterility is the natural result, since the spermatozoa cannot reach the urethra, but, under these circumstances, if the testicles are healthy, the patient is fully potent, his desire, his erection, his ejaculation, his pleasure, are normal ; his ejaculated fluid resembles semen in every respect except that it contains no seminal element. The relief of sterility depends upon its cause, which often cannot be directly reached by treatment. SBLP-ABTJSE. Self-abuse is the production of the venereal orgasm upon one's self. The term masturbation signifies that an orgasm is produced by means of friction with the hand, as it most commonly is. Masturbation is not a malady. It does not necessarily produce disease, unless it is carried to excess. The practice of it is not confined to man. Monkeys are often masturbators, bears have the same habit, goats, making use of the mouth, indulge in it, turkeys sometimes practise it upon a round object, like a smooth stone. In the human being it is practised by both sexes, at all ages. Females are much less given to it than males. The majority of women have very little passion, and suffer the approaches of a lover or husband largely as a matter of complaisance. There are undoubtedly numerous exceptions to this rule, but still a rule it is that the female, naturally modest, retiring, refined, learns what passion is only as the result of education after marriage. With the male it is SELF-ABUSE. 455 different. His passion is natural. He often has erections while yet a child, and sexual yearnings long before puberty. Planque ' mentions two children four years old whose sexual organs were so developed that they could perform sexual intercourse. Rarely does a boy escape an initiation into forbidden pleasures by his school-feilows, or his elders, and, when he escapes these, he is still very apt, when handling himself during erection, to find the sensation agreeable, and go on, really ignorant of what he is doing, until he becomes a confirmed masturbator. Male babies are sometimes handled by their nurses to keep them quiet, a practice which is certain to beget the habit, even in the earliest years of life. Stone in the bladder, irritation of the prepuce from retained smegma, traumatic stricture and bladder-disease, ascarides, etc., lead a child to handle himself, and inevitably end in masturbation, if long enough continued ; indeed, there are so many causes, natural and un- natural, why a boy should masturbate, that probably few escape. The most common incentive, however, is undoubtedly instruction, and this is usually received by children from other boys at school. It may be safely assumed that a large proportion of mankind have at some period of life masturbated more or less, and it is equally safe to assert that at least ninety per cent, of such masturbators are not physi- cally injured by the habit. Sexual indulgence in the natural way will produce evil effects if carried to excess, yet it is probable that sexual intercourse is not only harmless, but even beneficial in moderation, when carried on naturally — as it can be only in the married state (p. 40). It is not the loss of seminal fluid which is of the first importance in producing disease from sexual excess, but the nervous shock of the oft-repeated orgasm. Babies and young children lose no seminal fluid, women have none to lose, yet, in all of these, evil results follow excess, as certainly as they do in the male after puberty. It is probable that any succession of nervous shocks as sharp and decisive as the sexual orgasm, even although they were purely intellectual, such as joy or fear, would shatter the vitality and nervous tone of an individual, per- haps as much as masturbation. Such writers as Lallemand, Acton, Belliol, certainly make too much of the solitary vice, while quacks find here the largest and most lucrative field for their nostrums. The latter scatter their books and circulars broadcast over the land, and often, under alluring titles, thrust them within the eager grasp of the young, the inexperience,d, the hypochondriacal, of the nervous, overworked, un- married youth, whose sexual needs, stimulated by his impure thoughts, do not find adequate relief. Here their tenets find ample faith and ready acceptance, and errors are implanted in the ingenuous mind which years of sober after-thought and experience, aided by the surgeon's care- ful and conscientious advice, are scarcely able to eradicate. Self-abuse is not confined to youth ; middle and old age are not free from it. ' Op. cii., Art. " Aocroisement." i56 MALADIES INVOLVING THE GENITAL FUNCTION. The numerous foreign bodies found in the urethra and bladder attest the tendency that men of all ages have to meddle with their genitals. Dr. J. R Wood, of New York, has a long, thick, leather thong which he was called upon to remove from a patient, who had introduced it through his urethra into his bladder, and amused himself by working it backward and forward until the free end in the bladder became knotted, and Dr. Wood was called upon to extract it, finding the patient with several inches of the thong projecting from his meatus. The use of tobacco, alcohol, and, it might be added, tea, is as wide- spread as is the habit of masturbation ; and each of these habits, or cer- tainly the first two, inflict as much injury upon the human race as, in all probability, does the secret vice ; yet who would affirm that every man ■>.vho smoked would have headache, dyspepsia, heartburn, neuralgia, in- termission of the heart-beat, etc., would become thin, depressed, nervous, sleepless — effects all of which may be produced by an excess of tobacco; or that another who drank liquor would necessarily have delirium tre- mens, cirrhosis of the liver, fatty kidney, and die with ascites and Bright's disease ? As it is with whiskey and tobacco, so is it with mas- turbation carried to excess. It is capable of producing, it must be recog- nized, the most serious results, among which idiocy, insanity, epilepsy, dementia, physical prostration, hypochondria, impotence, and sterility, are prominent, but these are practically very rare — so rare, indeed, that they are encountered, as a rule, only by the specialist, and very rarely by him ; and, finally, even when these serious results can be traced to masturbation as a fiirst cause, it will often be found that some othei cause has acted in conjunction with the masturbation, such as a blow on the head, hereditarj' tendency to the disease in question, natural feeble- ness of nervous tone, irregular and self-indulgent habits, abuse of stimu- lants, syphilis. Hence it becomes plain that, while the intelligent physi- cian must recognize the possible physical evils produced by masturba- tion, he should oppose himself boldly to that sickly sentimentality which shrouds in mystery one of the failings of our physical nature, because it involves the sexual function, and should try to look the subject honestly in the face, and handle it as if it were a problem in mathematics. Looking at masturbation in this wa}-, the truth is, that the majority of mankind who indulge in it do so just before and after puberty. Most of them are ignorant at first that they are harming themselves, but thev soon find it out by one means or another, and then sooner or later give it up. The longer and the more frequently they yield to the vicious habit the stronger aoes its hold become, so that in case they escape the mental and physical disorders to which excessive venery in extreme cases may give rise, still they may pay the penalty of excess by some diminution of vigor in after-life, by throwing confusion into their sexual hygiene, and establishing sexual necessities which they find it difficult to meet suitably; and, finally, they may continue on through life victims SELF-ABUSE. 457 to a perverted sexual sense, shunning women, from -whom they aver that they derive no pleasure, totally vcreoked as to their morale, often hypo- chondriacs, and suffering from all sorts of functional distress, physical and intellectual, real and fancied. The chief reason why so much is said of venereal escess by mastur- bation, and so little of sexual excess, in the natural way, is, that the former is so much more common, and not that the act itself is physically more harmful. The solitary vice, as it is aptly styled, may be practised on all occasions, even in company, by the hand in the pocket, or by friction against some prominent object. In schools, not infrequently, boys practise it upon each other ; but, generally, masturbation is per- formed in bed, and in solitary places, where there is no possibility of disturbance. Hence the frequency of its performance is, in some cases, very great, and the effects of often-repeated nervous shock more pro- nounced. Sexual intercourse, on the other hand, requires the consent of two individuals, and opportunities which, relatively, are hard to find. Moreover, a man's moral sense will often keep him from committing excess with a woman, when nothing will restrain him while alone. In married life, excess is the exception ; sexual hygiene is more apt to be correct, man is in his natural condition, other emotions enter largely into his daily life, and it is rare that the surgeon encounters in his prac- tice a man happily married complaining of any disorder of the genito- urinary system, except those of a purely physical nature. Symptoms of Masturbation. — ^A young child, who has been taught to masturbate, will be seen constantly at work at his genitals, and ob- served to have erections with unnatural frequency. No further signs are needed. Such children become fretful, peevish, thin, nervous, ex- citable. They sleep badly, have a haggard look, seem to be prone to convulsions, and, it is said, are apt to have epilepsy. Boys who masturbate to excess usually have a long prepuce (they may have none, for Jews masturbate) ; they get a sallow look, have a sheepish, hang-dog expression ; their ej'es are deep-set, they incline to melancholy broodings, to sitting by themselves, and reading over a fire rather than to joining their companions at play. They become absent- minded, and their memory seems defective. The hand is apt to be cold and moist in the palm. The skin is often pallid ; the innocent frank- ness of youth is absent. The young man is over-shy, unambitious, he shrinks from a steady gaze, blushes readily, and seems to be conscious of having done some- thing unmanly and little. Men who masturbate often show no sign of the habit. They are apt to be cowardly, mean-spirited, poor specimens of humanity ; but it is rare for adults to practise masturbation to great excess, and, if they suffer from any of the supposed evil consequences of the habit, it is either on account of excess in earlier life, on account of imperfect iSS MALADIES INVOLVING THE GENITAL FUNCTION. sexual hygiene, or irregularly gratified sexual desire, their symptoms assuming a multiplicity of expression, and generally being such as are arranged under the term hypochondria, and manifestly not dependent entirely upon masturbation, since the same symptoms are very common ia patients who do not masturbate, who, indeed, are perfectly conti- nent, and since they are not infrequently relieved by marriage. As to atrophy of the genitals, varicocele, chorea, epilepsy, idiocy, insanity, it is quite doubtful if these are often due to masturbation, acting alone ; and although this vicious habit may be the most important cause in a given case, and should always be sought for, and if possible corrected, yet undoubtedly usually some other obscure cause of disease is in action, and is, perhaps, to blame for the masturbation as well as the idiocy or epilepsj-, as may be inferred from the following (personal) case: Case XL. — A young lad, vrliose intellect was beginning to fail, was frequently caught in the act of masturbation. All moral, physical, and medical means to correct the habit having proved ineifective, as idiocy was becoming more pronounced, the parents de- manded castration as the only means of saving the intellect of the child. Instead of cut- ting out the testicle, it was decided to exsect a portion of the vas deferens on either side, which was accordingly done. The operation was of no advantage, the intellect failed until idiocy became complete, and the testicles both went on to atrophy. AYhen last seen, the idiot was sitting in the comer of a cell in the institution to which he had been sent, fingering himself vigorously, and crying because he could not get an erection. If it had been loss of semen, in this case, which was producing the loss of mind, the cutting of the seminal ducts would have arrested the progress of the idiocy ; furthermore, there must have been some cause at work, which was not apparent, for atrophy of the testicles followed exsection of the ducts, of which physiologists have proved it is not the result (Curling). The same cause which produced the atrophy of the testicles was in this case undoubtedly to blame for the idiocy. Some- times, after a severe blow on the head, the intellect fails, epilepsy comes on, the boy approaches nearer to the brute and is found to masturbate in excess, and this result of his injury frequently is blamed as the cause of all his troubles. The foregoing remarks are not intended to palliate, in the least de- gree, the baseness of the practice of self-abuse, or to deny that lack of physical and sexual vigor, spermatorrhoea, neuralgia of the urethra, etc., may be frequently caused by its excessive indulgence, but they are ki- tended to oppose the idea, seemingly so prevalent, that very few men indulge in the secret vice, and that all who do so suffer ; and they are also intended to advance the proposition that in the vast majority of instances masturbation does little harm to the individual, except in regard to his morale. It unmans him, makes him untrue to himself, and cowardly; and most sensible boys find this out before a great while, and give up the practice, which they feel to be sapping their man- hood and self-esteem. Treatment. — It is infinitely better that a boy should never mastur- SELF-ABUSE. 459 bate, if lie can be saved from it. Prophylactic treatment may save him. In the case of babies who do not do well, nurses should be watched, and discharged as soon as there is any evidence that they are handling the child. If the infant have already acquired the habit, his hands must be tied when he sleeps, and at all other times he must be watched, untU he grows out of the habit. Boys should always be made to sleep alone, never allowed to consort habitually with any other boy, especially if the latter be the older ; all close intimacies between boys of different ages should be broken up, and, on the appearance of any of the signs of masturbation, a close watch should be kept up. It is not good policy in most cases to ask a boy if he fingers his privates. He will be pretty sure to say no, and then to tell other lies to substantiate the first. It is the safest course to assume the fact after a careful study of the case, and the boy, thrown off his guard by the statement that he does masturbate, will rarely deny it, or will do so in such a feeble manner — occasionally with such over-positiveness — that he will convict himself. Finally, when the patient has confessed his folly, it is not wise, in most cases, to try to terrify him out of his habit by brilliant and exaggerated statements of the possible misery he may bring upon himself if he does not stop. This is appealing to a base motive, fear of an indefinite evil in the future, and, although sometimes successful, it is often inadequate to the proposed end, for a healthy boy cannot realize what it means to be sick; he cannot understand it, and consequently is not afraid of it. The method of treatment which is most effective, but at the same time the one which requires the most force to carry out, is to elevate the boy out of his bad habit, to shame him, to make a man out of him, to reason with him, and talk to him honestly and openly, without reserve or mysticism ; to sympathize with him, not to wound him ; to study him and treat him morally. This course will succeed with the greatest number, provided only suiBcient time and attention be given to it. When a man comes complaining of the results of masturbation, an attentive study of his symptoms will not infrequently disclose his disease to be hypochondria, and his malady ungratified sexual desire, with often some neuralgia of the vesical neck. His training should consist in en- couragement and continence, with absolute purity of thought, and sub- sequently marriage, to regulate his sexual hygiene. After marriage it is rare to hear any further complaint from these cases — always provided there is really nothing more than functional derangement at the bottom of the patient's complaint, as is the case in the vast majority of in- stances. As for medicines, they are of little or no value ; camphor, bromide of potassium, or lupulin, might be given as placebos, but it is doubtful if they are of any efiScacy. Cold sponge-baths, out-door sports, physi- cal fatigue, sleeping in a cool room on a hard bed, with a light covering, 4,G0 MALADIES IXYOLVING THE GENITAL FUNCTION. are all useful ; eating lightly at night, not retiring until very sleepy, and rising immediately on waking in the morning, are powerful assistants in breaking up the habit, but all will be of no avail unless the morale of the patient be elevated, unless he keep his thoughts pure, and desire, for the manliness of it alone, to be rid of his bad habits. POLLUTION. Pollution is a term applied to involuntary emissions of semen in ejaculation, attended by a venereal orgasm, more or less marked. Pol- lutions are nocturnal or diurnal. Nocturnal pollutions are exceedingly common. They usually accom- pany an erotic dream, and the patient wakes just as the ejaculation is occurring. Sometimes, when sleep is profound, the patient does not wake, or, if he does, he forgets his dream. The sensation of pleasure undoubtedly accompanied ejaculation in these cases, but was faint, and forgotten. Xocturnal emissions in moderation are entirely natm-al, and by no means a sign of disease. Their frequency compatible with health varies with the purity of mind and the sexual vigor of the patient. A man who is happily married rarely has nocturnal emissions whUe living with his wife, but, if he leaves her for several weeks, it is natural, and entirely the rule, that there should be a formation and collection of semen which, distending the seminal vesicles, excites erotic fancies, and, in the relaxed condition between sleeping and waking, escapes at the conclusion of a dream. Any man suffering from ungratified sexual desire is normally in a condition demanding relief for his over-distended seminal vesicles, and, if that relief be not afforded in some way by the patient, it will come spasmodically during sleep. This is all the more certain to be the case if the patient has established a habit of rapid formation of semen by frequent calls for a supply of the same in exces- sive sexual intercourse, or masturbation practised as a habit for a consid- erable length of time: and especially if, when natural or unnatural gratification is given up, lascivious thoughts are indulged in, and im- pure associations continued. Occasionally nocturnal emissions may be over-frequent, and indicate a condition of irritation in the deep urethra — some modification of neuralgia of the vesical neck which requires treat- ment. Treatment. — -When emissions do not exceed three times weekly they should be disregarded, and attempts made only to purify the thoughts of the patient, elevate his tone, and get him, if possible, happily mar- ried. "SVhere they become very frequent, as nightly or several times a night for a considerable time, besides the employment of aU known tonic and hygienic means and the measures detailed above, certain special attempts to correct the habit are advisable. The patient should exercise and develop his muscular system. He should endeavor to sleep soundly by tiring himself out through the day by physical work. Dry frictions, SPEKMATORRHCEA. 4gj cold bath, cold douche, locally, are useful. He should sleep on a hard bed, lightly covered. The stomach should not be full on retiring. Most patients have involuntary emissions toward morning, and, waking, find themselves lying on their back. This position, with the bladder some- what distended, tends to beget erection, and, by avoiding it, pollution may be escaped. This is accomplished by causing the patient to tie a towel round his waist on retiring, with a hard knot in the back over the spine. When he lies upon this knot it will wake him. Besides these means, among all of which purity of thought comes first, bromide of potassium, camphor, and lupulin, may be given internally, with strych- nine and a mineral acid, or such tonic as the physical conditions seem to call for, and locally decided advantage may be derived from the gentle use of the steel sound, as in neuralgia of the vesical neck, and finally the cupped sound with tannin, as in spermatorrhoea, or possibly a stimulat- ing prostatic injection. Diurnal pollution is rare. In some impressionable patients, espe- cially if suffering from prostatic irritability due to venereal excess, the sight or thought of certain women will produce ejaculation, as may a touch upon the glans penis. Ejaculation of semen may be produced by a variety of causes. Lallemand ' speaks of a man who could produce it by striking his head with his knuckles. Sudden injuries to the spine sometimes produce the same effect. Lallemand quotes from Hedelhofer that a man fell upon the sacrum, and immediately had an ejaculation. In decapitation by the guillotine, unless the neck is severed too low, ejac- ulation is quite common. The treatment of diurnal pollution is by steel sounds and local astringents to the prostate, together with most of the means detailed for nocturnal emissions. Circumcision should be performed if the glans penis is sensitive. SFiEBMATOKRHCEA. Few terms are more abused and distorted in their significance than spermatorrhoea. The young man into whose hands some pamphlet on " Manhood Restored " has fallen, imagines himself hopelessly doomed to impotence, paralysis, and idiocy, because he has spermatorrhoea, which spermatorrhoea consists in nocturnal pollution, escape of mucus during prolonged erection, appearance of amorphous phosphates in his urine — often in a gleety discharge, due to stricture or a damaged patch of mu- cous membrane in the urethra, and sometimes, where the diseased mind of a youth suffering from ungratified sexual desire can find nothing else to confirm its suspicions, the natural, healthy, flocculent cloud of mucus collecting normally in all urine, after it has stood a while, is pointed to, in dejected triumph, as a demonstration of the never-ending loss of seminal fluid. Occasionally a patient will even bottle his urine and keep ' " Dea Pertes seminales," Montpellier, 1836, 1842. i62 MALADIES INVOLVING THE GENITAL FUNCTION. it a week, until it has decomposed, and then bring it to the surgeon in its murky condition, to prove that he has " spermatorrhoea." Most of the symptoms which a patient usually mistakes for sperma- torrhoea have been already disposed of in other portions of this work, and need not be again alluded to (gleet, phosphatic urine, vesical mu- cus, decomposing urine, etc.). It falls to the lot even of the specialist to see but very few cases of true spermatorrhoea. Spermatorrhoea is an escape of seminal fluid containing spermatozoa, without ejaculation and without pleasurable orgasm — usually at stool, with the urine, or, to a slight extent, at all times. During prolonged erection under intense sexual excitement, a small amount of true sem- inal fluid is apt to escape into the prostatic sinus, and to be passed at the next urination. This may happen to any one occasionally, and does not amount to disease. Causes. — Spermatorrhoea sometimes follows excessive masturbation, occasionally it appears as a sequence of acute general prostration — as after typhoid fever ; it may come on in connection with imperfect diges- tion and general nervous distress from overwork or other cause, or fol- low chronic disease, of the inflammatory type, of the floor of the prostatic sinus and seminal vesicles. S>/mptoms. — ^In true spermatorrhoea it is usual for spermatic fluid in small quantity to pass from the meatus during defecation, especially if the patient is constipated, and for a certain amount of the same fluid to be voided during urination, particularly in the morning ; while, occa- sionally, jolting, riding, etc., cause a little oozing of a bluish fluid from the meatus, which, on examination, is found to contain spermatozoa. These symptoms alone constitute spermatorrhoea, or indeed the disease may be said to exist where the urine habitually contains spermatozoa, although no semen, as such, is involuntarily passed through the urethra. The subjective symptoms of spermatorrhoea are most varied — very often the patient does not know he has the disease. He complains of some feeling of weight in the prostatic region, of dyspepsia or some nervous derangement, has little care for his sexual functions, and is not disturbed on the subject of impotence ; presents, indeed, a most strongly-marked contrast, as far as expressions of distress go, with the hypochondriacal patient imagining himseK impotent from spermatorrhoea, and taxing the capacity of his language to express his woe. Patients with true sper- matorrhoea are not by any means necessarily impotent, but their sexual appetite is always small. In many cases, however, the general symp- toms are those of great lack of nervous tone, dyspepsia, headache, mel- ancholy, neuralgia, loss of spirits, pains in the back, groins, testicles. Such patients tend to grow thin, to lose their ambition and their zest for all ordinary pursuits, to run down, become fanciful, indeed hypochondria- cal, and often to fret seriously and unceasingly about their malady, of which they entertain only faint hopes of a cure, which they urgently de- SPEEMATOERH(EA. 463 mand. Finally, in the most severe cases, all the above symptoms are aggravated ; the penis shrivels, the testicles become small, flabby, very sensitive, not infrequently neuralgic, the veins of the cord large and full ; the loss of semen continues for a long time, finally becomes thinner, more like simple mucus, and at last ceases to contain spermatozoa, being made up of the fluids of the seminal vesicles, the prostate, and Cowper's glands. At last the patient becomes truly impotent, incapable of erec- tion. Treaimeyit. — All the hygienic, general, and local measures advised for cases of pollution and sexual weakness, already given, become impera- tively necessary in treating true spermatorrhcea, with the hope of success in mild cases, and without despair . in severe ones. The use of the steel sound and of elec- ™ tricity helps to give tone to the parts. Roubaud thinks well of ergot — two to eight grains daily — in atonic " cases. The use of a local astringent to the prostatic ^ sinus is often of marked advantage. The best agent for effecting this is tannin, and the cupped sound the most convenient method of applying it. The cupped sound (Fig. 130) is an ordinary steel instrument, of rather long curve, with six little cups, each as large as a pea, three on either side of the convexity of the curve. In the cups is placed a solid paste of glycerine and tannin, and the instrument is ready for use. In making the application, a steel conical sound, as large as the urethra wUl conveniently admit, is first introduced, and immediately withdrawn ; then the charged cupped sound is oiled and rapidly carried down the urethra, until the cups rest in the -prostatic sinus. Here the sound is al- lowed to remain from one to five minutes, according to the effect desired to be produced. On withdrawal it will be noticed that more or less of the taniio-glyceral r paste has melted off and remained behind. The patient experiences some heat in the prostate, possibly pain, if the application has been prolonged. The next follow- I ing act of urination, which should be delayed as long as ' convenient, is usually attended by pain, possibly accom^ panied by a little blood, but the abnormal sensation soon I disappears. The applications are to be repeated once _ or twice weekly, according to the effect, and after a F.a. 130. gjj^jrt time a change in the symptoms for the better is usually manifested in mild cases. Should these simple means fail, re- course may be had to prostatic injections with the deep urethral syr- inge (Figs. 22, 23), a solution of nitrate of silver, not stronger than five to ten grains to the ounce, being used. Failing with this, hope 46dt MALADIES INVOLVING THE GENITAL FUNCTION. must be based upon the continuance of general and local tonic and hy- gienic measures. The use of the fused nitrate of silver with Lallemand's instrument is not justifiable, for fear of including the orifices of the ejac- ulatory ducts in an eschar,, and obliterating them by cicatrization. EROTOMANIA. Erotomania is a species of insanity. It is a disease of the central nervous system, characterized by the existence of erotic desires vrithout the power of accomplishing them, sometimes apparently without the wish to do so, as in a case, which is on record, of a patient so affected, who, when asked what he would do if put to bed with a woman, re- marked that he " would go to sleep." The malady is not a disease of the genitals, and does not call for any more lengthy description here. SATy-RIASIS. Satyriasis is constant desire with erection ; erotic delirium. It is also a brain-disease. An illustrative case is quoted by Acton,' of an old man who was eminently satyriasic, so much so that he would mastur- bate in the presence of ladies. Dying, a tumor of the size of a split-pea was found in the pons Varolii. PRIAPISM. Priapism is more or less continuous erection without desire. With some forms of priapism intercourse with ejaculation may take place. The connection between injuries of the cerebellum and spinal cord and erection has long been observed. Roubaud ' quotes Serres in stating that out of eleven cases of cerebellar haemorrhage erection of the penis was noted six times. Death by hanging is often accompanied by par- tial erection. x\fter injuries to the spine, and in some diseases of the cord, producing paraplegia, erections are often absent, returning as the paralysis improves. On the other hand, certain diseases and injuries of the cord are notably attended by priapism, disappearing as the para- plegia gets well. Lallemand ' quotes a case from Fages, of an officer who was thrown from his horse, and became at once paraplegic, and simultaneously had priapism. The latter annoyed him excessively, as it produced retention, relievable only by local and general refriger- ants, which reduced the erection. As his paraplegia gradually got well his priapism ceased. Lallemand gives another very interesting case * of a soldier who, climbing out of garrison to see his mistress, fell upon his sacrum and became partially paraplegic with priapism. He had no venereal desire yet, because the priapism interfered with his making water, he attempted 1 (( On the Reproduotiye Organs," fifth edition. ■-■ Op. cil. p. 280. Op. cit, vol. ii., p. 62. 4 On. citl, toI. ii., p. 64. PRIAPISM— ASPERMATISM. 465 frequently to free himself of it by masturbation, but without success- there was no ejaculation. On one occasion, with the mistress on at- tempting to see whom he had acquired his malady, he indulged in cop- ulation almost continuously for several hours, until he had exhausted his partner — but all to no effect. He had no pleasure or ejaculation, yet when asleep he had lascivious dreams, with ejaculation and slight sensation. This was a mixed case, since some of its characteristics are those of aspermatism. The effect of large doses of cantharides in producing erection with- out desire is well known. Prolonged mental exertion, over-anxiety, and other causes capable of reducing the tone of the nervous system are sometimes attended by priapism, due perhaps (immediately) to some local injury, as illus- trated in the following personal case : Case XLI. — A married gentleman of thirty-seven had gonorrhcea at twenty-seven. No functional or other distress followed for several years. After a time he had nocturnal emissions, for which a physician used the steel sound — causing slight epididymitis. Two years before his application for relief, a steel sound, .about No. 10, had been introduced. At the time he was overworked, and somewhat run down in health. The muscles of the membranous urethra opposed considerable spasmodic resistance to the passage of the sound. About one hour afterward he had a sudden severe pain at the neck of the bladder, " as if he had been shot," and shortly afterward his testicle began to swell. His priapism commenced at the same time. It never troubles him while awake, but after he has been asleep a few hours he has a distressing dream — such as trying in vain to catch a train — and wakes up with a powerful erection. This subsides shortly, but recurs at once on at- tempting again to sleep, and so continues waking him several times before morning. The erection is not accompanied by desire. He rarely has emissions. This state of things has been repeated nightly for two years, with the exception of one night. He has satisfac- tory intercourse with his wife once a week, but with no effect upon his nightly priapism. He has been under various treatments for two years, without benefit. His prostatic urethra had been cauterized, without bringing any rehef. General health seemed fair. Priapism in children is often due to stone in the bladder, tight pre- puce, worms in the rectum, etc. Extreme cases are on record where priapism has terminated in gangrene of the penis. Treatment. — Priapism usually gets well under hygienic and symp- tomatic treatment, beyond which no special measures can be suggested, except irritating the lower part of the spine, blistering the perinseum, an India-rubber seton at the nucha, possibly the use of electricity, and strychnine, ergot, bromide of potassium tentatively. ASPERMATISM. Aspermatism is a peculiar condition of very rare occurrence, amply illustrated in the foUovring (personal) type cases, one of which has been already published. There are erection, some desire, no ejaculation — in other words, impotence : Case XLII.— A married gentleman of thirty comes, complaining of inability to have children. He is spare, undersized, but healthy, and strong, straightforward, and truthful 30 i-QQ MALADIES INVOLVING THE GENITAL FUNCTION. in manner. He has lascivious dreams at two to six weeks' interval, attended by profuse seminal emissions. He can never, with hia wife or in any other way, provoke or bring about a venereal orgasm or a discharge of semen. The effort is attended by no pleasure at the time. He indulges once a month as a duty to his wife, and in the hope of a more success- ful issue. In his dreams he has a full orgasm and emission — awake, never. He has never attempted to mastuibate, or had any desire to do so. His prepuce being very long, cir- cumcision was performed, but neither that nor any efforts in the way of treatment proved beneficial. Case XLHI. — A farmer from the West, aged thirty-six, married at twenty-seven, comes with the following story : When first married, nine years ago, he had sexual intercourse three or four times weekly, latterly only once a month. During the first two years after marriage he frequently had intercourse three or four times a night, vainly trying to get an ejaculation. Before his marriage he never attempted copulation, and never in his life, he says, before, during, or after the sexual act, has he had the least pleasurable anticipation or excitement. He had intercourse only in the hope of producing an ejaculation, and having children, which he ardently desired. He is a plain-spoken, straightforward, honest, truthful farmer, living out-of-doors, eating well, performing all his functions excellently, but now s, little depressed by the fact that years of treatment have done hi m no good. He never masturbated, as he had no desire to do so. In sleep he occasionally dreams of sexual intercourse, and wakes with a pleasurable sensation, to find that he has had an emission of semen, which he discovers on his linen. His testicles are large and perfect, he has fuU, vigorous erections, and can have continuous sexual intercourse for half an hour, only stopping because he is exhausted, his erection continuing as powerfiil as ever A full-sized sound passed into his urethra produced the ordinary sensations in the fore part of the canal, but the prostatic urethra was absolutely insensitive. These two cases tell the whole story of aspermatism. In both of them there was undoubtedly a little desire by anticipation, or at least from memory of dreams, or the patient would not have indulged " three or four times on the same night." The theory advanced to account for this strange malady is that, by reason of spasm about the ejaculatory ducts, the semen is prevented from getting into the prostatic sinus. This, however, is untenable ; for, were there desire and pleasure, prostatic mucus would be secreted in excess, and would be thrown out by ejaculation, while the semen proper would collect and distend the seminal vesicles and ducts below the ejaculatory orifices, and would escape and flow away from the meatus, after the relaxation of spasm, brought about by the fatigue following " half an hour's sexual intercourse." But this is not the case. The fault is evidently in the nerves. There is no pleasurable sensation, no call for secretion of prostatic mucus, or for a supply of spermatic fluid. There is anaesthesia of the prostatic sinus, and, although the power of having an orgasm and an ejaculation remains, as proved by dreams, yet there is some connecting link missing in the chain, which transforms friction of the glans into pleasure at the prostate, and finally into secretion in the testicle. Treatment. — Roubaud advises antispasmodics, on the theory that muscular contraction is the essence of the disease. He speaks of suo- SPASM OF THE CREMASTER. ^.g/r cess in one case of a young man, by blistering the perineum, and pow. dering the surface for several days with morphine. Since the absence of sensation in the prostatic sinus is present in some cases, it is possible that the local use of electricity to that region might be of advantage, or even of astringents with the cupped sound. CHAPTEE XXVII. DISEASES OF TEE COED. Anatomy. — Spasm of Cremaster. — Varicocele, mild, severe. The cord is made up of the vas deferens, the habenula or remains of the peritoneal process going from the tunica vaginalis to the abdomen, vessels and nerves, all held in an atmosphere of connective tissue, con- taining unstriped muscular fibre (internal cremaster of Henle). Outside of these there is a continuous layer of connective tissue, adherent to the tunica vaginalis below, and continuous with the fascia transversalis above, called tunica vaginalis communis. Outside of this the cremaster muscle lies in loops, some embracing the testicle in a fan shape, others extending only a short distance down the cord. The arteries are the spermatic from the aorta, the deferential from the superior vesical, the cremasteric from the epigastric. The veins from the testicle and epididymis unite in the pampiniform plexus, and constitute the bulk of the cord. The larger veins have valves ; they unite usually to form one large trunk, which empties, on the left side, into the renal vein, on the right side into the ascending cava. The sper- matic plexus of nerves is derived from the renal, aortic, superior mesen- teric, hypogastric, and lumbar (genital branch of genito-crural nerve supplying the cremaster). The cremaster muscle varies in size and power, in different subjects ; it is a voluntary muscle ; most persons can exercise it simultaneously on both sides, drawing up and holding the testicles against the abdomen ; occasionally the muscles can be exercised separately, one testicle being elevated while the other is lowered. The function of the muscle is to assist in sustaining the testicle by its tonic contraction, and to compress the organ during the sexual orgasm. The muscle is subject to painful spasmodic contraction in kidney-colic, in neuralgia of the testicle, and sometimes in connection with prostatic or urethral irritation. A large portion of the cremaster muscle was excised by the late Valentine Mott, for obstinate spasm. Case XLIV.— Mr. , aged thirty-five, was married to a wife suffering from uterine iisease. His sexual relations were irregular and unsatisfactory ; he had slight stricture ^68 DISEASES OF THE CORD and neuralgia of the vesical neck. With this, he complained of painful spasmodic con- traction of the left cremaster during sexual intercourse. Eegular sexual relations with his wife, and the use of a steel sound, relieved all the symptoms. (For spasm of the cremaster, see also the case quoted at p. 372.) The spermatic cord is rarely diseased. There is more or less tur- gescence of the veins, with sensibility to pressure, in the different inflam- matory conditions of the testicle and vas deferens, and injury may lead to local inflammation, to be assuaged by rest, hot fomentations, etc. Diffuse and encysted hydrocele and hematocele of the cord have been considered in connection with similar conditions of the testicle. Fatty tumors are occasionally found. They cannot be diagnosed from encysted hydrocele without an exploratory tapping, and are liable to be mistaken for hernia when located within the inguinal canal. They generally occur later in life ; if large, they have a doughy feel, and are lobular in character ; treatment is rarely required. In cases of doubt, when the tumor might be an omental hernia, the utmost care is necessary in operating for removal. Calcareous deposits have been encountered in the cord. VemeuU ' found a large, gummy (syphilitic) tumor in the cord. VAEICOCELE. Varicocele is constituted by a varicose enlargement of the pampini- form plexus and veins of the cord. In a mild form, it is perhaps the commonest affection of the genital organs. It has been esti- mated that about ten per cent, of males have slight varicocele. It occurs almost invariably on the left side ; when very marked on this side, it may exist slightly on the right, but varicocele of the right side alone is almost unknown. Pott met with it on both sides only once. Breschet, in one hundred and twenty operations, operated only once on the right side. Slight turgescence of the veins of the cord does not deserve to be called a disease. The chief factor in its production is ungratified sexual desire, frequent erotic fancies not finding relief, or, less often, the oppo- site condition, abuse of the sexual powers, by which the veins are kept constantly engorged. The largest proportion of slight varicoceles which are encountered are found in young unmarried men, or old bachelors ; the affection rarely commences after twenty-five ; it is unusual to find it in a married man whose sexual relations are satisfactory. The slight turgescence of the veins constituting the varicocele of the young bachelor and often causing him incessant and needless alarm usually disappears after marriage, together with the uneasy sensations which accompanied it. Old men whose testicles are inactive rarely have varicocele, though their legs show many tortuous veins, and their tissues be degenerating. This fact is of the utmost importance, and is dwelt upon thus early in the consideration of the disease, in order that attention may be specially directed to it. The idea that slight varicocele is often a sexual derange- ' "Bulletin de la Society d'Anatomie," second series, vol. i., 1856. VARICOCELE. .go ment, a functional disorder depending upon bad sexual hygiene, is not brought out by text-books, and is rarely appreciated by practitioners. Young men in many cases distress themselves unceasingly, and impor. tune their surgeon for an operation to cure a disorder which would be more speedily and effectually removed by marriage. The degree of varicocele alluded to above may be dismissed briefly. It is found upon the left side ; the vessels are a little full, the cord loosej feeling like a small bundle of earth-worms, perhaps as large in some cases as the thumb; the testicle is perhaps over-sensitive (irritable), and there is usually a slight dragging sensation in the groin, but beyond this nothing except the fancied ills and the hypochondriacal complainings of the youngman who is cheating Nature or abusing her gifts. The proper treatment of such cases is found in the employment of all hygienic and tonic measures. The patient's mind must be diverted, •he must be dissuaded from an operation, told to wear a snugly-fitting suspensory bandage, and if possible to forget his sex untU an opportunity of marriage affords him a chance to get well. As a local measure, the free application of cold water to the parts daily is a very useful adju- vant. Varicocele serious enough to constitute a disease and demand ac- tive surgical measures for its relief does, however, occur, though rarely. It is an exaggeration of the milder form ; it comes on in early manhood, and has no connection with varices of the legs or anus (haemorrhoids). It is found on the left side, rarely on the right. The cause of this is beheved to lie in the following facts : The left testis hangs habitually lower than the right, only the larger veins of the cord have valves ; the left vein empties at a right angle into the left renal vein, the right at an acute angle into the ascending cava ; the position habitually assumed by men, of standing on the left foot, has been supposed to add to other predisposing tendencies. The veins of the cord, in any case, would seem to be in a position ready to become over-distended, as they lie loose and dependent in the scrotum, and then pass through the compar- atively narrow inguinal canal. The position of the sigmoid flexure of the colon, on the left side, so often distended by fecal accumulation, is also believed greatly to assist in the formation of left varicocele, which is always worse during obstinate constipation. In the female, the ovarian veins are rarely found varicose, except in the left side. Sir Astley Cooper never saw it on the right ; the sigmoid flexure seems at fault. Pressure upon the veins at the groin, abdominal tumors, etc., assist in causing varicocele. Sometimes, during sudden effort, varicocele ap- pears at once, and increases rapidly ; occasionally it occurs acutely shortly after orchitis. Pott ' has recorded three cases, where, after fatigue, local injury, and cold, sudden pain in the back set in, followed, m a few days, by relief from the pain, and an acute varicocele, which in ' Quoted by Curling. ^70 DISEASES OF THE COKD. its turn was succeeded after some days by complete wasting of the affected testis, in one case, of both. Probably, in these cases, there was some inflammatory condition obliterating the veins above. Symptoms. — Except in acute cases, such as those just detailed, vari- cocele comes on gradually, and is discovered by accident. The amount of pain complained of is very variable ; a very large varicocele is often attended by absolutely no pain, while a very slight enlargement of the veins may give rise to considerable uneasiness, extending up the back and down the thigh, perhaps amounting to neuralgia of the testis. Landouzy ' has noticed that the symptoms are markedly relieved during and immediately after coition, but become worse on the following day. In a full-formed varicocele the vessels are elongated, their valves broken down, their walls affected by fatty atrophy, and thickened, as is also the surrounding connective tissue. The mass fills up one side of the scrotum, perhaps encroaches on the other; its shape is some-' what pyriform ; the loops of veins often hang below the testicle. The mass feels soft, like a bunch of earth-worms ; there may be phlebolites in the veins. The veins of the testicle, also, between the tunica vaginaUs and the tunica albuginea, are in bad cases varicose. The scrotal veins may be similarly affected. The scrotum is thin and relaxed, the dartos powerless ; sometimes the integument is so thin that the blue color of the blood in the veins of the cord is visible. In long-standing cases of severe varicocele the circulation of the testis is liable to be interfered with to such an extent as to cause the gradual atrophy of the organ, a result in no way due, as has been intimated, to the weight of the mass of veins. The only general symptoms in varicocele besides pain are those of hypochondria and defective morale, so common in all affections of the genital organs. Diagnosis. — There is perhaps no disease less liable to be mistaken than varicocele ; the wormy feel and peculiar look of a cord surrounded by large tortuous veins are hardly to be confounded with anything else, unless, possibly, omental hernia. A simple test, however, removes all doubt. If the patient lie down, the whole swelling may be readily re- duced. The fingers are now placed at the abdominal ring, and the patient is told to rise; hernia wiU be retained, the swelling of varico- cele wiU return, the vessels filling from below upward. If the pressure at the ring be strong enough to compress the arteries as well as the veins, the tumor will not reappear. Varicocele complicated by large hydrocele, or by hernia, is more diflBcult of diagnosis. Treatment. — ^If varicocele be large, but the symptoms to which it give rise inconsiderable, the palliative treatment already recommended for simple cases will suffice. Varicocele never compromises life rarely deteriorates health, and, when it is simply clumsy and mechanically in- convenient, it should be overcome by mechanical means. All the opera- » " Du VaricocMe." VAKICOOELE— TREATMENT. 471 tions proposed for varicocele have been attended by fatal consequences, and it is unsurgical to endanger life for a disease in itself harmless. A well-fitting suspensory bandage is a fair substitute for a tight scrotum, and is efScient by sustaining the weight of the engorged mass. It is more comfortable than Wormald's expedient of pinching in a portion of the scrotum drawn through a silver ring, and better than the other palliative treatment which has been proposed, of covering the scrotum with many coats of a solution of gutta-percha, or than a truss to sustain the weight of the mass of blood at the ring. In those cases of serious varicocele where the patient is kept in a state of constant unrest, and worried into bad health by morbidly dwell- ing on his troubles, when there is much dragging pain or neuralgia, when the testicle seems liable to atrophy, when the suspensory bandage fails to relieve, or the patient refuses to be satisfied by it, it becomes neces- sary to operate. In the vast majority of cases but one operation is allowable, namely, cutting off the redundant scrotum, and thus forming a natural tight suspender to take off the weight of the testicle from the cord, and mechanically shorten the column of blood. All the other operations without exception, ligature — mentioned by Celsus, and which cost Delpech his life in the well-known case where this operation on both sides caused atrophy of both testes, and led to the subsequent as- sassination of the surgeon by his patient — Brodie's division of veins, Petit's excision, figure-of-8 pressure over a pin beneath the veins, the numerous methods of subcutaneous ligature, of which, perhaps, Ricord's is the favorite, Luke's fistula toiu'niquet, Breschet's external clamp, in- jection of persulphate of iron, division of the veins by galvano-oaustic, galvano-puncture — all of these, and others like them, are subject to the grave objection that they have in view the inflammatory obliteration of the offending veins, and are liable to be attended by general pyaemia (thrombosis, embolism) and death. Success has been reported after each of these operations, but there have been many failures, and some deaths. The objections to these operations are four : 1. Danger of pyasmia. 2. If all the veins be not occluded, a relapse is to be feared. 3. If absolutely all the veins should be secured, atrophy of the testis follows. 4. If the artery be accidentally included with the veins, atrophy follows. In short, no operation proposed offers a fair prospect of relief with- out serious accompanying risks, except excision of the scrotuin. The objections urged against this operation are possible erysipelas and hemorrhage. The former is not to be dreaded if the patient's general condition will warrant any operation, while the latter may m- variably be controlled by opening the wound, if necessary, and search- ing for bleeding points. The operation bears the name of Sir A. i72 DISEASE OF THE VAS DEFEKENS AND SEMINAL VESICLES. Cooper. It is only curative in the sense of preventing further disease, arrresting atrophy of the testis, and usually relieving pain. The result is nearly uniformly satisfactory, although occasional failures to relieve pain have been reported. But in this latter particular even castration sometimes fails, and, should pain persist after ablation of the scrotum, there would always remain, after the employment of sexual hygiene by marriage, the treatment of neuralgia of the testis ; or, finally, one of the many operations for occlusion of the veins, of which the simplest is, perhaps, to carry a silver wire gubcutaneously around all the larger veins inclusively (this requires transfixion of the scrotum), leaving out the artery and vas deferens (which always lie near each other), and bringing the ligature finally through the same orifice at which it entered. The operation is claimed by Bozeman. In the performance of the operation for curtailing the scrotum, a special clamp is necessary. Several good clamps have been devised for the purpose, and may be found in the shops. In operating, the danger is not of taking too much, but too little tissue. The patient is etherized, an ample fold of scrotum pinched up parallel to the raphe and includ- ing it, the clamp applied and tightly screwed. The redundant tissue beyond the blades is removed, and interrupted sutures closely applied, the more the better. If bleeding be greatly feared, each suture should be a foot long, so that the lips of the wound may be widely separated, and bleeding points secured before the edges are coapted. Every little clotted point must be scraped with the nail, to find the bleeding vessel, which should be tied. Finally, the edges of the gaping wound are brought accurately together by the long sutures first applied, and strips of adhesive plaster ; a compress and T-bandage complete the dressing. Secondary haemorrhage is to be feared into the loose tissues of the scro- tum, unless all bleeding vessels have been Hgated. The patient remains in bed until union is accomplished. CHAPTEE XXVIII. DISEASE OF THE VAS DEFEBESTS AND SEMINAL 7ESIGLES. Anatomy. — Inflammation, acute and chronic. The excretory duct of the testicle commences at the taU of the epididymis, forms one of the principal constituents of the cord, passes through the inguinal canal, curves down into the cavity of the pelvis, skirts the base of the bladder, and, joining with the duct from the semi- Qal vesicle, terminates as the ejaoulatory duct on one side of the summit of the veru montanum in the prostatic sinus. The canal is nearly two feet long, from a line to a line and a half in diameter. Foui-fifths of THE SEMINAL VESICLE. 473 its structure is muscular. It is very dense and hard, and feels like a whip-cord when rolled between the fingers. Its outer coat contains con- densed connective tissue, elastic fibres, vessels, nerves, and a little longi- tudinal unstriped muscle. The middle tunic is muscular, its external and a few internal fibres run longitudinally, the middle fibres are circular. The internal tunic is mucous, provided at its commencement with cili- ated epithelium. This membrane lies in longitudinal folds, more or less reticulated, particularly in that part of the canal lying within the brim of the true pelvis. Here the cavity of the canal usually enlarges into a sort of reservoir, while the sides are furnished with pouches and diverticula, recalling the appearance of the seminal vesicles. The dilated portion of the canal is well supplied with simple sacculated glands. They are filled with numerous yellowish-brown granulations which give a peculiar color to the mucus of the part. The vas deferens may end in a blind extremity or be deficient when there is no testis. It is rarely diseased. It participates in tubercular and pseudo-tubercular disease of the epididymis. Portions of its struct- ure so diseased may soften and form abscesses, which break externally, or perhaps internally, followed by a slight discharge of bloody pus from the urethra, and perhaps leading to occlusion of the canal during cicatri- zation. DISEASES OE THE SEMINAI, VESICLE. The seminal vesicle is a reservoir connected with the vas deferens. Its function is to collect seminal fluid, dilute it by an admixture with its own secretion, and hold it ready for use. The vesicle, from one to two and a half inches long by half an inch broad, lies at the outer side of its own vas deferens, its apex embedded in the prostate, its fundus di- verging from its fellow of the other side, so as to skirt that portion of the bladder which usually lies in contact with the rectum, and corre- sponds to the trigone within. The vesicle is simply a tube so rolled up and doubled upon itself that its blind extremity nearly corresponds in position to its neck. When unrolled, the tube measures from four to eight inches. It is plentifully supplied with diverticula and branched pouches, so as to present on section the appearance of a cellular cavity. At the neck a short constricted canal joins the vas deferens at an acute angle, to form the ejaculatory duct. The minute structure of the walls of the seminal vesicles is identical with that of the vas deferens. The convolutions of the tube are united by connective tissue, containing a large amount of unstriped muscle. After surrounding the vesicle, this tissue crosses over and envelops the vesicle of the other side. The whole is known as the posterior aponeurosis of the prostate. The arteries of the seminal vesicles come from the inferior vesical and middle hsemorrhoidal. The veins join the plexus on the sides of the bladder. The lymphatics go to the pelvic ganglia. The fluid of the vesicles is albuminous, and contains many yellowish bodies and masses 474 DISEASE OF THE VAS DEFERENS AND SEMINAL VESICLES. of spermatozoa. The vesicle discliarges by contraction of its own wall, of the muscular membrane surrounding it, and of the levator-ani muscle. An acquaintance with the position of the seminal vesicles is essential to the performance of puncture of the bladder by the rectum, or of the retro-yesical operation for stone. When the bladder is ftill, the vesicles are pressed apart, and it would be difficult to wound them. CruveUhier,' however, speaks of a specimen, presented to the Anatomical Society by Deville, where the two vesicles were confounded in a single median pouch with two differential canals. This anomaly is very rare, Ateopbt of the seminal vesicle follows atrophy of the corresponding testicle or its ablation. The vesicle is also absent or defective where there is no testicle of the same side. The vesicles are partly embedded in prostatic hypertrophy, and become involved in prostatic cancer. The only morbid conditions of these organs, however, commonly met with in practice, are inflammatory and tubercular disease. Congestion of the prostatic sinus, in individuals given to venereal excess, especially if they be weakly, leads to a lack of tone in the ejaculatory ducts, so that they remain more or less patulous. Under these circumstances involuntary emissions are frequent, and a flow of semen may occur on urination, or during efibrts at straining, particularly at stool, if there be constipation. The pressure of the levator ani and of the fecal mass upon the seminal vesicles forces their contents through the relaxed ducts (spermatorrhoea) . lui-LAMiiATioif OF THE Seiuxal Vesigles. — This affection is rare. It is usually unilateral, and is due to extension of inflammation from the prostatic sinus. Symptoms. — Digital examination by the rectum reveals a hot, sensi- tive, oval swelling behind the prostate, in the position of the seminal vesicle, perhaps on both sides. The size is double, or more, that of the normal vesicle. The surface is hard and uneven, or fluctuating. There is complaint of a continued, heavy pressing (perhaps pricking) pain in the rectum, low down, shooting toward the sacrum. The pain often involves the testicle, which is sensitive and turgescent. Urination may be difficult, on account of the pain, which is increased by rectal examina- tion, and greatly aggravated during defecation. There may be frequent painful erection, perhaps priapism. Any attempts at sexual intercourse greatly aggravate the pain. There may be involimtary painful nocturnal emissions of semen mixed with pus and streaked with blood, and a con- stant viscid purulent discharge from the urethra, also colored or streaked with blood, and containing spermatozoa. These symptoms may subside after a few days or persist in a chronic form indefinitely, there being a gleety discharge containing seminal ele- ments, and more or less sexual irritability. This may wear the patient out, leading to serious melancholy or hypochondria. The symptoms, • Op. cit., p. 375. TUBERCULAR DISEASE OF THE SEMINAL VESICLES. 475 however, may gradually improve with the general health up to com- plate recovery. If the inflammation reach a high grade, the duct of the vesicle becomes obliterated, abscess forms and discharges into the urethra or rectum, leaving fistula behind. After such abscess and fistula, the vesicle sometimes gradually atrophies, and with it the vas deferens and epididymis of the same side are very apt to dwindle away. Finally, the chronic inflammation, under the influence of general impaired vitality, may lead to thickening of the walls of the vesicle, cheesy degeneration with softening, abscess, fistula, calcification, etc. Treatment. — The treatment for acute inflammation of the seminal vesicles is absolute rest in bed, with opiate suppositories, and perhaps camphor and lupuUn, to modify erection. This, with local application of heat, warm enemata, and an early opening through the rectum of any abscess that may form, constitutes the treatment. Any chronic inflammation, with gleety discharge, which may be left behind, must be combated with general hygiene and tonics. Tubercular Disease of the Seminal Vesicles. — This affection may occur without any antecedent local inflammation, or may follow chronic inflammatory disease. Cheesy, yellow masses of deposit occur, which tend to soften centrally. It rarely is seen, except in connection with more advanced disease of a similar character in the prostate, epididymis, kidney, or bladder. The vesicle is often involved synchronously with the vas deferens, and may be felt through the rectum, hard, knobbed, irregular, perhaps insensitive to pressure, perhaps tender, more or less inflamed, and with softened spots. If abscess form, it discharges into the rectum, or perhaps into the prostatic sinus, leaving a cavity in connec- tion with the latter, which furnishes a constant supply of gleety material such as escapes from the urethra in tubercular prostatitis. Treatment. — Local treatment is symptomatic. The general measmres, which may be curative if conscientiously followed out, have been given in the sections upon treatment of the same morbid condition of the pros- tate, bladder, and epididymis. PAET II. CHANCEOID AND SYPHILIS. CHAPTER I. CHANCROID. Definition. — ^Transmissibility to Animals. —Cause of Chancroid. — ^Indefinite Inoculability. — ^Eelative Fre- quency. — ^Methods of Contagion. — ^Explanation of Apparent Long Period of Incnbation. — Situation of Chancroid. — Symptoms. — Conrse. ^Character of Scar. — Tariation of Chancroid from Type, in Ini- tial Form, in Shape, in Kumber, in Size, in Dnration, in Pain, in Condition of Base, la Course (Ee- lapse). — Complication by Vegetations, by SyphiUtic Chancre, by Inflammation, by Gangrene and Gan- grenous Phagedena, by Pultaceoua Phagedena, by Bubo, by Lymphitis. — Diagnosis of Chancroid. — Prognosis. CusTosi in America has adopted the name " chancroid " (originated by Clerc), to express that form of contagious venereal ulcer which is not accompanied by any constitutional sj-philitic infection. It is widely known also as soft chancre, or simple chancre ; but, of the many terms, perhaps chancroid is the least liable to lead to ambiguity, and it is essentially appropriate, as signifying a disease which, ■while it is like a (syphilitic) chancre, is stiU, in fact, widely different from it. For true chancre, the initial lesion of syphilis, the term syphilitic chancre will be adopted. Foumier's ' definition of chancroid is clear, comprehensive, and could hardly be improved. Chancroid " is a specific malady, consisting in a peculiar ulcer which secretes a virulent, auto-inoculable pus. It is a malady exclusively local, never giving rise to any symptom which can be referred to a constitutional infection." Of the three distinct venereal diseases — gonorrhoea, chancroid, syphilis — gonorrhoea is, strictly speaking, the most venereal, being prac- tically never acquired except in sexual intercourse. Chancroid, equally virulent, is less venereal, and recognizes many methods of infection 'Art. " Chancre," "Diet, de M6d. et de Chir. pratiques." CAUSE. 477 besides sexual congress ; while syphilis is of all the least virulent (in the sense of the facility with which it may be acquired), and the least venereal, as will be shown, when treating that subject. Chancroid is an affection only perpetuated by contagion, but for this sexual intercourse is not essential. Wherever upon the human body a chancroid is found, there, it may be positively affirmed, pus from some other chancroid has been deposited under conditions favorable for its absorption. No amount of sexual excess, no degree of uncleanliness, no irritation, traumatic or chemical, however prolonged, no simple or ■ poisonous ulceration from other specific source (syphilis, cancer, glanders, etc.), nothing, in short, can produce chancroid except chancroid (chan- croidal bubo of course included) : so that, as Fournier puts it, if all the patients in the world with chancroid would avoid contact with others until their malady got well, the disease would cease from off the face of the earth. Of syphilis this much cannot be said ; its methods of propa- gation are far more numerous than simple local contagion. Chancroid, furthermore, is transmissible to animals. Some experi- menters have obtained only negative results ; others have been success- ful, showing that, although animals may receive the disease, they do so imperfectly and often not at all. Chancroid developed on animals heals quickly. Auzias Turenne, in 1844, first successfully inoculated mon- keys, rabbits, cats, and dogs, with chancroid. Robert de Weltz, in 1850, inoculated his own arm four times with pus taken from chancroids arti- ficially developed upon a cat and a monkey : all four inoculations took and produced the characteristic ulcer. Diday, in 1851, from a chancroid which had been produced by inoculation upon the ear of a cat, inocu- lated himself successfully on the penis. The ulcer became phagedenic and was attended by suppurating bubo. Ricordi ' brought about a chan- croidal bubo in a rabbit, which he had inoculated with pus from the chancroid of another rabbit. It was in connection with experiments of this order that Auzias Turenne invented the term " syphilization," since he found that reinocu- lation of chancroid pus upon animals resulted in a less and less perfect ulcer each time, until no effect was produced at all." As Auzias Tu- renne recognized no difference between chancroid and syphilis, he sup- posed that this immunity of the skin of animals to chancroid pus indi- cated that they were saturated with syphilis, " syphilized," and exempt from all further trouble from that disease. Hence the term syphiliza- tion, which, starting in a misconception, has been perpetuated even to our day, and has still some conscientious advocates. Cause. — As already stated, the cause of chancroid is unique. It can be produced only by the contact of pus from a similar ulcer upon some portion of the skin or mucous membrane under conditions favorable for absorption. No one is exempt. The bearer of a chancroid is just as » Quoted by Bumstead. ' Letter to the Academy of Sciences, 1860, quoted by KoUet 478 CHANCKOrD. liable to be poisoned by the pus of his own sore as is a perfectly healthy person. Other diseases do not furnish any immunity.' Positive results are obtained by inoculation upon patients with cancer, with syphilis, with scrofula, with elephantiasis, and a previous attack of the disease does not insure in any manner against succeeding attacks. RoUet,^ following Von Roosbroeck's lead, has demonstrated by ex- periment that the contagious principle resides in the pus-corpuscles, and, if these be filtered out, all inoculations with the remaining fluid prove negative. What this contagious principle or virus is, has not yet been discovered. Assertions have appeared from time to time (Doim6, Didier, Salisbury), that a peculiar parasite has been discovered, now animal, now vegetable, which was the essential poisonous agent, but the authors of all such theories thus far have failed to substantiate their claims, and it still remains for the chemist or the microscopist to de- monstrate in exactly what the poison of chancroid consists. Thus far the pus of chancroid is identical, under all tests, with pus from any other ulcer. By its poisonous effects alone it is distinguishable. These effects may be studied by inoculation. Chancroidal pus preserves its poisonous properties if kept cool in tightly-corked bottles. Boeck states (oral communication) that they are in the habit of sending it from the hospitals of Christiania into the sur- rounding country for purposes of " syphilization." It may be frozen, and still inoculable when thawed. Boeck believes that it loses its viru- lence after having been dried. Dried pus certainly sometimes fails to give positive results when remoistened, but this cannot be relied upon, as Sperino " used a lancet which had been laid aside for seven months, upon the point of which was some dried chancroidal pus. Three punc- tures were made with this lancet, all of which took. Heat, however, at the boiling-point, destroys the activity of the virus ; acids, alkalies, alcohol, all destroy its virulence at once, and decomposition is fatal to it. When gangrene attacks a chancroid, the sore is no longer poisonous. 1 It has been stated that chancroid will cot take upon a patient suffering at the time from acute febrile disease. To test this point, Dr. Fiset, at the Charity Hospital, at my suggestion undertoolf some experiments. They were, unfortunately, interrupted after tbe doctor had inoculated one patient three times upon the thigh — the gentleman in charge of the ferer wards being fearful lest syphilis should be introduced among his patients. The one case inoculated was, however, carefully studied by Dr. Fiset. The inoculations were made at the end of the second week after chill, the patient's temperature ranging at 103-101° Fahr. Boeclc's method was used, and three punctures made, one-quarter of an inch apart." Two of the punctures took perfectly, although the process of ulceration was very slovr. On tbe thirteenth day pus from one of these ulcers was inoculated upon a healthy patient, with the effect of producing a characteristic chancroid. The ulcers on the leg of the typhoid patient finally became confounded in a single ulceration two inches m diameter, which was dressed with iodoform, and on the patient's discharge from the hospital, convalescing, after a sojourn of fifty-three days, the ulcer was reduced to a diameter of one inch, and was healing. The ulcers were under observation after inocula- tion forty-six days. The evening temperature remained near 104° for several days after moculation. — Keves. * " Traits des Maladies v^neriennes," Paris, 1866. • " Studi clmici sul Tims sifilitico," Turin, 1863. INDEFINITE INOCULABILITY. 4^9 With the above, and kindred exceptions, a mixture of chancroidal pus with any indifferent menstruum does not injure its virulence; such as water, urine, saliva, sweat, mucus, muco-pus, spermatic fluid. As to the amount of pus required to effect contagion, probably one microscopic pus-corpuscle is sufficient. The smallest possible prick of the skin to which the pus is applied will produce just as characteristic a chancroid as will the bountiful smearing of a raw surface of any size. Puche ' got positive results by inoculation from a drop of pus diluted with half a glass of water. The poisonous effect of chancroidal pus is evinced by its power of rapidly begetting a chancroid whenever it is brought within the reach of absorption, by a removal of the cuticle or external layers of epithelium from any surface. Inoculation or hetero-inoculation signifies the contact of this pus with an abraded surface of any individual other than the one who furnishes the pus. Auto-inoculation signifies such con- tact upon the body of the bearer of the chancroid. Evidently such in- oculation may be the result of accident or design. Chancroidal poison is indefinitely auto-inoculable. Lindmann inocu- lated himself 3,700 times, and was still making successful auto-inocula- tions when last reported by Fournier. The body of Auzias Turenne is said to have been found covered with chancroid scars at his death, showing that he did not shrink from practising his pet theory, " syphUization," ' upon himself. By the process of syphilization, immunity of the skin to the poison is obtained. A certain pus is employed, and reinoculated until it will no longer produce a pustule ; then fresher pus from some other younger chancroid, until it also fails ; and until, finally, no inoculation gives a positive result. This much syphilizers have taught us, and they have also taught us that the different regions of the body are susceptible in a different degree to the action of a chancroidal pus of given virulence ; for, after the chest fails to take, the arms may still be inoculated success- fully ; and, finally, when the arms have acquired immunitj^, the thighs will still furnish characteristic results upon inoculation. This immunity, however, obtained by frequent and continuous irritation of the skin with numerous chancroid ulcers, is more apparent than real, since it is only temporary ; for, after the skin has had a rest for some months, inoculations often again give a positive result (Boeck, oral communica- tion). Hence the rule, practically true : an individual may have chancroid as often as he is exposed ; there is no limit to the number of possible attacks. ' Ricord, " Le90ns sur le Chancre," Fournier. ' The terra syphilization ia here used in the sense first given to it by Auzias lurenne, but it must be understood that, in accordance with the views advanced in this treatise, the term is essentially incorrect, as the virus of true syphilis is entirely distinct irom that of the chancroid ulcer. 480 CHANCEOID. Feeqtjexct of CHAifCEOiD. — Statistics as to the relative frequency of chancroid and syphilitic chancre are usually made up £i-om hospital experience. Such statistics show that chancroid is twice, or sometimes more than twice, as frequent as syphilitic chancre. Puche, from ten years' statistics at the HCpital du Midi, gives eighty per cent, of chancroid cases. Fournier arrives at a far different result from the statistics of his patients seen in private practice, patients whose social position was usually high. Out of three hundred and thirty-four cases, he found ' only eighty-two of chancroid, while all the rest were syphilitic chancre. The reasons of this singiilar difference of figures are obvious. The lower classes of society who enter hospitals are given to intem- perance, and careless in their habits. Furthermore they are poor, and consort with the lower orders of prostitutes, those who are unable to care for themselves when diseased, but must continue at their profession to gain their daily bread. Most of these also are old, have had syphilitic chancre, and contagious secondary lesions in their youth, and are there- fore incapable of giving syphilitic chancre, while many of them possess old chronic chancroid, which is kept from getting well by constant local irritation, and which forms a hot-bed of infection for all who approach. Old prostitutes get used to the idea of having a chancroid, and consider it a small matter. The more refined and wealthy males of the upper classes, on the contrary, are careful in their selection of females. They seek the young, and those apparently sound. Young prostitutes are often unaware of having syphilitic chancre or secondary lesions of the vagina, while they can scarcely be ignorant of the presence of the more formidable-looking chancroid with its possibly accompanying inflamma- tory bubo, and fear prompts them to seek medical aid, and give up their profession temporarily in the latter case, while they might innocently continue it in the former. Furthermore, none of the upper classes appear at hospitals, and few of the lower who have syphilitic chancre (often an insignificant-looking, painless lesion), while they run in all haste for relief for the painful, angry-looking chancroid. Finally, syphi- litic chancre occurs but once in a lifetime, and rarely lasts long ; while chancroid may be acquired an indefinite number of times, and may possibly in certain forms last a number of years. Hence the rule : in hospitals, chancroid far outnumbers syphilitic chancre. The same holds for the practice of the young surgeon, or for those who attend the poorer classes ; while, in the higher walks of Hfe, ulcerations about the penis wiU be mainly herpes, or abrasions, or balanitis, syphilitic chancre next in frequency, chancroid least common. Methods of Contagion. — Contagion is immediate, i. e., by direct contact, as in sexual intercourse, or manipulation of chancroids with fissures or abrasions on the hand ; or mediate, i. e., through some inter- vening agency, as by carrying the poison upon the fingers in scratching, ' " Diet, de M6d. et de Ohir. prat." METHODS OF CONTAGION. 48 j and thus inoculating some abraded surface. The virus is fixed and not volatile, and actual contact with the pus is essential to infection. Con- tagion takes place in the vast majority of instances during the sexual act, but, as any abraded surface upon any part of the body is capable of absorbing the virus, cases of accidental, mediate, or immediate contagion occasionally occur, as on the finger of the accoucheur. Spontaneous auto-inoculation is common, especially where the virulent pus is retained between two tegumentary surfaces lying in contact, as beneath the prepuce. Mediate contagion in sexual intercourse is possible. Thus, a man with a long prepuce, but no abrasions, may carry the virus from one woman and deposit it in another, with whom he cohabits at a short in- terval. Then washing himself, he may escape infection, after having none the less occasioned chancroid in the last-mentioned woman. The same intermediate part may be played by the sound vagina — a woman receiving the poison from one man, transferring it shortly to another in sexual intercourse, and herself escaping. This is mediate contagion. Cullerier's ' two famous experiments on women establish beyond dis- pute the fact that chancroidal pus may lie for some length of time in con- tact with a vagina, presenting no abrasions, without being absorbed. In these experiments chancroidal pus from the groin was deposited in the vagina, the latter showing no abrasions, and its secretions being inocu- lated with negative result. In one case the pus was left in the vagina thirty-five minutes, in the other nearly an hour ; the patients, ignorant that they were the subject of experiment, were made to walk about, closely watched. Finally, some of the vaginal secretion was again col- lected, and successfull}- auto-inoculated in both cases. The vagina was thoroughly washed out with an astringent solution, and did not become ulcerated in either case, although the poisonous pus had remained for some time in contact with its walls. These two cases at once raise the question. Can chancroidal pus be ab- sorbed except through an abrasion? Evidently not at once, as the two cases prove, nor probably in any length of time through the hard epi- thelium of the skin, for hospital patients, little careful as to cleanHness, handle with impunity their chancroids from day to day, and do not in- oculate their fingers, except through preSxisting abrasions ; but that the poison may enter through a mucous surface not visibly abraded is cer- tain, whether by direct absorption, or by corroding for itself a way, has has not as yet been demonstrated ; but in all probability by the latter means. In this way may be explained chancroid with a comparatively long period of incubation. A man lies with a woman having chancroid. He inspects himself after the act and finds no abrasion, but, neglecting to wash himself, pulls forward the prepuce and goes on his way. A small quantity of virulent pus remains in the little pocket alongside of ' " Quelquea Pointa de la Contagion mediate," M^m. de la Soc. de Chir. 31 i32 CHAIfCEOID. the frffinum, -where the mucous membrane is very thin and always moist. The pus, by its acridity, destroys the superficial layers of epitheliimi in a few days, and then, finding a loop-hole for absorption, poisons the spot at once, and the patient appears, perhaps a -week after his suspicious in- tercourse, with a chancroid only just commencing, the long period of incubation here being more apparent than real. In like manner a few pus-corpuscles rubbed into the mouth of a minute follicle during the friction which accompanied the sexual act could not be washed away, and by the same process of corrosion give rise to a characteristic ulcer, after a period of apparent but not real incubation (follicular chancroid). SiTTjATioir OF Chajs^cboid. — Chancroid is rarely found far from the genitals, for the obvious reason that it is usually too conspicuous to be lightly handled, except by the accoucheur or the surgeon who has it under treatment. It was at one time supposed that chancroid could not occur upon the head or face, but now medical literature contains several cases of undoubted chancroid of the face, giving positive result by auto-inocu- lation, and not followed by syphilis (Bassereau, Boeck, Puche, Rofeta, and others) ; while syphilizers have abundantly proved that the head and face, as well as any other portion of the tegumentary expansion, may be successfully inoculated with chancroid. Boeck, however, in studying the susceptibility of the different portions of the body to the action of chancroid poison, found that inoculation produced upon the cheeks or head only small, shallow tdcerations of comparatively short duration ; ' the chest and abdomen come next, then the arms, and, finally, the thighs, which would furnish positive results to inoculation, after the latter had become impossible upon the upper portions of the body. Chancroids upon the male genitals appear by preference in the sulcus on either side of the fraenum, but may occupy any position even to the inside of the urethra, where they are occasionally found, usually occupying the meatus, and thence extending inward, or wholly con- cealed inside the canal. Duncan inoculated his own urethra by transport- ing into it some chancroidal pus. He got urethral chancroid with double bubo.' Ricord figures a case of deep urethral chancroid, with chan- croidal-looking ulcerations of the bladder, but tubercular ulceration has been suggested to explain this unusual case, Intra-uterine chancroids in the female have been reported (Delmas and Combal). Scrotal chan- croids mainly result from auto-inoculation of abrasions by discharges from some chancroid of the penis or under the prepuce. Chancroid of the anus is rare in the male. In the female, where the poisonous dis- charges trickle from the posterior vaginal fourchette over the anus whenever the patient lies upon the back, they are not uncommon. In the male, when not resulting from pederasty, they are rare. That ' But that chancroid may be occasionally severe on the head is proved by a case re- ported by R. W. Taylor, in Brown-Sequard's " Archives," No. 5, 1873. The article con- tarns an excellent digest of the literature of the subject. ' " Cours des Maladies syphilitiques," Petit-Radel, 1812. SYMPTOMS. 483 chancroid may develop upon pathological as well as normal tissues is proved by the successful inoculation by Boeck and others upon ele- phantiasis, and by a case reported by Breslau ' of chancroid found upon an epithelial cancer of the uterine neck giving positive results by inocu- lation. Symptoms. — The symptoms of chancroid may be best observed by studying the course of the artificial ulcer produced by inoculation. The smaller the inoculation the more perfect the result. It has been noticed in the large chancroids produced by inoculation of scarified surfaces that the lesion often develops from many initial centres, numerous points on the scarified surface " taking," the whole constituting a multiple chan- croid, which soon unites into one. To inoculate properly, a lancet or pin should be used ; the latter can always be obtained new, clean, and sharp. If a lancet be employed in any doubtful case to inoculate as a test, it should always be scrupulously cleaned before use. With the lancet, Boeck's method is the best. Scrape a little pus on the point of the instru- ment, hold the point at right angles to the surface of the skin, and cause it to penetrate just barely below the epidermis, then rotate the instru- ment, held in the same direction, half round and back, withdraw it and smear over the little red point with whatever pus remains upon the end of the lancet. Within twenty-four hours after such an inoculation, a reddish blush will envelop the puncture ; on the second day the little dark speck of dried blood is surrounded by a faint, inflamed areola. Occasionally there is already commencing pustulation on the second day, usually on the third day, sometimes later. The red areola enlarges, and surrounds a vesico-pustule. Break this, and beneath will invariably be found an ulcer, a perfect, fully-formed chancroid in miniature. If left alone, the vesico-pustule becomes an eothymatous pustule, which usually breaks in a few days after it has reached the size of a split pea. The circular ulcer which results, continuing circular, enlarges and deepens. It usually becomes stationary before it reaches the size of a half-dime, but may become as large as a silver quarter of a dollar, or occasionally far exceed it. This ulcer is a true chancroid, resembling in every minute particular the ulcer from which it sprung by inoculation, and tending to run a similar course. It is evident, from the foregoing description, that chancroid has no period of incubation or hatching. When the virus is placed in a position where absorption is possible, it commences its work at once, and rapidly reaches the stage of ulceration. In the same way the chancroid acquired in sexual intercourse has no period of incubation, this point being perhaps of all the most important, as distinguishing it from syphilitic chancre. Usually by the third day after suspicious intercourse, occa- sionally as late as a week, or rarely later, where the pus has had to employ several days to corrode the epithelium before gaining access to • " Arohiv der Heilkunde," 1861. 484 CHANCROID. the vascular tissue beneath,' a small ulcer will be found, which has the characters of a chancroid, characters which apply to a chancroid ul- ceration of whatever size, wherever situated, originating from natural contagion or from inoculation. These characters are : a rounded, some- times oval margin, abrupt, perpendicular edges, looking as if they had been cut out by a sharp-edged punch, sometimes everted. The ulcera- tion is rather deep considering its extent ; in very rare instances, shallow, like herpes ; the bottom is irregular, velvety, grayish-yellow, covered by a pultaceous, adherent substance resembling false membrane, or wet wash-leather, composed of partly-destroyed elements of the skin and pus, with perhaps some irregular, pale granulations. The whole is usuallj' bordered by a pink areola. Under favorable circumstances, there is no surrounding inflammation, there is no hardness under or around the ulcer, which rests on a perfectly soft base. The suppuration is abun- dant, rather thick and creamy, mixed with organic detritus, not gener- ally tinged with blood. There is little or no pain. Such a description applies to a type case which has never been irritated mechanically or chemically. This single ulcer runs through its stages of increase, station- ary period, and repair, provided it is allowed rest and is not irritated, and pursues a natural course, as follows : CoTTRSE OF Chancboid. — ^It increases in size for one or two weeks, preserving its characteristics, and reaching a variable size, often not larger in diameter than a quarter of an inch. Of this size it remains for a period of perhaps two weeks, undergoing no appreciable change ; or there may be no stationary period, repair setting in at once after the ulcer has reached a certain size. Finally, repair is announced by a more creamy, laudable condition of the pus, a sloping of the abrupt edges, and a clearing up of the cavity of the ulcer, which becomes rosy, granular, and gradually cicatrizes from the edges toward the centre. During the whole period of its existence the chancroid furnishes auto- inoculable pus. The old theory, that after repair was well advanced the secretion ceased to be poisonous, is no longer tenable. Truly the degree of virulence is lessened with advancing repair, but Fournier has recently been able to obtain occasional positive results by auto-inocula- tion from chancroids which were nearly cicatrized. This important fact, that the secretions of chancroid are contagious until the cicatrix is formed, has but two exceptions : 1. When gan- grene attacks a chancroid, its discharges are not contagious, nor does the granular surface left by the separation of the slough any longer afford a poisonous secretion; 3. Certain very old chancroids, usually such as have been of considerable size, and are situated in positions where they are kept irritated and prevented from healing, perhaps for ' Fournier, in a carefully-observed statistic of fifty-two eases, where the patient -would acknowledge but one sexual contact for the previous four or five months found twenty- four developed within the first four days, forty-one within eight days, others later, ths sote being often quite large when discovered. VARIATIONS FROM NATURAL TYPE. 485 years, sometimes lose their poisonous properties finally, and become simple chronic ulcers, kept open by contact of irritating discharges, muscular contractions, and motion of the parts on which they are situ- ated. Such ulcers are found in the anus and rectum of the male, and iu the vaginae of old prostitutes — p. 486 (e.). The scab left by chancroid varies with the depth of the ulcer. It may be so faint as shortly to disappear, leaving no trace ; or, again, mav remain indelible, as a seamed and puckered, unsightly scar, of a size pro- portioned to the previous ulceration. But this mild and simple sequence of events in chancroid is far from being constant. All sorts of variations from the natural type occur: in (a) initial form, (J) shape, (c) number, {d) size, (e) duration, (/) pain, (cf) condition of base, (A) relapse, and finally the complications of : (^') vegetations, (J) syphilitic chancre, {k) inflammation, [I) gangrene and gangrenous phagedena, (m) phagedena, (w) bubo, (o) lymphitis. (a.) Vaeieties in Initiai, Foem. — Usually chancroid of a mucous membrane presents itself from the first as an ulcer, but occasionally the initial pustule may be seen. This breaks, disclosing the characteristic ulcer, or, occasionally on the skin, does not break, but dries into a scab. The scab increases in size by additions of pus from beneath, and covers the ulcer ; but the pus which may be squeezed from the sides, by pressure upon the loosely-attached crust, is auto-inoculable, and if the crust be removed true chancroid is disclosed. The French call this form "ecthymatous chancroid." Again, the chancroid pustule may originate in the orifice of a sebaceous gland of the scrotum, or penis, and be mistaken readily at first for simple acne, or the lesion may re- semble a small boil at its commencement (follicular chancroid). The primary lesion may be a papule surmounted by a pustule, or, still more rarely, a bulla (Fournier). These latter forms are exceptionally rare. (b.) Vaeieties IjS" Shape. — The usual round or oval form of chan- croid is subject to exception. If a wound be inoculated, the chancroid takes the form of the wound. So of a fissure, as is often beautifully seen in chancroid of the anus, such a chancroid being frequently multiple, standing off in rays from the puckered centre, or extending up irregu- larly into the gut, perhaps for several inches. Two neighboring chan- croids may coalesce, producing one sore of irregular shape, with borders composed of segments of circles. The ulcer may undermine the fras- num, or follow around the sulcus behind the corona glandis. It may cicatrize on one side, and advance on the other, or finally assume any variety of shape from the modifying influence of gangrene or phage- dena. (c.) Vaeieties in Numbee.— Chancroid may be unique, or any given number may coexist. Sperino, in practising syphilization, was in the habit sometimes of inoculating in eighty places at once, since he found that, by so doing, the size of the resulting ulcers was smaller. Chan 486 CHANCKOID. croid is often multiple from the iirst, when several abrasions are simul- taneously inoculated during the sexual act ; or, starting unique, may become multiple to any extent by auto-inoculation, especially inside the prepuce ; anal chancroid is usually multiple. It is not uncommon with a tight prepuce to find half a dozen small chancroids situated just on the preputial margin, or the whole rim may be one ulceration. Usually, when chancroid is multiple from the beginning, each ulcer is small. {d.) Vableties dt Size. — The size varies from that of the head of a pin to enormous phagedenic siu:faces, covering half the belly. (e.) Vaelbties rs' Dueation. — A chancroid untreated never lasts less than a month. The larger the size the slower the repair, other things being equal. Grangrenous sores may continue for months, and phagedenic serpiginous chancroids, as a rule, for many months, excep- tionally for a number of years. Chancroids of the meatus urinarius, con- stantly irritated by urine, are very slow in getting well. Certain old chancroids of the rectum, which have partly cicatrized, forming stricture, may be kept open by local irritation, and perhaps never get well, although their secretions finally cease to be inoculable. The same may be said of certain old chancroids in the female vagina, which erode large por- tions of the walls of the canal and the labia, perhaps at the same time extending over the peiiniEum, and including the anus and rectum. These also finally cease to progress, but remain open for years, as simple chronic ulcers, not auto-inoculable, perhaps surrounded by hardened cicatricial tissue, attended by little or no pain or inflammation ; perhaps resting on a hard base, looking pultaceous or sometimes dry and red without granulations. These ulcers are kept from healing by the con- dition of the patients, mostly middle-aged prostitutes, broken-down hos- pital cases, often sufi'ering from syphilis at the same time, and by the contact of urine and the movements of the parts ; the hard, unhealthy base of the ulcer proves also a decided obstacle to healthy action in the sore. This variety of ulcer has been best described by Boys de Loury et Costilhes.' These ulcerations in the female vagina are often mis- taken for tertiary syphilitic serpiginous ulcers, especially if the patient have syphilis at the same time. The distinction is often diflBcult, even impossible, except by studying the history of the ulcer. Syphilitic ulcer will be found to have commenced as a tubercle, having no connec- tion in point of time with sexual intercourse, and there wiU often be . some tuberculization of the edges of the sore. Tubercular syphilitic ulceration, once started, may become phagedenic, just as well as chan- croid ; and the contact of urine, the habits of the patient, motion, the callous condition of the base of the sore, etc., may prevent anti-syphilitic remedies from exerting such a marked beneficial influence as might have been expected, so that diagnosis becomes exceedingly difficult. Should '"Des Ulcerations chroniques, ou Chancres ehroniquea des Parties g^nitales de la Fcmme," Paris, 1845. VAEUTIONS FKOM NATURAL TYPE. 487 Bome of the poisonous secretions, however, still remain upon the ulcers, auto-inoculation, if it takes, will at once remove all doubt, and this test may be employed. A negative result, however, does not prove that the lesion was not a chancroid at its commencement, and the probability is always in favor of such a supposition. Phagedena alone does not de- stroy the inoculability of the discharge. Some authors describe these ulcers as a variety of lupus. (/•) Varieties m Padst.— Chancroid may be aloiost entirely pain- less, only attended by some itchy, prickling sensations. Any irritation applied to it, however, occasions pain at once, so that clinically, instead of being absent, pain is usually a diagnostic symptom of chancroid, serv- ing to distinguish it from syphilitic chancre. All sorts of irritating and many simple stimulating dressings are liable to cause pain, some- times even cold water (Pournier). The position of the sore on the end of the penis, which usually hangs down, erections, which pull upon its edges, contact of urine, retention of pus on the surface, all these causes serve to inflame a chancroid and give rise to pain. In two pathological conditions pain is often very severe in chancroid, when it is attacked by gangrene, or by phagedena, and when it is advancing rapidly. {(/.) Condition" of the Base (iNDrEAxiON). — The chancroid when not irritated reposes upon a perfectly soft base. When irritated or in- flamed, an induration is caused, sometimes slight, sometimes extensive, recalling the hardness around a boil. This is an accidental and not a natural phenomenon, and is an important distinguishing mark between chancroid and syphilitic chancre. The base of herpes, excoriations, abrasions, vegetations — in short, of any lesion about the genitals — is liable to indurate if irritated or inflamed. Sometimes this induration resembles syphilitic induration very closely, but usually it is easily dis- tinguishable. It is an inflammatory hardness, the tissues are evidently glued and matted together, the edges of the induration lose themselves gradually in the surrounding tissues, and do not end abruptly as in syphilitic induration. There is more pain on pressure than in the latter. The induration never precedes ulceration as in syphilitic chancre, and, finally, the feel itself is difi^erent, very unlike the woody, cartilaginous, elastic feel of syphilitic induration. Besides inflammation from any irritating cause, contact of urine, friction, position (chancroid of the meatus urinarius almost invariably indurates, as do most often chan- croids under a tight prepuce, which has become phimotic from inflam- mation), many substances commonly applied as dressings to chancroid are directly instrumental in causing hardness of the base; all caustics, acid, or alkaline, especially if applied sparingly, and perhaps most par- ticularly nitrate of silver, solution of corrosive sublimate, or chromate of potash (Fournier). In fact, there are so many natural, accidental, and medicinal causes for induration, that it is rather surprising that any i88 CHANCROID. chancroids escape tlaem all and remain soft to the end, as many of them certainly do. (A.) Relapse. — A chancroid may have fairly entered the period of repair, or even be far advanced in it when, suddenly, perhaps from irri- tation, often -without appreciable cause, it relapses, resuming all the characteristics of chancroid, and advancing a second time for a variable period. More rarely a relapse may occur a second or even a third time. COMPLICATIONS OF CHAUCBOID. Of all the complications of chancroid — inflammation, vegetations, phimosis, paraphimosis, lymphitis, erysipelas, gangrene, phagedena, simple bubo, and virulent bubo — not one is peculiar to chancroid, except the last. Each and all of the others may complicate any herpetic, sim- ple, inflammatory, or even syphihtic lesion of the genitals, but naturally they are oftener found with the more virulent sore — chancroid. This fact must be constantly borne in mind. [i.) VEGETATioifS. — These papillary growths may complicate chan- croid, as they may any other lesion (inflammatory, sj'philitic, or gonor- rhoeal), especially of the prepuce or around the anus (for Vegetations, see page 31). (J.) Syphilitic Chancee may complicate chancroid by appearing alongside of it, or on the same spot as mixed chancre (which see, p. 526). (k.) iNTLAMMATiosr, spontaneous (from plethora, debility, drinking), mechanical (from friction, erection, position), chemical (from contact of urine, lack of cleanliness, inappropriate dressings), is a frequent compli- cation of chancroid. Especially is this true when the ulcer is sub-pre- putial, if the prepuce be long or congenitally tight. Phimosis and para- phimosis are often encountered with chancroid, lymphitis is very liable to occur (with enormous oedema of the prepuce, perhaps of the whole penis), and possibly erysipelas, while the retained discharges and the tension of the parts predispose strongly to sloughing and phagedena. An inflamed chancroid gets painful at once. It indurates, and may be- come livid, its secretion grows thinner and more bloody, while its ulcera- tion deepens. Inflamed chancroid is very liable to be attended by suppurating bubo. Abscess may form in the thickness of the prepuce, and, opening, remain indefinitely fistulous. With phimosis pus may be retained and burrow backward, sometimes in a narrow tract at the end of which an abscess forms, opens, furnishes inoculable pus, and remains fistulous. This burrowing may sometimes go on to an enormous extent. Vidal saw a case where the whole skin of the penis was separated up to the root of the scrotum. The integument of any portion of the body may undermine from retained chancroid pus, by a species of subcuta- neous phagedena. In patients who are run down constitutionally, chan- croid sometimes pursues a course of slow, chronic inflammation. Such ill ulcer is painful, surrounded by a red areola, with perhaps a hard base (JUMi-LiUJATiUJNS. 489 and undermined border. The base looks pultaceous, discharges a thin, perhaps sanious, secretion, which often dries into a scab. Chancroids of this description may increase in size and become phagedenic or re- main stationary for a long time. They are sometimes attended by paroxysms of feverishness, with symptoms of gastric disturbance. (Z.) Gangrene and Gangeenotts Phagedena. — Gangrene is a complication not confined to chancroid, as it may be engrafted upon other lesions of the penis. It is of two kinds : total (self-limiting), or progressive (phagedenic). The first-mentioned variety commonly ac- companies a high degree of inflammation, as in connection with inflam- matory phimosis or paraphimosis, where the tension of the parts is great, and they suddenly and in totality fall into gangrene. In this way the whole prepuce may be lost, artificial circumcision being neatly performed by the separation of the slough. The whole glans penis may slough away, or a swollen and inflamed prepuce, retaining the pus of the chan- croids within, perhaps suddenly becomes blackish green over a greater or less area, a slough forms, separates, letting the head of the penis through, leaving behind a seemingly double-headed, unsightly member, the remains of the prepuce below becoming hardened, oedematous, some- time's greatly increased in size by chronic inflammatorj' hypertrophy. Total gangrene rarely attacks chancroid, except where the ulcers are Bub-preputial. Besides the immediate exciting cause (great inflammatory tension), the predisposing causes are any debilitating agencies, malarial or other cachexife, old age, alcoholism, etc. Total gangrene of the whole chan- croidal surface at once destroys it just as certainly as does the thorough application of an efiicient caustic. In both cases alike neither the slough nor the pus formed beneath it in the natural process of its elimination possesses any poisonous, inooulable properties. After the slough has fallen, a healthy, granulating, non-virulent ulcer is left, which usually goes on at once to repair, with rapidity proportionate to the vitality of the individual. But just as an imperfect application of caustic to a chancroid only produces a partial slough, and does not do away with the poisonous properties of the sore, since the virus is secreted by all portions alike, and if any is left the whole is repoisoned, so there may be spontaneously progressive gangrene of the phagedenic sort, attack- ing a chancroid not thoroughly destroying the secreting surface, and consequently not interfering with the inooulable properties of the pus.. Under these circumstances a black slough forms on the surface of the sore, but it does not separate ; pain continues, and a new slough forms or the old one progresses ; and so on, in a phagedenic manner, sometimes slowly, sometimes rapidly, often large portions of skin and underlying tissue being destroyed before the sloughs finally separate, and leave healthy surfaces beneath. This variety of gangrene constitutes one (the less common) form of phagedena, and is responsible for many of the i90 CHANCROID. extensive mutilations accompanying chancroid. With forming or ad- vancing gangrene there is intense pain, and always some general con- stitutional disturbance, fever, etc., -which does not obtain in true phage- dena.' The physical signs of gangrene, when attacking a chancroid which is visible, are similar to what is observed in gangrene elsewhere. The ulcer first begins to look grayish, the patient suffering great pain ; then it becomes violet, finally greenish black, while the discharge grows thin and fetid. A line of demarcation finally forms, surrounded by an in- flammatory areola, and, if the slough includes the entire ulcer, its separa- tion leaves a healthy granulating surface behind. (m.) Phagedena is molecular gangrene. But molecular gangrene is not able to destroy the poisonous surface rapidly enough to make the ulcer a healthy one ; hence phagedena, as applied to chancroid, signifies large extension of the ulcer with preservation of its specific (inoculable) properties. Phagedena, most commonly found with chancroid, is not confined to this variety of sore. Syphilitic chancre is sometimes phage- denic (RoUet thinks only in the gangrenous form) ; different ulcerated syphilides and scrofulides occasionally become phagedenic. Phagedena advances superficially, or in depth, or both at once. It is pultaceous in type, or, more rarely — as detailed above — gangrenous. The latter form, often largely destructive, is comparatively rapid ; the common form (pultaceous, superficial, serpiginous, ambulant) is exceed- ingly slow. Phagedena advancing on one side often gets well with pro- portionate rapidity on the other. Clerc has established that a chancroid never commences phagedenic, but always becomes so secondarily, after having existed for a while un- complicated. Chancroidal phagedena seems often to be arrested by coming into contact with tissue of a different order from the one it is attacking. It shows a predilection for cellular, connective tissue, as in undermining the skin of the penis. Belhorame '' gives a striking instance of a phagedenic serpiginous chancroid of the skin stopping suddenly on reaching the mucous membrane. This cannot, however, be always counted on, but the tendency exists, as is well shown by the fact that ves- sels, nerves, and glands, are often dissected out, and spared by the ad- vancing ulceration. The corpus spongiosum, corpora cavernosa, and testicles, may be bared by phagedena, but themselves remain untouched. Fascial expansions, and fibrous tissue generally, may be expected to op- pose the destructive march of phagedena ; but sometimes nothing is spared, all the tissues being eaten through indifferently — by the variety of phagedena which destroys in depth (mainly by slough). Phagedena attacks virulent bubo perhaps as often as it does chan croid. It seems, however, to spare all except virulent buboes. ' Cases of this sort are not uncomtDOn in hospitals. ' " Du Chancre phag^d^nique et de sou Traitemeat," These de Paris, 1862. ' ft COMPLICATIONS ^gj The serpiginous (serjiere, to creep) phagedena (unlike the gangrenous form) is attended by not very great pain, and no constitutional disturb, ance ; there may be slight headache, malaise, etc. As it commences, the surrounding skin reddens, the borders of the ulcer swell and under- mine. The true characters of chancroid are retained by the sore through- out, the base is uneven and (sometimes with exuberant granulations) covered by the same grayish, adherent, false-membranous-looking ma- terial, whence the name pultaceous chancroid. The edges are sharply cut, gnawed, uneven, abrupt. The discharge is thin, sanious, and inocu- lable to the end. The edges are often undermined, thin, purplish, perhaps oedematous. Pain of a burning character at the edges indi- cates advance of the process. This form of phagedena lays bare the penis, sometimes the testicles, and may travel up over the abdomen, and to any extent farther. Usually, however, the largest, most persistent chancroids originate in bubo (which see), but the characteristics of the ulcer are the same, whatever its origin. ZSTo definite duration can be assigned to phagedena. The chronic serpiginous form, untreated, always lasts many months, some- times many years. The longest case recorded (Fournier), commencing in the groin in a virulent bubo, was still present as an open ulcer of the knee after fourteen years, having healed up behind as it advanced, and this, indeed, was not untreated, but had been under Ricord's care for several years. The course of phagedena, like that of chancroid, may be continued by successive relapses. Perhaps after cicatrization is nearly complete, phagedena recommences without evident cause, and the whole cicatrix reopens. The causes of phagedena are (1) general and (2) local. 1. General. — Whatever depresses the vital force — ^bad hygiene, in- temperance, misery, digestive troubles (Ricord), scrofula, lymphatism, scorbutis, malaria. Chronic alcoholism and old age are prominent as general causes. 2. Local. — Lack of cleanliness, phimosis from retention of pus, fatty substances as dressings, particularly mercurial ointment, which Ricord considers a very active cause, all sorts of local irritation, friction, etc. Sperino,' Salneuve," RoUet, and others, have inoculated from phagedenic chancroid, producing only simple chancroid; and Sperino, with other syphilizers, has shown that the same pus inoculated on different individ- uals produced in some simple, in others phagedenic sores, while con- frontation — that is, examining the woman from whom the man received his sore, or vice versa — has frequently revealed a phagedenic sore derived from a simple one. Hence the conclusion : There is no special phage- denic virus. Phagedena is not a property belonging to chancroidal pus ; ' "Studi clinici sul Virus sifilitico," Turin, 1863. f "De la Valeur sdm^iologique des Affections ganglionnaires," ThSse de Pang, 1852. J.92 CHAXCKOID. it is rather a property of the tissues of the patient— an individual idiosyncrasy. This fact is substantiated by daily experience, for hetero- inoculations " with phagedenic pus have rarely produced more than a simple sore, while auto-inoculation of the same pus is not unlikely to be at- tended by phagedena. Again, certain individuals are recorded as having had chancroids on two different occasions, both times phagedenic." In some instances, however, we find ourselves unable to detect any cause of phagedena, which may attack patients apparently in the most robust health, where none of the general or local causes mentioned above seem to have been at work. Treatment will be considered under treatment of chancroid. (»i.) Bubo and (o.) lymphitis will be described after the section on treatment. Diagnosis of Chaxceoid. — The diagnosis of chancroid is with herpes, balanitis with excoriations, exulcerated abrasions, syphilitic chancre, simple ecthyma, ulcerated mucous patch, ulcerated (tertiary) tubercular syphilide of the glans penis or prepuce, epithelioma (p. 22). The distinguishing peculiarities of the four most common of these le- sions — syphUitic chancre, chancroid, herpes,' ulcerated abrasion — ^wUl be exhaustively considered side by side in the diagnostic table following syphilitic chancre. Of the others, the ulcerated mucous patch rarely presents the same depth of ulceration, or tendency to spread, and mu- cous patch furthermore is apt to coexist with other similar lesions of the mouth or anus. Discharge from mucous patches is in a measure auto- inoculable, but does not of course produce typical chancroid. Finally, tertiary syphilitic ulcerations of the glans or prepuce often resemble chancroid so accurately, that no physical characteristic is wanting. Usu- ally, however, the edges are harder, as is the base, the ulceration more irregular in outline, the tendency to eat deeply more marked, the pain and inflammation less. The discharge is not auto-inoculable. With any one of these lesions there may be local inflammation and consequent suppurating bubo, or even lymphitis, but, in any case, if a bubo suppurate and its pus be found auto-inoculable, it has derived its origin with abso- lute certainty from a chancroid, and from a chancroid only. In any case of doubt, in presence of a suspicious sore, there remains one infallible method of diagnosis ; namely, auto-inoculation. Auto-inoculation is most safely practised in one of three situations: under the nipple, where Boeck has shown that chancroid naturally runs a mild course, over the insertion of the deltoid, or on the outer part of the thigh. In all of these localities the artificially-produced sore is not liable to be complicated by bubo, on account of the distance of the ' Inoculations upon one individual from another. ^ If egroes saifer more than whites from phagedena, as indeed they do from chancroid, bubo, syphilis, or even gonorrhoea as a rule. ' Legendre (" Memoire sur I'Herpes de laTulve," Archiv. de iled., 1853) has brilliantlj described the difficulty of diagnosis in some of these cases in the female DIAGNOSIS. ^93 lymphatic glands, nor is it likely to accidentally inoculate surrounding parts. Of course after an inoculation has fairly taken, and served its end as a crucial diagnostic test, it should be promptly destroyed by a drop of acid. In certain cases it is absolutely impossible to arrive at a diagnosis without consulting this test, as where the chancroid cannot be seen— sub-preputial chancroid with phimosis, intra-urethral chancroid, anal chancroid resembling fissure. In intra-urethral chancroid, the auto- inoculability of the pus is sometimes the only diagnostic symptom • in other cases there is a painful spot in the urethra during erection and a lump that may be felt from the outside ; possibly virulent bubo accom- panies it, or, in rare cases, there may arise a peri-urethral abscess in connection with urethral chancroid. Such an abscess opens, furnishes auto-inoculable pus, and remains fistulous (Ricord, H^lot). Successful auto-inoculations have been made with pus, derived from irritated syphilitic chancre, secondary lesions, especially mucous patch, or in suitable subjects may sometimes be made with pus, from gonorrhoea, simple abscess, fluid around vegetations, pus from a pustule of scabies, etc., and even a pustule may be produced, by simply scratching the skin of certain individuals with a clean, new lancet, going through the mo- tions, but inoculating nothing. Pustules and ulcerations produced by any of these methods need not lead to error. They are not chancroids, and never have been proved to be such, through the production of characteristic chancroid by their hetero-inoculation. And, indeed, even in the first inoculation of these fluids, the chancroidal ulcer, as above described, cannot be produced. An ulcer, indeed, may form, and an ulcer whose pus may be feebly auto-inoculable, if the patient be in a condition favorable to suppuration, but the pustule is usually an abortive one, tending to dry up and scab, the ulcer is small, does not spread like chancroid, nor does it possess the well-known characteristics of the latter. Syphilitic chancre is only auto-inoculable after it has been irritated and made to suppurate freely, and so of the other substances mentioned above; the thicker the secretion is in pus-corpuscles, the more likely is it to occasion a slight ulceration by auto-inoculation, sus- taining Van Roosbroeck's theory of the contagious properties of all pus. Then, on the other hand, in certain individuals, any scratch, how- ever made, will fester and produce pus, but it would be difficult to con- found such an ulceration with chancroid. In short, these cases of exceptional auto-inoculability of other secretions than that of true chan- croid will rarely lead to error. They may serve to feebly uphold preconceived theories, but not to deceive the earnest searcher after truth. The real error to which the well-informed student is exposed, is that of inoculating from the secretion of a chancroid, which has been gangrenous, and deciding against chancroid, because the inoculation did not take, and perhaps, on this account, concluding that his patient has syphilitic chancre, or making the other error of inoculating from a mixed ^94 CHANCROID. sore,' and wrongfully deciding tliat there is no syphilis because auto- inoculation takes. Hence the caution to be remembered: chancroids attacked by total gangrene are no longer inoculable, and an ulcer repro- ducing itself by inoculation may possibly be a mixed sore. Another caution is equally important : only practise auto-inoculation of a phage- denic chancroid under the nipple of a patient. There is always a chance that the new sore, produced upon a subject already predisposed to phagedena, may itself take on the same morbid action, but the chance is less under the nipple than anywhere else, except on the face. Prognosis. — Chancroid does not endanger life, except very occa- sionally, from such complications as severe erysipelas, or extensive, sloughing phagedena, by opening a vessel or exciting peritonitis. Practically it may be said that chancroid does not kill ; even the im- mense chronic ulcers of serpiginous phagedena eventually get well. Certain results of chancroid, however, must not be forgotten. Exten- sive cicatrices left by phagedena may prove annoying by their subsequent contraction, and the actual destruction of the penis by phagedena prac- ticallj- unsexes the man. Then urethral chancroid is inevitably followed by more or less stricture of that canal at the seat of the lesion. So, also, may permanent phimosis be produced by the cicatrices of chan- croidal ulcerations at the orifice of the prepuce. Chancroids of the pockets on either side of the frsenum may, but very rarely do, eat into the urethra, and result in artificial hypospadias. Extensive adhesions of the prepuce to the glans penis may occur after chancroidal phimosis, as indeed after the simple inflammatory form. CHAPTER II. GHANGROID. Prophylactic Treatment.— Local Treatment of Chancroid. — Local Treatment of Phagedena.— General Treatment of Chancroid. — Bnho; simple; viralent. — Treatment of Bubo. — LymphitiB; simple; Tirulent ; syphilitic. — Treatment of Lymphitis. Prophylactic Treatment. — As a rule, chancroid does not come under the surgeon's notice untU it is already advancing and beyond the reach of any abortive measures other than actual destruction by caustics. But, on the other hand, it not infrequently happens that a crack or abra- sion on the surgeon's finger becomes inoculated in handling chancroids, and then any prophylactic treatment short of caustics becomes valuable. Abortive treatment applied to chancroids naturally acquired is not as effective as against the same produced artificially by inoculation. All the ' Inoculation of a preexisting tubercle-papule, or syphilitic ulceration, with the pus of chancroid, as well as mixed chancre, should be remembered as possibilities. TREATMENT. ^95 Stronger mineral and some of the vegetable acids, caustic alkalies, and certain salts— as the sulphate of iron, chromate of potash, in solution in water, so weak as not to attack the epidermis— prevent the develop- ment of the chancroid if applied over the artificially inoculated point for a considerable time— about two hours— within a period of three to six, and occasionally twelve to twenty-four hours after inoculation has been practised (RoUet). The longer the time which has elapsed after the introduction of the poison the longer must the preventive solution be locally applied to render it- inactive, and, naturally, if any portion (as by oblique puncture) has been introduced beneath the epidermis, this epidermis must be removed in order to allow the fluid to exert its power. According to Rodet and RoUet, a concentrated solution of citric acid yields the best results. Treatment of Chancroid. — Once present in its character of true chancroid, no treatment yields as satisfactory results as the entire de- struction of the ulcerated surface by an efficient escharotic, thus arti- ficially imitating Nature, which sometimes at once destroys the poison- ous character of the sore by total gangrene of the secreting surface. Any active caustic may be used, but among them three hold the most prominent places, as being easily manageable and least painful ; these three are : nitric acid, sulpurio acid, and the red-hot iron. The latter is often objectionable as greatly exciting the patient's fears, but indeed needlessly so, for the actual cautery is perhaps the least painful of all ; the idea, however, is repulsive to a patient. The caustic alkalies deli- quesce, and are unmanageable, besides paining more than the acids ; the latter remark holds good of the Canquoin, Vienna paste, etc. In ap- plying a caustic, every portion of the sore should be thoroughly and absolutely destroyed, and all existing sores, should there be more than one ; for, should any ulcer secreting virus be left active, it will speedily reinoculate the raw surfaces left by the separation of the eschars, and the result would be other chancroids, by auto-inoculation, larger than those first operated upon. Hence the rule : If cauterization be decided upon, burn every portion of every ulcer, no matter what its size. If there be sub-preputial chancroid, with phimosis, the folly of burning chancroids of the preputial rim is at once apparent. The same may be said of burning sores on the glans, or prepuce, if urethral chancroid exist. To apply nitric acid, all that is necessary is to clean off and dry the ulcer, and place upon its surface a drop of nitric acid, with a match or glass rod, holding the surface exposed until the drop has partly dried or until the pain has nearly ceased ; then, to insure success, again to dry off the surface and apply a fresh drop. It is necessary to have a moistened sponge ready to absorb immediately any portion of the acid which may be running over upon the sound skin. Finallj', the surface is washed, dried, covered with dry lint, and left to itself. The eschar 496 CHANCKOID. begins to separate in a few days, leaving a red, healthy ulcer, which may be dressed with dry lint, or with any of the mildly-stimulating lotions recommended for balanitis (p. 20) ; and, in a variable period, depending upon the size of the ulcer and the depth to which it was burned, cicatrization will ensue. Sometimes, when sub-preputial chan- croids are burned, if the prepuce be tight, inflammatory phimosis may be occasioned, unless the patient keep at rest after the cauterization. Sulphuric acid is best applied as the carbo-sulphuric paste of Ricord, This is formed by making a paste of pure -sulphuric acid, with pulverized vegetable charcoal. It is applied upon the dried surface of the sore, and pressed down into all its inequalities with a wooden spatula. It dries on as a black crust, which separates after several days to leave a healthy, granulating, simple ulcer; or, more rarely, cicatrization goes on to com- pletion under the scab. In using the hot iron, its point should be carried down into every portion of the ulcer, until a black dead eschar of the whole surface is produced. Cold-water dressing is applied afterward, and anodyne given until pain has ceased. All chancroids might be cured by this simple method of treatment, rest, cold, and astringent lotions being used afterward, to combat inflammation. Healing chancroids, however, need not be cauterized, nor should sores of the meatus urinarius be burned, nor very exten- sive ulcerations, except as a last resource, nor chancroids which are largely multiple, both on account of the uncomfortable degree of inflam- mation apt to be provoked, and the greater liability to leave some little secreting surface undestroyed, which may reinoculate the burned surfaces. Of the three agents for destroying chancroid, nitric acid is the best. It is the most manageable and least painful (Canquoin) to the patient. It destroys only a limited depth of tissue, but yet enough for the pur- pose, if it be properly employed. No anaesthetic is required ordinarily in applying nitric acid or the carbo-sulphuric paste. With the actual cau- tery it is necessary. When it is unadvisable to use caustic, or when the patient refuses to submit to the application, the surgeon is still possessed of remedies suitable to the disease. It is well to remember that greasy local applications to chancroids are bad. They become rancid, and prevent the escape of the poisonous pus. Mercurial ointment is believed by Ricord to be of all the most harmful. Perhaps the best treatment for simple, uncomplicated chan- croid, when not destroyed by caustic, is to cover the entire surface with powdered iodoform. The local action of this drug in chancroid is superior to any thing short of cauterization, but there are two objections to its use, namely, complaint of pain occasionally from sensitive patients,' ' A dQution of the powder witti one-third of tannin is said, by Dr. 0. C. Lee, to render the application painless. TREATMENT. 497 where a considerable surface is covered, and the very penetrating rathev disagreeable odor of the remedy. The second objection may prove the most serious one, and patients may refuse to use the powder. In such a case, the simple application of a little dry scraped lint, often renewed, so as to absorb the pus as it flows, is a fair treatment. It keeps the parts clean, and allows the sore to run its natural course, and get well in due time. Another good expedient is dusting the surface with dry, powdered oxide of zinc, or calomel with a little camphor, or bismuth, and covering the whole with lint soaked in a weak solution of aromatic wine, one part to three of water, or alcohol, one part to two of water, or permanganate of potash, gr. j-ij to the I j, or carbolic acid, one-half of one per cent. It is sometimes useful even to large surfaces to apply pure carbolic acid every other day, or a solution of bromine, 3 ij to the 3 j, dressing between-times with one of the above solutions. Such dressings should be frequently changed, as cleanliness is of the first importance. In the treatment of'any chan- croid, especially such as are situated near the fr^enum, where the lym- phatics are most abundant, rest is of the greatest utility in preventing inflammation and the formation of suppurating bubo. For chancroid of the meatus, nothing is better than a little plug of dry lint, sprinkled with iodoform, and patience, with an alkaline diuretic, to render the urine less irritating, and the absolute avoidance of any sexual excitement or erotic thoughts calculated to stimulate erection. Urethral chancroid may be benefited by the same general means and the occasional injection of a mild solution of aromatic wine in warm water. Suh-preputial chancroid requires no modification in treatment, unless, there be congenital or inflammatory phimosis. The prepuce, however, should not be dressed back, for fear of paraphimosis. "With phimosis frequent injections of the balano-preputial culrde-sao with warm water are necessary for cleanliness, and to prevent the pus from accumulating and burrowing. After the washing, any of the above-mentioned stimu- lating lotions may be injected, or a gr. v-xv solution of the nitrate of silver (Ricord), which, according to this surgeon, acts also as a local aneesthetic. For simple or erysipelatous inflammation of chancroid, the best treat- ment is absolute rest, and an elevated position of the organ, aided per- haps by a lotion of lead-water externally. Where the inflammation runs high, with phimosis, and the tension of the prepuce becomes very great, it should be slit up on the dorsum, or entirely cut away (circum- cision), if it be very redundant. When the pus issuing from beneath the inflamed prepuce begins to smell badly, the indication is to cut at once to avert gangrene or phagedena. Truly, the cut surface nearly always becomes inoculated, in spite of the best precautions, but, if gan- grene or phagedena be averted, the extent of simple chancroidal ulcer- ation is comparatively of small importance. When the prepuce is slit 32 498 CHANCROID. up, it is advisable to cauterize at once all the shancroidal ulcerations exposed, and the cut surfaces as well. For this purpose the hot iron is best, as the patient is under the influence of ether. In the treatment of chancroid it is always advisable to keep the ulcerated surfaces, if possible, covered with lint or some substitute, to absorb the pus as it flows, and protect the parts which would other- wise lie in contact with the diseased surface and run the risk of inocu- lation. In anal chancroid the merits of each case must decide whether it is allowable to employ cautery (hot iron). The greater the amount of tissue destroj'ed, the greater the degree of subsequent stricture. If an infected fistulous tract exists in connection with any chancroid, the latter should not be cauterized unless the former can be slit up, and similarly dealt with. Gangrene, not phagedenic, should be left unmolested. The fall of the slough may be hastened by the application of a poultice of camo- mile-flowers (Hammond), to which a little permanganate of potash or liquor sodas chlorinatiB may be added as a disinfectant, or some pow- dered charcoal, or yeast. Simple dressings for the healthy ulcer beneath are all that is required. Chancroid of the pockets beside the frmnum frequently undermine the latter, which, when very thin, may be accidentally ruptured, giving rise sometimes to considerable hsemorrhage from the artery of the fraenum. To anticipate this, it is advisable to pass a double thread beneath the fraenum, and tie both ends, letting the ligatures cut through. Where the prepuce is short, and there is much oedema about the frsenum, looking toward paraphimosis, the repeated judicious application of col- lodion to the swollen skin (after drying it) may prevent the latter com- plication. Where paraphimosis has come on, if it is reducible, or irreducible, without strangulation, absolute rest, coUodion, and evaporating lotions, are called for ; if there be irreducible paraphimosis with strangulation, the knife must be used to avoid gangrene. Local Treatment of Phagedena. — ^The proper local treatment for phagedena is unsparing cauterization, efi^ected by the free and care- ful use of nitric acid, the hot iron, or the carbo-sulphuric paste pressed well down into aU the sinuosities. Success depends entirely upon the destruction of the whole secreting surface, and the previous preparation of the ulcer has a great deal to do with the result of treatment. All sloughs, overhanging edges, and bridges of skin, must be cut away, fistulse laid freely open, as well as all sinuses and pockets, in which matter may have collected. Ether should be given in the case of large sores, since slowness and care are absolutely essential to success ; finally, when the wreck is cleared oflF, the surface should be dried as thoroughly as possible, and then the escharotic which has been selected applied TREATMENT OF PHAGEDENA. 499 with scrupulous care. Some morphine under the skin will tide the patient over the pain of the caustic. It is better to bum too much the first time, than to have to repeat the operation ; the caustic will destroy less tissue than will a few days of natural advance of the ulcer left to itself, so that destruction of tissue is actually economized by judi- cious use of the caustic, even where the operation has to be repeated, which unfortunately is often necessary in bad cases. The indication for a second cauterization is furnished by the general appearance of the ulcer, or a return of the old pain, so characteristic of advancing phage- dena, and which ceases after thorough cauterization. Erysipelas or other inflammatory complication is rarely lighted up by cauterization, an operation which, though severe in appearance, the experienced surgeon learns to regard with increasing favor. When phagedena has attacked a virulent bubo in the groin, and in the large ulcer are found several lymphatic glands, undestroyed by the phagedena, riding out from its base, it is better to remove these before resorting to cauterization. Sometimes these active local means cannot be employed, as where large vessels are exposed by the ulceration, when long and deep fistulse exist, which cannot be thoroughly or safely acted upon ; when the ulcer is- exceedingly large, and the patient's condition will not warrant the application of caustic to so extensive a surface. Here other local appli- cations are called for. Ricord considers a solution of the tartrate of iron and potash, gr. xx-xl to the % j, almost a specific for chancroid, especially its phagedenic form. Carbolic acid may be used pure (but not over too large a surface, for fear of poisoning) every other day, the half of one per cent, solution being kept constantly applied. Bumstead mentions some successful cases by Hinkle from the use of permanganate of potash ( 3 j C to the | j), put on every two hours, a solution of gr. x to the pint being constantly applied. Iodoform in powder is an excel- lent local application for phagedena. Erysipelas complicating phagedena sometimes on retiring leaves the ulcer in a healthy condition of repair. Phagedena of the anus and rectum is rarely in a position to be burned. The surfaces must be kept separated, and the parts cleaned by syringing ; enemata being given for every movement of the bowels. Subsequent stricture is combated by the careful use of bougies. The worst cases may call for lumbar colotomy. The old chronic sores left behind by phagedena in the femalevagina — p. 486 (e.)— are perhaps best managed by a free application of the actual cautery, with subsequent absolute rest and cleanliness, and tonic internal treatment. They are usually particularly obstinate. Bumstead speaks of the good effects of powdering the surface several times daily with persulphate of iron. During treatment the parts should be kept separated by pledgets of oakum. These cases are rarely seen except in broken-down prostitutes, old hospital cases. 500 CHANCROID, General Treatment of Chancroid. — Chancroid is a local ulcer. It does not in any'manner affect the constitution, but the constitution of the individual affects it, rendering it, perhaps, very slow and chronic in its course; or, from personal idiosyncrasy, phagedenic. Simple chan- croid, then, requires no internal treatment, except such as is suggested by common-sense, and general hygiene. Mercury rarely fails to do abso- lute harm and to retard cure, perhaps even to induce phagedena. Chronic sluggish cases, which fail to respond to local treatment, unless the trouble lies in the mechanical irritation of motion, may be bright- ened up and started toward cure by all known tonic means ; among which, change of air, cod-liver oil, and preparations of iron, hold the first rank. Phagedena being nearly always a constitutional, individual tendency, requires the active use of the last-named means, with good food, and perhaps wine. Ricord speaks highly of the tartrate of iron and potash internally. It may be given in gr. xx doses. Rodet praises large doses of opium as a means of cure. {n.) Bubo {PovI3u)v, groin) is a term which originally applied only to certain morbid conditions of the glands of the groin. It has, by modern usage, been adopted for inflammations or simply enlargements of these organs occurring anywhere in connection with lesions usually but not necessarily venereal. There are three distinct varieties of bubo: the simple inflammatory, including all the previous stages of engorgement; the virulent, the pus of which is auto-inooulable, producing chancroid ; and the syphilitic. Of these, the second is and can be found in connec- tion with no other conceivable lesion than chancroid. Its presence is absolute proof of the preexistence of that . form of ulcer. Syphilitic bubo, on the other hand, cannot exist unless the patient have syphilis. Simple inflammatory bubo, very common with chancroid, occurs also sometimes with any inflammatory lesion, gonorrhoea, syphUitic chancre occasionally, herpes, balanitis, or indeed may develop spontaneously. Pure syphilitic bubo does not suppurate, simple bubo usually does, but may not; virulent bubo necessarily does. Syphilitic bubo will be considered in connection with syphilis. The diagnosis of bubo is simplified by its arrangement in the Diag- NOSTic Table, Chapter IV. Bubo does not necessarily occur in the groin. It appears in glands which receive the lymphatic trunks distributed to that portion of the body where the exciting cause (chancroid) occurs. It may be found in the axilla, in the epitrochlear gland, under the jaw, or elsewhere. It is most frequently encountered in the groin, because its exciting cause is usually situated on the penis. Bubo is more common in the male than in the female. Fournier believes that it occurs with chancroid, about once in three cases. The proportion between simple and virulent bubo is unknown, as no statistics have been compiled. Simple bubo is hap- pily more common. The most usual seat of bubo is in the central gland BUBO. 501 or glands of the inguinal chain, those lying over the great vessels. Bubo is single or double, usually on the same side with the lesion (chancroid) or on the other side (crossed) or double for a single sore ; sometimes in double bubo, simple bubo will exist on one side and virulent on the other. Bubo only affects the first group of glands receiving the lym- phatics from a part, there is no implication of glands further on, either in the case of simple or virulent bubo. Bubo, simple (sympathetic or inflam- matory) or virulent, may appear early or late in the course of chancroid, even after the latter is nearly or quite healed. Simple bubo usually appears earlier (before the thirteenth day, Hairon ') than virulent bubo, although the latter, when it does commence, advances more rapidly. Puohe ' saw a virulent bubo come on after three years' duration of a serpiginous chancroid. Both forms of bubo are a little more commonly found with chancroid near the frasnum, where the lymphatics are numer- ous and large. Both forms may be attended by granulations upon the ulcerated surface, constituting so-called vegetating bubo. Simple Suho. — This is the form commonly known as sympathetic bubo. It is essentially the same inflammatory glandular swelling as occurs after vaccination, or from an inflamed corn. Any inflammatory lesion of the penis may be accompanied by such a bubo (single or double) in the groin. Chancroid is the most common exciting cause, and espe- cially chancroids which are inflamed. Bubo may occur without any visi- ble causing lesion. Symptoms. — The patient in walking feels a little pain in the groin, and thinks he has " strained " himself. On examination, he finds a small, oval swelling, perfectly movable under the skin, but painful on press- ure. If properly managed, this may extend no farther, but usually the lump gradually grows. It becomes adherent to the skin at one or more points. The cuticle grows red, feels thick and porky, perhaps gets oedem- atous; finally, a central spot of softening may be detected; the skin becomes thin and shining ; the bubo at last, like any other glandular abscess, bursts, discharges a creamy pus, and, after flowing for a few days or weeks, gradually contracts and gets well. The healing of bubo is very apt to be indefinitely postponed, in consequence of the motion to which the part is necessarily subjected in walking, every step opening the wound, and pulling upon the young granulations which are vainly trying to fill the cavity left by suppuration. Especially is this the case in feeble, broken-down constitutions, sickly youths, those who persist in drinking. Suppuration of simple bubo does not necessarily occur, and at any period, even after matter is formed, resolution is possible, but the majority open in spite of all efibrts. While abscess is forming, the ordinary constitutional symptoms exist. Pain, generally present, is sometimes wanting, but always increases as ulceration becomes imminent, and is generally greatly aggravated by ' Quoted by Rollet. * Ricord, " Le?ons sur le Chancre." Founder, 502 CHANCROID. motion. The formation of pus is frequently announced by chill, and at- tended by febrile phenomena. No\T, this simple glandular abscess is subject to variations in its course. With strumous patients, usually several glands swell on both sides, and become matted together into a vast lump. These grow slowly, often without pain. They are particularly sluggish, and show very little tendency to suppurate. Their pressure inflames the skin, which may get red, thick, porky, often threatening ulceration at different, points. The return circulation from the scrotum and penis is often obstructed, leading to oedema of these parts. Finally the inflamed tissues around the glands break down into pus, which, when discharged, is thin, watery, sanious. The breaking of the abscess imder these cir- cumstances does not materially diminish the size of the tumor, for the peri-glandular tissue has suppurated, and not the glands. The skin now gets thinned over the swelling, the opening from which the pus was dis- charged enlarges, perhaps one of the glands breaks down into suppura- tion, or it may protrude through the opening, covered by pale, flabby granulations. The pus may burrow along the groin, over the crest of the ilium, down the thigh, over the abdomen, into the scrotum, and new abscesses form at the blind ends of these canals, which opening, fistulous tracts are left, marked by a hard, cordy feel under the skin. The dis- charge of serous pus from these fistiJse continues sometimes intermi- nably. Instead of suppurating, strumous bubo may remain for months in a condition of almost painless, indolent enlargement. Again, simple bubo may be complicated by erysipelas or gangrene, but probably never by phagedena. The pus of simple bubo is not auto-inoculable. ViKHLBNT Bubo. — ^This form is often known as the bubo of absorp- tion, since some of the peculiar chancroidal poison must be absorbed in order to produce it, whether by ulceration into a lymphatic trunk, or by migration of pus-corpuscles, is unknown. "Without chancroid its ex- istence is impossible. Virulent bubo is usually single, in one gland, on one side. It suppurates necessarily, but, until it is open, there is no diagnostic feature which can positively distinguish it from simple acute inflammatory bubo, on the road to suppuration. This only can be said, that its course is more rapid, more acute, more inflammatory. Peri- adenitis occurs with virulent bubo also, the pus forming outside the gland usually ulcerating through the skin first. In such case the first pus that flows is simple, not poisonous, and the wound looks like that seen with simple bubo, but soon the deeper pus from the gland appears, poisons the wound, and gives it the well-known chancroidal aspect, and now the pus is freely auto-inoculable. Virulent bubo may discharge by a single opening. This is large at first, and subsequently enlarges, but, if, fortunately, adhesive inflammation has agglutinated its edges to the surrounding underlying tissue, no further poisoning takes place, the ab- VIRULENT BUBO. gQg scess assumes all the cbaraoter of a true chancroid (abrupt edges, pul- taceous, irregular base), passes through its regular stages, and finally gets well. Matters do not, however, always eventuate so fortunately, the thinned skin over the suppurating gland may fail to become bound down by adhesive inflammation, or to give way speedily at a single point, then the pus undermines a certain extent of integument, and per- forates it in a cribriform manner. Burrowings, more or less extensive, go on. Hard, sinuous, everted edges, overhanging flaps and bridges of thin, purpUsh skin, long fistulous tracts, and poisoned pouches full of pus, serve indefinitely to prolong the virulent bubo, making its duration a matter of months, perhaps years. Finally, virulent bubo, like any other chancroid, may be attacked by phagedena, or any of the other complications set down for chancroid (p. 488). Accidental auto-inoculation of the skin of the abdomen or thigh is not uncommon. The worst forms of phagedena are seen in connection with virulent bubo. The case which Fournier records as having lasted fourteen years and being stUl unhealed at the knee was phagedena of a virulent bubo. All the varieties of phagedena are found, but the pultaceous, serpiginous variety is most common. It usually travels up over the abdomen, but if very extensive seems to prefer to turn the flank and go down the thigh, rather than advance upon the chest, that region shown by Boeck to be unfavorable soil for chancroid. Phagedena does occur on the chest, but not commonly. The nature and character of phagedena have been described. A phagedenic bubo does not necessarily, or indeed usually, exist in con- nection with a phagedenic chancroid, which latter may be attended by simple bubo, or leave the glands untouched ; nor is lymphitis necessary, or indeed common. An insignificant-looking chancroid may be attended by a phagedenic bubo, and phagedenic chancroid may have no bubo at all Diagnosis. — The diagnosis between simple, virulent, and syphilitic bubo, will be found in the diagnostic table following syphilitic chancre. The bubon d^embl'ee does not exist in the sense originally attributed to the term ; namely, a bubo without antecedent venereal ulcer, ushering in syphilis, and furnishing auto-inoculable pus. The absurdity of this is self-evident, for a virulent bubo never ushers in syphilis, nor indeed has it any thing to do with that disease. It is nothing more nor less than a chancroid. A bubo, however, may suppurate in the groin without necessarily any antecedent chancroid, as in connection with herpes, gonorrhoea, balanitis, an inflamed corn ; or spontaneously, as may a gland in the neck or axilla ; such a bubo, however, does not furnish poisonous pus. When a gland in the groin suppurates, and its pus is auto-inocu- lable, it has been preceded by a chancroid. The latter may have cica- trized before the patient presents himself, perhaps was situated in the urethra, or even in the rectum, but somewhere it is or certainly has 504 CHANCROID. been. The intelligence of the surgeon may occasionally be taxed to find it. There are no diagnostic signs between a simple and virulent bubo at first. When opened spontaneously or by art, the outlet does not enlarge in simple bubo ; in virulent bubo it does, and shows all the character- istic marks of chancroid. Again, if suppuration can be arrested in an inflamed gland, it must have been simple bubo (unless syphilitic) ; viru- lent bubo must necessarily suppurate. Treatment of £ubo. — The preventive treatment of bubo is rest, and the avoidance of such causes as tend to inflame the chancroid. The most positive preventive treatment is the absolute destruction of the chancroid with caustic. In such a case if the simple ulcer left by the fall of the slough is still able to excite a simple bubo, yet virulent bubo and its attendant phagedena can no longer occur, tincture of aconite and of iodine locally are of little use without rest ; the successes attributed to them are largely coincidences. They perform one servdce, however — they give the patient something to do ; they keep him from incessantly handling the part to see how matters are progressing. Mercurial oint- ment spread upon lint may be laid on the surface for the same purpose; but all substances to be rubbed in are harmful, since friction is bad. Eest in bed and a very light poultice will usually disperse a bubo better than any of the above methods. Besides rest, there are three other agents which may avert suppura- tion : 1. Blister, repeated as soon as the skin has reformed. 2. Pressure, which, if applied early and judiciously in mild cases, is sometimes effective. 3. Leeches, plentifully applied around the swollen gland. The latter treatment is only applicable in the early stages of bubo, for, should the swelling prove virulent, suppuration is inevitable, and, if the leech-bites are near the point of opening and have not cicatrized, they are pretty sure to become inoculated and form so many chancroids. If the tendency to suppuration advance very slowly, the bubo is certainly simple ; if rapidly, large, hot poultices should be constantly applied to hasten it, and the abscess may be allowed to open itself ; but, if, from its ver}' rapid course, it is believed to be virulent, an opening should be made as soon as any fluctuation can be felt, to let out the poisonous pus, and save destruction of tissue. In this way burrowing may be averted, as it may also by properly-applied pressure. It is a good rule to open early in any case. If it be simple bubo, no harm is done ; if it be virulent, the chancroidal ulcer following is by so much less exten- sive. Small collections of pus should be punctured, large ones exten- sively laid open. If the skin does not appear to be adherent, some caustic paste may be preferred to incision. If any outside wounds exist (leech-bites) at the time of opening bubo, they should be carefully pro- LYMPHITIS. 505 leoted. Once open, if the bloody, thinnish, unhealthy look of the pus suggest virulent bubo, the poultice should be discontinued, otherwise it IS better kept up for some days. All cavities, if large, should be thoroughly cleansed several times daily with warm water, and then in- jected with a mild solution of carbolic acid or permanganate of potash, dilute alcohol, or some other detergent lotion. After virulent bubo becomes an open ulcer, its treatment is that of chancroid. Where large glands lie out in the ulcer and have not suppurated, or if all the sup- puration have come from peri-adenitis, in cases where tlie bubo was strumous, these glands should be removed. This is best done with the finger, tearing them away, or they may be tied off with a ligature. Even when cut away they rarely bleed much. Burrowing and phagedena in the groin are treated in the same man- ner as when occurring with chancroid. The pastes, carbo-sulphuric and Vienna, are well suited to phagedena in this region. Where suppura- tion has been stayed, and in all cases of chronic bubo in which strumous degeneration of the gland plays a large part, resolution may be hastened by counter-irritants and pressure. The latter is conveniently applied, the patient being on his back, by placing a bag of sand or fine shot over the swollen glands, or by a spica bandage over compressed sponge laid upon the swelling, the bandage afterward being slightly moistened. Trusses are too irritating, but it has been noticed that persons wearing trusses and afterward getting chancroid rarely have bubo upon the side of the hernia, probably from previous atrophy of the gland through pro- longed pressure (Ricord). Of counter-irritants mild repeated blistering is perhaps best. Tincture of iodine has positive resolving power in this stage. Punctate cauterization is well spoken of by Foumier. It con- sists in touching the skin in fifteen or twenty places over the tumor with the hot iron, repeating the operation every eight or ten days ; no scars are left. Internal remedies for chronic and phagedenic bubo are the same as for similar conditions of chancroid. (o.) Ltmphitis,' or inflammation of the lymph-vessel, never occurs without some accompanying inflammation of the connective tissue around the vessel, peri-lyraphitis. Its varieties are identical with those of bubo ; namely : 1. Simple inflammatory lymphitis, which may be found in connec- tion with any inflammatory abrasion, simple, chancroidal (most common), or syphilitic (least common). 2. Virulent lymphitis, only found in connection with chancroid. 3. Syphilitic lymphitis, found only with syphilis. The first two varieties are indistinguishable until they suppurate. ' The term " lymphitis " is critically incorrect, signifying, as it does,_inflammation of tha lymph. General usage, however, justifies its employment, since it is shorter than the more accurate term " lymphangitis "—inflammation of a lymph-vessel— synonymous with angioleucitis — mflammation of white vessel — first employed by Velpeau. 506 SYPHILIS. One or two hard, knotty cords are felt under the skin of the penis, usu- ally at the side. They commence at the chancroid (or other lesion), ex- tend for a greater or less distance up the penis, sometimes up to the glands in the groin. Occasionally they can be felt only toward the root of the penis. The integument over them, in mild cases, is unaltered ; in severer cases their course is marked by a red line. They are painful to the touch, and during erection. The penis is often red, erysipela- tous, swollen, oedematous, and, in severe cases, there are fever, sleepless- ness, etc. Lymphitis terminates in resolution or suppuration. In virulent lymphitis, the latter is inevitable. In the simple form suppuration may occur in one or more spots, resulting in abscesses, which discharge and get well. In virulent lymphitis similar abscesses form along the line of the vessel, open, furnish auto-inoculable pus, and remain as chan- croidal ulcerations. Either form may exist without bubo, with simple bubo, or with virulent bubo. The affection is not common, and bubo is most fre- quently encountered without it. Treatment. — ^Rest, cooUng lead-water or spirit lotions, coUodion for excessive oedema, perhaps pimcture, poidtice for severe pain, and open- ing abscesses, when they form, comprise the treatment. Simple ab- scesses are best treated with water-dressings; virulent abscesses ex- actly like chancroids, which indeed they are. Internal treatment has no influence over lymphitis. CHAPTER in. STPEILIS. Natore. — TTnity and Doality. — Len^ of Time reqTured for Absorption of Virns. — Analogy with Vaccine Vims.— Second Attacks of True Syphilis. — Transmissibility to Animals. — Incubation of Syphihiae Chancre.— Induration, parchment-like, split-pea, diffuse. — Ulceration. — Secretion. — Pain.— Nature of Scar. — Auto- and Hetero-Inoculation. — Vaccinal Syphilis. — Multiple Inoculation. — Fluids capable of transmitting Syphilis by Inoculation.— Methods of Transmission of Syphilis.— Duration of Chancre.— Kumber.- Size.— Situation. — Form. — Symptoms of Urethral Chancre.— Course of Chancre.— Compli- cations. — "Mixed Chancre." — Transformation into Mucous Patch. — Phagedena and Gangrene. — Treatment of Chancre. — Syphilitic Bubo. — ^Lymphitis, Stphilis is a general dyscrasial blood-disease caused by the absorp- tion of a pecuUar virus into the circulation, manifesting itself primarily by the appearance of a poisonous sore at the point where the virus entered, and afterward by a succession of morbid manifestations occur- ring at longer or shorter intervals — manifestations which, in their total- ity, interest every organ and tissue in the body. The virus is only known by its effects. Exactly what it is, has not yet been determined, either by the microscopist or chemist. Different ANTAGONISM OF SYPHILIS AND CANCER. 507 observers have claimed to have discovered certain vegetable spores in the secretion of syphilitic chancre and in syphilitic blood, but their investigations and conclusions have been disproved, and cannot be accepted. The last effort in this direction is the discovery in syphilitic blood, by Lostorfer, of certain peculiar microscopic bodies, vrhich he believed to represent the syphilitic poison. Further investigation, however, shovred that the blood of any cachectic hospital patient, and even of healthy individuals, would furnish the same bodies, thus prov- ing that they were not syphilitic corpuscles, and ending a charming delusion. Diday ' has called attention to the fact of an apparent antagonism between the syphilitic virus and cancer. Numerous inoculations in one case of syphilitic chancre, in others of secondary lesions, made upon patients with cancer by Diday, Rodet, and Rollet, have failed invaria- bly = (Rollet). Syphilis has been happily compared by Hutchinson' to the con- tagious exanthemata, small-pox, measles, scarlet fever, as possessing all the peculiar characters common to this group of diseases, namely : it is communicated only from one diseased person to another healthy one ; it has a stage of incubation before any sign of the disease appears ; it has a stage of efflorescence, which indeed in syphilis is prolonged and marked by relapses ; it has a period of decline, and sequelse — the later tertiary lesions — which do not always occur, and during which the disease often ceases to be communicable. Again, most of the various efflorescences of syphilis, like those of the other exanthemata, tend to pass away spontanteously after a time ; thus, as Fournier aptly puts it, affording a triumph to every method of treatment. One attack confers immunity from another often for life, always for a long period. The disease is transmissible by inheritance, as in the case of the other exanthemata when the chUd is born before the mother recovers from disease. Finally the sequelae do not constitute transmissible disease, even by in- heritance. As in the other zymotic diseases, a portion of the virus, how- ever small, is capable of infecting the whole body, as if by fermentation. Thus the analogy of syphilis with the contagious exanthemata is clear, only its febrile symptoms are less marked, its efflorescences more varied, and its course much more protracted — counted by months instead of days — and more subject to variation, as well as more amenable to treatment. Syphilis is fortunately only contagious, it is not infectious ; its poison is not volatile, is not diffused in the air ; direct contact of the virus with a surface capable of absorption is essential to the production of the disease. ' " Histoire naturelle de la Syphilis." ' Although this antagonism may exist, still cases of undoubted cancer have been encountered by the authors upon patients, who, at an earlier period of life, were certainly all'ected with syphilis. ' Reynolds's "System of Medicine.'' DOS SYPHILIS. The arguments and theories concerning the unity or duality of the syphilitic virus are out of place in a text-book. ^^Tiat syphilis is will be shown in the following pages — what it is not has been already set forth. In the early part of this century measles was not distinguished from scarlet fever, and the best pathologists set down chancroid, gonorrhoea, and vegetations, all as syphilitic. But truth has appeared, though slowly, and at the present day the great majority of the most reliable authori- ties on syphilis are in accord. Old writers are dangerous guides, for they had no aid from the light of experimentation furnished to the pres- ent generation by Ricord, Bassereau, Clerc, and a host of others. Few, at the present day can be found who could fall into the error of Hun- ter, and consider as gonorrhoea a urethral discharge producing syphilitic chancre by hetero-inoculation, since urethral chancre is so well known ; but many still look upon vegetations as indicating syphilis, and there are some distinguished names stiU laboring to preserve the identity of chancroid with syphilis — and that, mainly, because exceptional examples or obscure cases, not thoroughly well marked, seem sometimes to give the symptoms of syphilis after an apparent chancroid, and no syphilis after a seeming chancre. Rollet ' has ably dealt with these cases, about which something will be said farther on ; suffice it now to remark that the fight is based upon exceptions. In the vast majority of reasonably well-marked cases, syphilis is as diiferent from chancroid as night from day. A patient may have malignant scarlet fever and die in a day without a sign of eruption, but still he has scarlet fever, as no one denies. Even if one syphilitic chancre out of twenty were not indurated, the other nineteen would be amply sufficient to establish a rule. But the proportion is far larger, and there is, perhaps, no symptom of any dis- ease more constant than is the induration of syphilitic chancre, yet the patient does not have syphilis because his chancre indurates — as was formerly taught — on the contrary, he already has syphilis before his chancre appears. If he did uot have it, he could have no chancre at all, and the induration of that chancre is just as much one of its symptoms as is ulceration, of a chancroid. If a patient is exposed to measles, and dies during the period of incubation, before he is at all sick, he cannot be said not to have the measles ; the same of a patient who has absorbed syphilitic \'irus : he has syphilis at once, and because he has syphilis he gets a sore at the point of entrance of the poison, after a period of in- cubation, as the first symptom of the disease. This chancre may be de- stroyed by caustic, but the disease will run its course unaltered. Intervai befoee Absoeptiox — (Here" teUs of a medical student who washed himself immediatelj' after sexual intercourse, and on care- ful examination for several days subsequently detected absolutely noth- ' " Traits des Maladies v4n4riennes," Paris, 1866. ' "Traits pratique des Maladies T^n^riennes," Paris, 1866. ABSOKPTION OF VIRUS. 599 ing ; twenty-eight days afterward chancre appeared, followed by general Byphilis. Hill ' relates a very important case, bearing upon this point. A man in sexual intercourse tore his frsenum at 4 a. m. The wound bled freely. Fearing possible infection, he called upon Hill during the same day, within twelve hours after the accident. To quiet his fears, although there was no lesion evident except the abrasion, Hill cauterized the sur- face freely at once, with fuming nitric acid. The slough separated in due time, leaving a healthy surface, which cicatrized promptly. About one month afterward, the scar mdurated. It never ulcerated again, but the regular manifestations of true syphilis came on at the usual in- terval. What more striking evidence could there be of the inability of any local cauterization to interfere with the regular development of this blood-disease, after it has once been acquired ? Diday' cauterized a syphilitic chancre within six hours after its appearance ; but, although the sore healed promptly, general syphilis followed. No attempts have been made experimentally to destroy the point where true syphilis has been inoculated upon healthy subjects, but the experience furnished by the known action of other poisons may be used to form a conclusion by analogy. The rapidity of absorption of the poison of a snake-bite is well known, as is also that of rabies and the poison of a dissecting womid, and there is no reason why that of syphilis should be less so. The French veterinary surgeons have inoculated horses with the poison of glanders, cutting out the seat of inoculation one minute after insertion, but the disease followed just as surely as if noth- ing had been done. Similar experiments havie been performed on sheep, with the same result. Clerc ° vaccinated some children, destroying the inoculated point one hour afterward with nitrate of silver; vaccinia followed, and a second vaccination failed to take. Seven children were vaccinated by Aim6 Martin,* and the spot destroyed with Vienna paste, at intervals varying from one to twenty-four hours, after insertion of the virus. None of the children had vaccinia, but that the vaccination was protective is proved by the fact that in only one out of the seven cases could vaccinia be produced by subsequent insertion of vaccine lymph under the skin. This analogy seems perfect. The spot, even during the period of incubation, may be destroyed so thoroughly that no evidence of the entrance of the poison will be manifested by a subsequent characteristic sore ; yet, that the protective power of the poison (vaccine virus) operates as well as if the characteristic sore had appeared, is shown by the failure of subsequent attempts at vaccination. ' " On Venereal Diseases," London, 1868. ^ " Annuaire de la Syphilis," 1858. » Quoted by Hill. * " ThSse de Paris," 1863. 510 SYPHILIS. How different with chancroid ! Here there is no period of incubation as there is with vaccine and syphilitic poison. When the virus touches a denuded portion of tissue, changes commence at once. If our eyes were microscopic, we could probably appreciate those changes ; as it is, we have to wait some hours before the first signs appear. Chancroid can be aborted by applying certain fluids to the inoculated spot within a few hours, and destroyed totally by caustic after it has appeared. Syphilitic chancre is the first symptom which indicates that syphilis has taken possession of the patient. It is an abrasion or an ulcer some- thing like chancroid ; but, unlike the latter, it and the syphilitic mani- festations following it only appear once in a lifetime. This rule, like all others, has its exceptions. Second Attack of Teue Syphilis. — Hutchinson ' saw a well-marked case, in a physician, of two attacks of syphilis, each preceded by its characteristic syphilitic chancre. The same patient had had small-pox twice. Many other cases are found scattered through the literature of syphilis, and they go to prove that syphilis gets well, for, until one attack is recovered from, another cannot be acquired. Diday ^ has col- lected twenty-five cases, of which he personally saw twenty. All had had syphilitic symptoms, which had disappeared, except in a few, where some late (tertiary) symptoms remained. In all of these cases there was syphilitic chancre with characteristic induration, occurring a second time after a previous syphilis. In fourteen, the inguinal glands were not indurated, and there was no further sign of syphilis. In nine, general syphilitic symptoms appeared, but they were less intense than during the first attack. In two, the second attack was more severe than the first. In analyzing these cases, Diday found that in none did the second chancre appear until all signs of previous syphilis had passed away, or, in some cases, where tertiary (non-transmissible sequoias) symptoms alone remained. The nearer the second attack came to the first, the more feeble was the effect of (second) infection, yielding only chancre ; the greater the interval, the more marked the effect. The two severe cases followed their predecessors after more than nineteen years. The lighter attacks followed severe ones, and vice versa. Diday concludes that the minimum time for the cure of syphilis is twenty-two months, and that, where syphilitic chancre appears twice in the lifetime of an individual, the second attack should not be treated until symptoms of secondary syphilis appear, as these may never come on, the whole attack consist- ing simply in syphilitic chancre. Heinrich Koebner" has recently again collated the evidence on this ' Joe. cit. ^ " De la E^infection syptilitiqae, de ses Degr^a et de ses Modes divers," AreUves Generates de Medecme" July and August, 1863. 3 " Berliner klinische Woehensohrift," 46, p. 549, 72. " Ueber Reinfection mit consti- tutioneller Syphilis." SECOND ATTACKS OF TRUE SYPHILIS. 511 iect. He has collected into a table over forty oases of supposed feotion ; but that these cases of syphlilis, reoocurring in an individ- are still very exceptional, and not as common even as we might be to suppose from finding mention of nearly half a hundred in the same ly, is shown by a careful perusal of the article in question. Several ;he cases detailed by Koebner were certainly tertiary ulcerations of penis, mistaken for syphilitic chancre, as indeed Sigmund has already ited out in regard to some of these very cases,' and Case VIII., on ch Koebner lays most stress, is, of all, most clearly one of tertiary iration. The facts of this case are briefly these : A man of forty-five syphilis in 1866, and his wife an ulcerated tubercular syphilide in 7. In 1871 the man applied for treatment of a very hard, flat ulcer, ie large, and with sharp-cut edges, saying that it had ulcerated within previous twenty-four hours. Inguinal glands intact. His last periods exual intercourse were ten weeks previously with a prostitute ; nine nineteen days before date, with his wife. The wife was examined, id healthy, and remained so ; the patient stiU bore evidences of ter- y syphilis upon his person. His ulcer on the penis got well under de of potassium, and he had no eruption or other evidence of syphilis r it. Such a case requires no comment. While, then, a second true syphilitic infection is possible even while subject bears the marks of late tertiary disease, j^et such infection is nently exceptional, and allowance must be made in the reported oases (1) chancroid accompanied by some eruption, as a coincidence ; (2) lyma mistaken for syphilis, after which the first true syphilitic infec- 1 might pass for a second ; (3) false chancre, indurated mucous patch ; (4) cases of tertiary ulcer faultily diagnosticated. Teajj-smissibilitt to Animais. — Besides this peculiarity of only earing once in a given individual, syphilis differs from chancroid in being transmissible to animals. Lancereaux," quoting Ruiz Diaz isla, mentions fancifully that even plants have been accused of hav- syphilis transmitted to them by sprinkhng them with water ch had been used to wash syphilitic ulcers. Horses and asses suffer etimes from a disease, the " doury," perhaps remotely analogous to tiilis, which is transmitted only by sexual intercourse. It comes on, r an incubation of four to six weeks, with fever and cutaneous lors (net the subcutaneous tumors of farcy). The mucous mem^ les, glands, eyes, and bones, take part in the disease. Atrophies paralyses follow. It lasts from two months to three years, and is transmissible by inoculation. These animals also have a local con- ous, venereal affection (Lancereaux). Cows are said to have some- ,t similar affections, but it has been found impossible or very diffi- to propagate any of these maladies by inoculation, and their com- son with syphilis is at best fanciful. 1 Pitha und Billroth, Handbuch. ' " ^^ Syphilis." 512 SYPHILIS. Depaul speaks of a syphilitic monke}', aud Vernois ' of a cat with syphilitic cachexia ; but these badly-defined examples cannot stand against the innumerable efforts which have been made, without success, to transmit syphilis in any form to any animal by inoculation. All such efforts have failed absolutely, and authority speaks plainly on this point, that the sad privilege of having true syphilis belongs alone to mankind. iNCUBATioif OF Syphujs. — After the poison of syphilis has been absorbed, the break in the epithelium, through which it entered, heals, and the virus ferments, as it were, in the blood, until it is ready to give itself local expression, first at the point of entrance, in the form of syphilitic chancre. Such an abraded point may be kept open by dirt or local irritation, but usually nothing at first evinces to the patient that he is infected. This period of incubation, or hatching, has been criti- cally studied by many authors, both by inoculation upon healthy sub- jects, and, clinically, by close observation of patients. The results arrived at are in the main identical. The usual period after contact, or inoculation, at which a chancre first appears, is about the end of the third week. It is not unusually at four, and may, in exceptional cases, be much later, reaching ten weeks. Foumier ' gives one case of sev- enty-five days, quoting A. Gu^rin for another of seventy-one. During all this interval of incubation, the patient bears no sign of disease. The shortest limit of incubation, clinically, has not been absolutely de- cided upon, but rarely, if ever, does true syphilitic chancre appear before the tenth day ; chancroid, as already shown, rarely appears as late as the tenth da}'. This is, perhaps, the most valuable mark of a syphilitic chancre, and practically all sores appearing later than ten days after suspicious contact must be regarded with distrust, while those coming sooner may be more lightly considered. In establishing a period of incubation for syphilitic chancre, EoUet gives a table of twenty-six collated cases, where inoculation was prac tised upon healthy subjects. The inoculating fluid was derived in eleven cases from syphilitic chancre, in the rest from mucous patches, syphilitic pustules, ulcer of tonsils, blood, pustules of inherited syphUis. In all a positive result is reported. The shortest period of incubation before the appearance of chancre was ten days (from ulcer of tonsils), the longest thirty-nine days (from chancre), the mean twenty-five days. The mean from inoculation of chancre was twenty-four days ; blood, thirty ; mucous patch, twenty-two ; pustule, thirty. Iotjtjeation of Syphilitic ChaitcRe. — The period of incubation of a chancre cannot, clinically, be always obtained with accuracy. Induration can always be felt, when present, and in well-marked cases it is absolutely pathognomonic. It consists in an infiltration of the tis- • Bvl. de CAcad., 1864. » "Sur la Syphilis," Paris, 1873. INDUKATION OF CHANCRE. 5I3 sues underlying the chancre with small round or oval and spindle cells, some granular matter, and free nuclei. It may only partially underlie the ulceration m exceptional cases. It exists in three varieties : 1. A thin superficial layer of induration, aptly called "parchment- like," exactly underlying the ulceration. This may escape notice, un- less the sore be pinched up carefully with the thumb and finger, placed on either side, and Hghtly pressed upon, so as not to be bent or folded by the pressure. This is the commonest form. 2. The induration may resemble a split pea, situated exactly beneath the ulcer, which is upon its fiat surface. This induration is easily felt and is unmistakable when present. It is little or not at all sensitive, freely movable over the parts beneath, hard, like bone or wood, or like cartilage, having indeed a certain springy, elastic feel. It is sharply defined, clean cut as it were, ends abruptly, and does not shade off into the surrounding tissues, like inflammatory induration. 3. The induration may be very extensive, far surpassing the bounds of the ulceration placed upon it, excavated or convex upon its surface, but here all the characters and qualities of the induration are the same as those detailed above for the split-pea variety, only there is more of it. The skin over it is not usually red, and the feel is far difi'erent from the boggy, inelastic sensation given to the fingers by pressure on an inflammatory induration. Induration is greater or less, according to the tissue in which it is formed. It is usually greatest in chancres of the skin, lips, nipples, be- hind the corona glandis, and near the frEenum of the penis. In spongy tissues like the glans penis, the induration is often very slight. In cer- tain very rare cases, it appears to be altogether absent, probably some- times because it had not yet appeared at the moment of examination, or had passed away, and undoubtedly sometimes because the true syphilitic lesion was not detected, but some chancroid, existing simul- taneously, was discovered, found soft, and believed to be the origin of the syphilis that followed. Again, when a syphilitic chancre becomes phagedenic, it loses its induration at once. The induration of a syphilitic chancre may precede the ulceration, or may follow it. In the latter case it comes on during the first week. The parchment-like variety disappears the soonest. It has been observed to last only twelve days (Clerc). Usually, however, any form of indura tion will outlast the ulceration — remaining, indeed, for two or three months. More rarely it lasts for years, as a cicatricial hardness similar in feel to the true syphilitic induration. Ricord records one case of thirty years' standing. Fading induration may suddenly reappear, and increase on the outcropping of general symptoms. Foumier " first de- scribed certain indurations which occasionally appear in the neighbor- hood of a syphilitic chancre, though not immediately connected with it • " :6tude clinique sur I'lnduration syphilitique primitive," Arch. Qen., 1868. 33 524 SYPHILIS. They are formed in and around the lymphatic vessels, and may very rarely also ulcerate. Ulceeatioij^ of Syphiutic CnAifCEB. — Properly, syphilitic chancre does not ulcerate. It consists, in more than half the cases, simply of an excoriated surface, looking red and bloody, perhaps pultaceous, very superficial, not infrequently scabbed when exposed to the air. Indeed, it may never even excoriate, although this is exceedingly rare, the lesion consisting in a simple indurated tubercle which scales off a little at the top, but from which the epithelium is never absent, in other words, which is never even moist. Chancre, however, especially of the genitals, rarely escapes more or less inflammation, hence it is the rule to find some shal- low, occasionally deep, ulceration. When shallow, the ulcer is round or oval, with slanting borders, often a red base, sometimes partly covered with a pultaceous deposit. When deep, the borders are never abrupt, as in chancroid, but always sloped off. The cavity is funnel-shaped. The borders of the ulcer are adherent all around, never by any chance undermined, as they occasionally are in chancroid. Sometimes the induration, left behind on the healing of a chancre, reidcerates. Chaeactee of the Discharge. — Pus does not form as such on true syphilitic chancre, unless it be inflamed, when the thickness of the pus will vary with the degree of the inflammation. Ordinarily the discharge is sero-piffulent, or purely serous in appearance, often bloody, and some- times, on the dry, indurated papule, there is absolutely no discharge at all. PAiif. — In unirritated syphilitic chancre as a rule there is absolutely no pain. A patient often carries a chancre for a considerable time with- out suspecting its existence, and sometimes, undoubtedly, it comes and goes without being discovered at all. In this way may be explained many singular cases of undoubted syphilis, apparently not preceded by any primary lesion. Case XLV. — A young girl of sixteen entered the hospital covered with a roseola, with sore-throat, etc., evidently syphilitic. She denied any sexual intercourse. On ex- amination she was found to be >■ virgin ; no ulceration could be discovered about the genitals, the mouth or throat, or upon any part of the body. The only evidence of any previous lesion upon her skin was a small cicatrix of purplish color, shghtly hard, upon the radial aspect of the right arm. When the girl's attention was called to it she ex- pressed entire ignorance of the presence of any ulceration or other lesion upon the part ; in fact, seemed to see the little discolored cicatrix for the first time. Upon close investi- gation it was found that the girl was a nurse, that she took care of a young baby, and carried it frequently, often without a napkin, upon her bare right arm. Exammation of the child proved that its anus was surrounded by mucous patches. Here was a case of chancre of the arm innocently produced, utterly ignored by the patient, and so small as to have easily passed unnoticed. Many other equally curious and instructive cases have been recorded. If this girl had been a prostitute, and had happened at about the same time to have chancroid, acquired in sexual intercourse, how naturally AUTO-INOCULATION. 515 would the most conscientious surgeon have deceived himself in attribut- ing the syphilis to the chancroid I An inflamed chancre does pain more or less, but usually far less than chancroid. CiCATEix.— The scar left by chancre varies. In the majority of cases where there is only a slight excoriation or exulceration, no scar what- ever is left behind. In other cases the scar is proportionate to the depth of the ulcer. These scars are occasionally pigmented. At first they are discolored — of a dark, vinous hue, like the ordinary syphilitic tubercle, of a color aptly compared by Fallopius to the flesh of raw ham. This color may be followed by the true copper-colored (Swediaur) or bronzed pigmentation. The latter sometimes approaches a black. It clears off gradually from the centre, to leave the scar finally whiter than the surrounding skin. iNOCuiiATiON. — Hetero-inoculation of syphilitic virus upon healthy individuals was first performed by Wallace in 1835, with virus derived from mucous patches. It has since been very thoroughly studied by the few experimenters who have practised it, aided by the light of chancroid inoculation. Clinically vaccinal syphilis has furnished am- ple opportunities to study the eifects of hetero-inoculation — accidental it is true. AuTO-iNOCULATiONS have been performed without number, the result (with some little exception to be mentioned below) having been invari- ably negative, unless the chancre had been previously irritated by fric- tion, savin-powder, tartar-emetic, or other irritant, or was itself in a state of inflammation, producing pus. Under such circumstances auto- inoculation will often produce a pustule, followed by a small ulcer, remaining open, perhaps, for some time, furnishing pus, also auto-inocu- lable, but this ulcer has not the rapid march nor the characteristic ap- pearance of chancroid, and has never been proved to be such, by being inoculated upon a healthy individual and there producing a character- istic chancroid not followed by syphilis. This may be and has been done by inoculation from a mixed chancre, but never from pure syphilitic chancre. The pustule and ulceration produced by auto-inoculation of chancre is similar to what may also be produced by inoculation of pus of other syphilitic lesions, or sometimes with that of gonorrhoea or abscess ; in other words, it is the pustule and ulceration of simple in- flammatory irritation, not the special poisonous sore known as chancroid, which is so freely inoculable, and as simple dirt and irritation may call out a mucous patch or pustule upon a syphilitic subject, so may also auto- inoculation of some of the syphilitic products. The difi"erence between the inoculation of chancroid and syphilitic chancre has been strikingly illustrated not a few times. The three fa- mous cases of Lindmann, Warnery, and Danielssen, are perhaps the most conclusive. Lindmann inoculated himself a number of times with chan- croidal pus, always with success, but with no syphilis ; finally, as the 516 SYPHILIS. doctrines of syphilization were in vogue, believing himself protected, after having produced a dozen chancroids, he inoculated himself with matter taken from the ulcerated tonsils of a syphilitic friend. This was followed on the eleventh day by a papule (not a pustule, as after the previous inoculations). The papule ulcerated slightly, and in forty-five days a general syphilitic eruption appeared. The doctor now recom- menced his inoculations with chancroid matter, and when last heard from was still continuing, then having reached the twenty-seven-hun- dredth successful chancroid ulcer. Wamery, of Lausanne, under the same " syphilization " delusion, inoculated himself plentifully with chan- croids, which took, but produced only local ulcers. Finally, he employed the syphilitic virus once, and an indurated chancre appeared after twenty- three days' incubation, followed by syphilis in due course. Danielssen, a disciple of syphilization, inoculated a man, who had elephantiasis, two hundred and eighty-seven times with chancroid, until he had temporarily exhausted the irritability of the skin, and no more chancroids could be produced by inoculation. In other words, the patient was " syphilized," as it is called. Now, one inoculation was made with true syphilitic virus. An indurated, syphilitic chancre appeared, and in sixty-eight days a general syphilitic eruption followed. Since then very little has been said by its advocates of " syphilization " as a prophylactic. The course of syphilitic chancre observed by hetero-inoculation is briefly as follows : A chancre is always produced with or without ulcera- tion, a mucous patch never, although certain published observations state the contrary. A strict analysis of these cases proves that they commenced as indurated chancre, and became mucous patches only sec- ondarily after an intervaL The first result of hetero-inoculation has often been a pustule, just such a little fester as might appear after the prick of a pin, but this pustule heals entirely in a few days. It is acci- dental, and in most instances nothing remains to mark the inoculated point except the dried speck of blood. This finally rubs off, and the skin becomes absolutely normal. No change occurs for a period varying from ten to thirty-nine days in the reported cases. Then the first signs of chancre appear, not as in chancroid by a pustule, but as an indurated papule (which, becoming larger, may be called a tubercle), of a dark, vinous-red color, without pain, or perhaps with a little itching. This may remain dry, being covered after a while by a scaly crust, or may, and usually does, ulcerate after a few days, often scabbing secondarily. The epidermis may raise as a pustule before ulceration. The ulcer has sometimes been noted as appearing from the first, but usually at a mean of five days after the papule. It persists for a variable period, several weeks, possibly months, and, getting well, leaves often a pigmented cicatrix behind. The neighboring lymphatic glands indiu^te, do not suppiu-ate, and general syphihs follows. This is the course with no appreciable variation, no matter what fluid MULTIPLE INOCULATION. 5jfr is inoculated— chancre secretion, pus from mucous patch, blood, or other discharge. An apparent exception to the above course exists for vaccinal chan- cre, where chancre-virus or syphiUtic blood is introduced along with vac- cine virus. Here the vaccine virus, having a shorter incubation than the syphilitic, develops sooner, and the vesicle runs along regularly, per- haps, at first, but varies from the true type after a time, in that the base indurates and the surface ulcerates ; or, perhaps it may scab, the whole resembling a large, scabbed, ecthymatous pustule. Sometimes only the syphilitic virus takes, when, after a longer incubation, the regular papulo- tuberole of syphilitic incubation appears and runs its usual chronic course ; or the vaccine vesicle may be imperfect and abortive, the sore soon putting on the appearance of a cutaneous chancre, and general syphilis following in due course. There is one source of error in regard to vaccinal syphilis ; namely, that the vaccinal fever may develop latent, possibly unsuspected, syphilis from which a child is already suffering by inheritance, or previous con- tagion. Here the vaccination will always be accused of being the cause of the syphilis. The distinction is easy. If vaccination develops latent syphilis, it does so as does the application of a blister or other irritant, and a more or less general eruption comes on quickly, usually starting from the point of irritation, vaccinal or other ; whereas, in true vaccinal syphilis, there is first a period of incubation, then a local chancre, then indurated glands, and after a second incubation a general (at once) syphilitic eruption, which does not tend to start from the irritated point. Chancres of inoculation are of course liable to the same complications as chancre naturally acquired. When the inoculating fluid is rubbed upon a scarified, or a blistered surface, the lesion appears multiple at first, many little papules spring- ing up in the patch, as if many separate points had been simultaneously inoculated, which is indeed the case ; these, however, soon coalesce into one mass, forming one lumpy, tubercular chancre-patch. This explains at once how syphilitic chancre may be multiple, several different points having been inoculated at the same or nearly the same time. Multiple iNOCULATioif. — In testing this point it has been found that, where many points were inoculated at the same time, usually all took and appeared simultaneously as chancres. Where the intervals of inoculation were a few days apart, upon the same individual, nearly all took. Puohe inoculated twice at twenty-two days' interval; chancre appeared upon both points at the same time. In other cases the second inoculations have appeared to require a longer incubation than the first. Again, inoculations made upon different individuals, with virus derived from the same lesion, have required different periods of incubation for their development. These apparent exceptions to the fact first noted by Hunter, that 518 SYPHILIS. syphiKs was not reinoculable upon an already-infected person, are still further borne out by tbe results of other experiments, such as those of Wallace, who produced an indurated chancre by using chancre-virus upon a man who had reached the eruptive stage of the disease. Wallace, Bidenkap, Sperino, Lee, and others, have performed auto-inoculation soon after the appearance of chancre, in some cases -with success, pro- ducing a small, ill-defined, indurated chancre, usually with short incuba- tion. Foumier and Puche believe that about two per cent, of auto- inoculations of syphihtic chancre take, presumably when some irritation (inflammatory) of the chancre exists, but the vast majority, especially where the chancre is fuUy developed, yield only negative results, and in no case does the auto-inoculation of syphilitic chancre produce the pustule and rapidly-advancing characteristic ulcer known as chancroid. The rule, then, is practically this : reinoculations of syphilitic virus upon patients already syphilitic produce no result. Auto- or hetero- inoculation upon a patient with very young chancre is occasionally successful. A more constantly favorable result might be expected from hetero-inoculation during the late tertiary stage of the disease. At both of these periods the patient is not fully protected, the system not being satm-ated with the syphihtic poison at first, and the virus being at a minimum toward the end. Between these periods very rarely wiU reinooulation of any syphilitic virus produce any efl"ect, although an irritative ulceration may be produced in some subjects by the inoculation of any inflammatory pus, and chancroid is inoculable at will in its full vigor on all subjects. This subject finds an apt and analogous illustration in the results of inoculation with vaccine virus. Any number of such inoculations made at the same time may take fully. Reinoculations practised before the first inoculation has taken or while the vesicle is young, will also yield positive results, but to a less degree. Then, w^hile the protecting power of the virus lasts, the result is invariably negative, or only abortive pustules are produced (false takes). Finally, after a variable period the protection becomes weak or exhausted, and inoculation produces a partial or even perfect result. /Secretions capable of transmitting Syphilis hy Inoculation. — This subject has been carefully studied by inoculations, as well as clinically by confrontations, that is, by examination of the individual from whom a given patient acquired his syphUis, and comparing the lesions. The first confrontations of syphilitic chancre were made in 1853, by Bassereau.' Later, the confrontations of Diday, Rodet, Foumier, Clerc, Musset, RoUet, were published by Dron." Foumier ° followed, and numerous other contributions, since made, furnish in aU a very full collection from which to draw deductions. The results arrived at have been identical ' " Dea Maladies de la Peau symptomatiques de la Syphilis," Paris. » " ThSse de Paris," 1856. » Eicord's " Le9ona sur le Chancre," 1858. FLUIDS CAPABLE OF COMMUNICATING SYPHILIS. 519 Inoculations of healthy subjects with the fluid secreted by syphilitic chancre, mucous patches, any secondary cutaneous, or mucous lesion, yielding a discharge, aud of syphilitic blood (Pellizari, Waller, Lind- wiirm) drawn from a patient with an eruption, taken either from a papule or tubercle, or from the healthy skin between the lesions— all such inoculations yield indurated chancre after a period of incubation, which chancre is succeeded by general syphilis. Whether the blood of syphilis is poisonous in the intermediary periods between the eruptions, when the skin and mucous membranes are sound, is not yel established, but certain observations of vaccinal syphilis would go to prove that it is. The secretions of other pathological lesions, not syphilitic, will not produce syphilis unless some of the patient's blood be inoculated at the same time. Gonorrhoea, acquired from a syphihtic patient having at the time only gonorrhtea, reproduces itself as gonorrhoea, and not as syphilis. The same is true of chancroid, even by inoculation, if no syphilitic blood be inoculated along with the pus. Certain confrontations and inocula- tions of mixed chancre go to prove that from such a sore may be derived either simple chancroid or mixed poisonous chancre. Diday inoculated pus from a pustule of acne produced upon a patient " in full syphilis," by the administration of iodide of potassium. The result was negative. The same is true of the vaccine virus. Pure vaccine virus, taken from a syphilitic patient before there is any pus in the vesicle, will produce vaccinia only, if no blood is inoculated. This is well shown in some of the vaccino-syphilitic epidemics, where many children were vaccinated at the same sitting, from the same child, the virus being taken from arm to arm. Often, in such cases, the result has been that those first vac- cinated developed vaccinia only and no syphilis ; others a little later, when the virus was giving out, developed vaccinia, followed by indurated chancre on the same spot, usually before the vaccine pustule got well ; finally, those last vaccinated developed only an abortive vaccine vesicle or none at all, while indurated chancre appeared after incubation upon the vaccinated spot, and general syphilis followed. All the controversy on vaccinal syphilis cannot be reproduced here. Suffice it to say, syphihs can be communicated by vaccination, but only where blood has become mingled with the vaccine lymph, or where a true chancre lies hidden under the vaccine vesicle and mingles its discharge with the vaccine lymph. If pure lymph be taken early, neither does chancre follow at the vaccinated point, nor syphilis afterward ; but, since a little blood may readily be mixed with the lymph, and not be perceived, no amount of caution is too great, and in no case should vaccine lymph, derived from an individual even remotely suspected of being syphihtic, be employed. If not the lymph, much less should the vaccine scab be used, as it neces- sarily contains, besides vaccine lymph, both pus and blood, and a portion of the solid tissue of the skin of the individual from whom it was taken. Inoculation has failed to produce positive results from ulcers of the 520 SYPHILIS. late tertiary period of syphilis. Diday ' inoculated sixteen times vith blood from patients suffering from tertiary syphilis (nodes), always with negative results. The fact that patients with tertiary syphilis may occa- sionally acquire a chancre and the earlier eruptions anew, and the other undoubted fact that such patients may procreate healthy offspring, ren- der it still more certain that late tertiary syphilis is no longer either communicable or transmissible. Bumstead ' mentions one case of prob- able transmission of syphilis by inoculation from blood in the tertiary stage. The victim was a surgeon of Ohio, who reports that he inocu- lated an abrasion on his finger while operating upon a case of syphilitic necrosis of the skull. Chancre and general syphilis foUowed in due course. As for transmission, on the other hand, patients who have posi- tive tertiary symptoms undoubtedly procreate diseased children some- times, just as they as certainly often produce healthy ones. Hence, ter- tiary syphilis may be said to be generally, but not always, free from the dangers of transmission and of communicability. The older the disease, the less apt it is to be transmitted. The male loses the power of trans- mission seemingly before the female. None of the physiological secretions or excretions can produce syph- ilis by inocidation. Mucus from the mouth or vagina may be inoculable, if any syphilitic lesion (chancre, mucous patch) exist upon the mem- brane from which the fluid is collected, otherwise the result is invariably negative. The same has been proved by experiment to be the case with tears, sweat, urine, semen, milk. Milk from a syphilitic woman is nei- ther inoculable experimentally, nor does it give the disease to the child who drinks it. Apparent infections by milk, without any recorded primary lesion (Melchior Robert, Lane, Parker, Mahon, Bell, and others), are set off by other carefully-observed cases, where children suckled by a syphilitic nurse have escaped disease, even where the nurse had a spe- cific lesion of the nipple (Dug^s, Ricord, Cullevier, Nonat, Vemot, and others). Where the nurse has a syphilitic lesion of the nipple, the chUd surely becomes poisoned, if it have a fissure or other abrasion of the lips through which the poison can be absorbed ; but in such case syphiUs in the child is always preceded by chancre of the lips or mouth. Semen, although not inoculable, is believed sometimes to contain the germ of the poison, infect the ovule, through it the child, and through the child the mother. Methods of TEAxsmssiON of Syphilis.— SyphUis always com- mences as a chancre, with two exceptions : 1. Inherited syphilis. If the father be syphilitic and the mother healthy, the child seems sometimes to escape infection, probably because at the moment of impregnation the virus in the father, either from the effect of treatment or from a natural lull in the disease, was not in a ' Gasette Ifldicale, 1849. ' Keferring to Medical Times and Gazette, August, 1861. METHODS OP TRANSMISSION. 521 state of activity,' or because he had advanced too far into the tertiary stage to be able to transmit it." Fathers with tertiary syphilis cer- tainly, as a rule, where the mother is sound, procreate healthy children as far as syphilis is concerned. Where the mother and father are both diseased m the earlier stages, the child is invariably syphilitic. Where the mother alone has syphilis (except in the later tertiary form), the child IS also always infected, unless the mother is under treatment.' Eicord and Baerensprung believe that the child is rarely if ever infected, if the mother acquire her disease after the seventh month of pregnancy'.* 2. Where a mother becomes poisoned by carrying a syphilitic child in her uterus, the germ of the poison having been communicated to the child through the spermatozoon of the father, the mother having no chancre. That this method of infection occurs is doubted by some high authorities.' Chancre is produced wherever upon the human body the syphilitic ' Hippolyte Mireur has collated the evidence on the subject under discussion in an admirahle essay, " Sur l'H6r6dit6 de la Syphilis," Paris, 186V. He leans toward the belief that, if the mother escape, a syphilitic father cannot produce a syphihtic child. He gives the following case (page 26) : About a year after contracting chancre, followed by well- marked secondary symptoms, which had disappeared entirely under treatment, M. C married. Ten months afterward his wife was delivered of a vigorous, healthy child, " the image of his father," who remained perfectly well up to the age of two years. At this date a little indolent erosion appeared upon the lip of the father. The latter paid no attention to it, but continued to fondle and kiss his child. After a time there appeared upon the lip of the child a livid, indurated excoriation, one centimetre in diameter, accompanied by indolent bubo under the jaw. After a time, in spite of treatment, the child devel- oped a characteristic syphilitic roseola and mucous patches at the anus. ^ Mireur (page 91) relates the case of a syphilitic mother and father, where the dis- ease ran its course without specific treatment. After two miscarriages and a still-birth at term, the fourth and fifth children were born alive, but developed syphilitic erup- tions shortly and died. The sixth and seventh children were born healthy and continued well, notwithstanding the fact that both father and mother had subsequently " gummy tubercles and ulcers scattered abundantly over the extremities," for which they finally piaced themselves under specific treatment. ^ In Thurman's case (Journ. de Med. et de Chir., Toulouse, October, 1S51), two syphi- litics were married. Both had been treated, apparently recovered, and never after- ward, while under observation, manifested any symptoms of syphilis. Seven children were born, became covered with a syphilitic eruption, and died. Pregnant for the eighth time, the mother was brought under the infiuence of mercury. The child was born healthy, and grew up sound. Pregnant for the ninth time, the treatment of the mother was re- peated, a healthy child resulted, who remained well. Pregnant for the tenth time, treat- ment was neglected. A child was born, seemingly well at first, who developed a syphilitic eruption, and died after six months. In her eleventh pregnancy the mother again took mercury. A healthy child was born, who remained well. ^ In Chabalier'a case [Journ. de Med. de Lyon, May, 1864), Madame X , at the end of the seventh month of pregnancy, had intercourse with her husband, who had been traveling for five months. Thirty-eight days afterward (during the ninth month of preg- nancy) Ohabalier found three indurated chancres on the vulva. The child was born at term, seemingly healthy, and was immediately given to a healthy wet-nurse. One month after confinement the mother left her child to join her husband on his travels. At the end of six weeks Chabaher was called to see the infant. He found it covered with a papulo- vesicular eruption, with intense coryza, and mucous patches on the scrotum and in the mouth. At the same date the mother, while traveling, developed mucous patches at the vulva and anus. The child died. 5 Sturgis, of New York, " Hereditary Syphilis " [New York Medicaljournal, July, ISIl), has again collated the evidence, endeavoring to show that syphilis in the child depends solely on syphilis in the mother, syphilis in the father being a matter of no importance, so long as the mother does not become directly diseased by him. 522 SYPHILIS. v^irus contained in the secretion of chancre, in blood, or any secondary syphilitic lesion, is brought within reach of the absorbents, by being placed upon a surface deprived of epithelium. That it may make for itself a way through the tender epithelium of mucous membrane, if left long enough in contact with it, as does the poison of chancroid, has not been proved, but, from certain cases, seems highly probable. It cannot get in through the epithelium of the skin without an abrasion of the latter. The methods of contagion are immediate and mediate. The latter method is much more common for syphilis than for chancroid, owing to the numerous lesions of all parts of the body capable of secreting the poison, their long duration, and apparent insignificance. Hence syphilis is very often transmitted by means other than sexual contact. Surgeons and accoucheurs get chancre of the fingers by inoculating abraded spots in the exercise of their professional duties. Chancre is not infrequently transmitted in kissing, a little mucous patch in the mouth of one party poisoning any fissure on the lips of the other with which it may come into contact. Both of these methods are immediate. Case XLVI. — A young gentleman bronght his sweetheart to be treated for a hard, excoriated, globular lump upon her lip, which failed to get well under the assiduous care of a homoeopathic physician during many weeks. The lump was as large as a cherry, and very hard, as were also the sub-maxillary glands of the same side. The surface of the lump was excoriated, bleeding, tending to scab. It got well promptly under the internal administration of mercury. The young gentleman had mucous patches in his month. The couple were married, and the young lady subsequently aborted. Children acquire chancre of the Ups from nursing-women with mu- cous patches of the nipple, and, on the other hand, healthy nurses get chancre of the nipple by suckling children with inherited syphilis, who have mucous patches of the lips. In this way nurses have been accused of giving syphilis to their nurslings, when the truth was, that they (the nurses) received the disease from the children. CoUes's law, that a child with mucous patches of the mouth cannot produce ulceration of the nipple, if it sucks its mother, depends simply upon the fact that its mother abeady has syphilis before the child is bom, and consequently cannot get a new chancre of the nipple. Many interesting examples of mediate contagion have been recorded. Puohe speaks of a gentleman with a long prepuce, who, after marriage, encountered an old mistress, with whom he had intercourse. Retm-ning home shortlj', without having washed, he repeated sexual intercourse with his wife, depositing the virus from his prepuce in her vagina. He escaped, but, in due course, she developed chancre and general syphilis. A similar authentic instance is related of a woman who proved un- faithful. Her husband, embracing her shortly afterward, relieved her of the poison left in her vagina by her lover, himself developed chancre, while she escaped. Smokers of a pipe sometimes get chancre of the lips, the virus being DURATION OF CHANCRE. 523 deposited upon the mouth-piece of the pipe by some previous smoker, who had mucous patches of the lip. Case SLTII.— Aa old, gray-headed man came into the hospital with an extensive indurated ulcer upon his upper lip. This, it was found, he had acquired by smoking the pipe of a friend, who had mucous patches. General syphilis of a severe type succeeded. Glass-blowers get syphilis in the same manner, as they work in sets of three at the same tube, passing it from mouth to mouth. Syphilis sometimes runs through a whole family, from the use of the same spoons or cups, passed from one mouth to another. Washer-women be- come infected in cracks of the fingers through the virus contained upon soiled clothes. Wet cups ' once started an endemo-epidemic of syphilis. Transplanting teeth has proved another source of mediate contagion, catheterization of the Eustachian tube has done the same, as has also the operation of circumcision, with instruments which were infected with syphilitic virus, and, in the religious rite, possibly though not probably, the act of sucking the wound.'' Vaccination is a familiar in- stance of mediate contagion. In all such cases chancre precedes the development of general syphilis. DuRAiTOiir OF Stphiutic Chan-oeb. — The duration of syphilitic chan- cre is from two weeks to several months. In about fifty per cent, of the cases a general syphilitic eruption appears before the chancre has cica- trized. A chancre once healed occasionally reindurates and reulcerates. Ntobbb. — Syphilitic chancre is most often unique, because com- monly only one point is inoculated. It may be multiple to any extent, according to the number of points deprived of epithelium and capable of absorption, which are primarily exposed to infection.' When multiple, however, it is usually so from the first and not consecutively, like chan- croid, because its secretion is not auto-inoculable. Size. — Syphilitic chancre may occasionally reach a large size, as large as a quarter or half dollar. This is, however, exceedingly rare ; commonly it does not grow to the size of a nickel penny ; it is often as small as a split pea and sometimes smaller. In size and general appear- ance it compares unfavorably with its more formidable-looking rival, chancroid. SmjATiON. — Syphilitic chancre occurs indifferently on all points of the body. No regions are exempt from it, or even less liable, as is the case with chancroid. Syphilitic chancres of the head, face, and breast, are not very uncommon. They reach their full size and development. Indeed, chancre of the lip is particularly prominent, large, hard (spher- ' Rollet, p. 620. ,^r -^r Tirj T ' R. W. Taylor has written an excellent essay on this subject (iv. Y. Med. Jour., December, 1873). . ' During the past year a gentleman under the authors' care acquired syphilis through multiple points of contagion, and had eight simultaneous chancres, all of about foul weeks' incubation. 524 SYPHILIS. ioal), and chronio in its course. The genitals, of course, furnisli the favorite seat, but simply because they are most often exposed. The favorite position on the penis seems to be the mucous layer of the pre- puce, often just behind the corona glandis. Urethral chancre is not very uncommon. A well-marked case is reported in the American Journal of Byphilography and Dermatology^ of a patient vcho was treated for gonorrhoea, Ms symptoms being creamy discharge from urethra, with pain on urination. After a while he developed a general syphiHtic eruption, and enlarged, indolent, painless ganglia were felt in the groias. An endoscopic tube was now introduced, and detected on the roof of the urethra, one and a quarter inch from the meatus, the chancre, as a slight oval ulceration, not yet healed. There was no lumpiness around the urethra, no painful spot on erection, no blood in the urethral discharge, but undoubtedly the case was one of urethral chancre ; for gonorrhoea does not produce ulceration of the urethra. The endoscopic tube intro- duced long afterward disclosed a faint whitened cicatrix, marking the position of the old ulcer on the roof the canaL These appearances were verified by several gentlemen. Another (unpublished) case has been observed by the authors during the past year. Chancre of the skin around the genitals and anus is not very uncommon. FoEJi OF Syphilitic Chah^cee. — Syphilitic chancre appears after an incubation of not less than ten days, usually not till the end of three weeks, as a reddened spot, which quickly excoriates ; or as an elevated solid papule, which excoriates or ulcerates. It may take any one of four forms, in the following order of frequency : (1.) Erosion ; (3.) Ulceration ; (3.) Deep ulceration, funnel shaped (Hunterian chancre) ; (4 ) Indurated papule, which remains dry. (1.) Erosion. — This form is believed to include two-thirds of aU syphi- litic chancres. Bassereau put it at three-quarters. Its favorite seat is mucous membrane. It is very common inside the prepuce. It is oval or a little irregular in shape, with a polished, raw-looking surface of a vinous- red, sometimes very dark from extravasation of blood or from pigmen- tation, or of a more subdued gray color ; occasionally there is a central adherent pultaceous membrane (Olero), but usually the only discharge is a sanious serum, and that scanty ; no pus being visible whatever. This is indeed an erosion, and not an ulcer. The induration of this form is most often parchment-like, as if the erosion reposed upon a thin sheet of parchment slipped beneath it. The induration is sometimes central, occasionally annular. These erosions are flat. Sometimes an erosion may cap an enormous induration as large as a marble, as on the lip, and not be attended by an appreciable discharge of pus. The sur> face of these elevated, indurated erosions sometimes granulates, becoming ' 1871, page 37— Keyes. FOKM OF CHANCEE. 535 papular. Large flat erosions may occupy the skin, but they usually scab, (3.) Ulceration.— Super^oial ulceration with slanting edges is found with parchment, but more commonly with the split-pea, induration. The ulcer may be quite superficial if the induration stand out prominently, or the induration itself may be excavated, when the ulcer will be deep. The base is often grayish, discharging a slight amount of sero-purulent fluid. (3.) Sunterian Chancre.— This, form is less common than either of the above, but is actually an advanced condition of the last variety. The induration is often extensive, far overreaching the edges of the ulcer, which latter seems to have eaten down into it. The induration is the specific, cartilaginous, elastic, woody induration of syphilis. The ulcer has sloping, adherent edges, never undermined, not the abrupt borders of chancroid, and the funnel-shaped appearance of the ulceration is not found in any other variety of sore. The shape is rounded or oval. The discharge is similar to that of the last-described ulcer. (4.) Indurated papule which does not ulcerate is found sometimes on the skin after inoculation, natural or artificial, and occasionally on the penis, even on the mucous layer of the prepuce in patients whose prepuce is loose, short, and dry. These indurated tubercles would undoubtedly excoriate or ulcerate if kept moist, and in fact the elevated excoriated chancre often remains for weeks as an induration before the surface erosion appears. Indurated papules of the skin, which do not erode or ulcerate, scale off after a time, or become covered with a scaly crust. The color of these papules is a dark vinous-red. Under any of the above forms may uncomplicated syphilitic chancre appear. The course is about the same in all. They rarely heal within two weeks, and often last for months. There is rarely more than one of them, and, if two or more coexist, they are usually of the same type. The induration, which generally may be found from the first, occasionally does not appear until after some days. It may disappear within a fortnight, but usually outlasts the sore, remaining behind in the cicatrix. Chancre uninflamed and unirritated is painless. The symptoms of urethral chancre, which cannot be seen, are usually a discharge coming on long after suspicious connection, gener- ally thin, often bloody, a painful spot along the urethra during erec- tion, and a lumpiness felt through the skin ; but all these signs are some- times lacking, except the discharge, and even this may be quite creamy. The endoscopic tube may be used in certain cases, making an absolute diagnosis of ulcer, and the condition of the inguinal glands goes largely to clear up its nature. Urethral chancre is more often situated just within the meatus, and may be seen by separating the lips of the latter. C0UES33 OF Chancre.— Syphilitic chancre progresses slowly, reach- ing its height in a few days or weeks, and then, with or without a 526 SYPHILIS. stationary period, repair begins by a change in color of the sore, which becomes more rosy, the induration often simultaneously commencing to abate. Thicker pus forms on the ulcer, and it goes on to cicatrization from the edges. The poison of the secretion remains to the end. COMPLICATIONS. The complications of syphilitic chancre are : (a) vegetations ; (S) inflammation ; (c) chancroid (mixed chancre) ; (d) transformation into mucous patch ; (e) phagedena and gangrene ; (/) syphilitic bubo, which is indeed not a complication, but a necessary accompaniment of syphi- litic chancre ; (g) lymphitis. (a.) Vegetatioxs. — Warty growths are liable to spring up aromid syphilitic chancre of the prepuce or anus, as they are with other forms of irritative disease (chancroid, balanitis, gonorrhcBa, p. 21). These are rare and purely accidental. Syphilis as a poison has nothing to do with their production. (b.) IxTLAHMAHoif may complicate syphilitic chancre, from position, mechanical or chemical irritation, etc., occasioning pain, and a more purulent discharge, which latter may be auto-inoculable, producing an abortive pustule, or a small, transient ulcer, and liable to lead to the further complication of suppurating bubo. (e.) CnAifCEOiD may complicate syphilitic chancre, the two sores ex- isting together side by side, each with its own peculiar characters, or the same spot may have been simultaneously or successively inoculated by the two poisons, giving rise to what is known as " mixed chancre," a sore which possesses the characters and qualities of both of these lesions. The two poisons are distinct, and run their own course, each unmodified by the other, but, if both develop upon the same spot, the character of the lesion is altered, and it becomes a mixed sore. When a syphilitic chancre is inoculated with chancroid pus, the ulceration rapidly deepens and progresses, putting on all the characters of chancroid ; but the syphilitic induration remains. On the other hand, when a chancroid is inoculated with syphilitic virus the ulcer is unmodified, but, after a prop- er incubation, syphUitic induration sets in. These facts, which have been proved experimentally, have been also verified clinically by confronta- tion. If a given abrasion be inoculated with both poisons in sexual in- tercourse, the chancroid develops first, and, for a time, nothing but a chancroid, exists, furnishing auto-inoculable and hetero-inoculable pus producing chancroid only, and not syphilis. After a certain variable in- cubation, however, the soft sore indurates spontaneously, and then the chancre is mixed, capable of imparting chancroid alone by contact, since the chancroid poison is more virulent, more contagious, than the syphi- litic ; or mixed chancre, followed by general syphUis. Finally, if the period of incubation of the syphilitic virus happens to be very long, the chancroid may get weU, or be cured by cauterization, but in due time COMPLICATIONS OF CHANCEE. 527 the syphUitic chancre appears upon the same spot, and then hetero- inoculation will produce only the syphilitic chancre, with its inevitable accompaniment, general syphilis. The literature of experimental syphilis furnishes some very striking examples of mixed chancre. The following two are particularly instructive : Melchior Robert' inoculated a student with the secretion of a mixed chancre. A classical chancroid followed, the pus of which proved auto- inoculable. After the ulcer, the result of inoculation with the mixed poison, had nearly healed, induration set in, the sore reulcerated, and general syphilis followed. LindwUrm " had a female patient with multiple chancroid. Upon one of these only he inoculated the secretion of a syphilitic chancre. No change occurred. The patient got nearly well, and left the hospital, but eight days afterward she returned ; the ulcer which had been in- oculated had broken out afresh, and had indurated. This sore remained open, while all the other chancroids got well and remained well. General syphilis followed. Mixed chancre, then, is a reality, and does exist clinically. Hence the rule : Wherever the secretion of an ulcer possessed of specific in- duration, and followed by syphilis, produces by auto-inoculation a char- acteristic chancroid ulcer, itself auto-inoculable, such indurated ulcer is invariably a mixed chancre. Mixed chancre is liable to all the complications which may affect either form of ulcer, even virulent bubo. The methods of acquiring mixed chancre clinically are self-evident. Both poisons may enter simultaneously through the same abrasion. An individual with either variety of sore may inoculate himself, during sexual intercourse, upon the same spot with the other virus. {d.) Teau-sfoemahon esto Mrrcotrs Patch. — A chancre, which has lasted until the period for secondary manifestations has come on, may granulate upon its surface, retain or lose its induration, become covered with a whitish pellicle, and, in short, change into a mucous patch. This change has been critically studied by Ricord, Fournier, Deville, Devasse," and others. It is most often observed upon women and children, and particularly upon thin skin and mucous membrane where there is con- tinual moisture, a circumstance greatly favoring the change. (e.) Phagedena and Gangkene. — Phagedena, already studied in connection with chancroid (p. 490), may also, though more rarely, compli- cate true syphilitic chancre. The form most usually seen is the gangren- ous. The gangrene may involve all the induration, in which case the latter ceases to be perceptible. The pultaceous and serpiginous varieties of phagedena are very rarely found with pure syphilitic chancre. Their existence, especially the latter, which is most uncommon, makes it prob- able that the chancre was originally of the mixed variety. Sometimes ' Op. at. ' Quoted by Eollet. ' Archives Gen. de Med., 1846. 528 SYPHILIS. the ulceration outstrips the induration, in which case the latter disap- pears ; rarely both advanse together. In four hundred and fourteen cases of syphilitic chancre, Bassereau found phagedena in sixty. In ninety- eight cases, Foumier found eleven of phagedena. A healing chancre may reuloerate and then become phagedenic. Bassereau, Diday, and others, believe that, when syphilitic chancre is phagedenic, the type of the general syphilis which follows is severe.' For diagnosis of syphilitic chancre, see Diagnostic Table. JProffiiosis. — If the chancre is syphilitic, so also is the patient. For (/) syphilitic bubo, and (g) lymphitis, see below. Treatment of Syphilitic Chancre. — No amount of cauterization nor any local treatment can prevent the development of general S3rphilis after the poison has once been absorbed, much less after the chancre has appeared (p. 509). Cauterization often hastens the healing, but induration is liable to reappear and to reulcerate, and nothing is gained to compensate for the pain of the operation. General syphilis is inevitable. The best local treatment consists in the use of dry lint, or any mild astringent lotion, or, perhaps better, sprinkling with iodoform, or calomel, or the use of black or yellow wash. The sore is not painful, and will leave less of a scar, if unmolested, than if irritated and in- flamed. Mixed sore is better cauterized to destroy the chancroidal virus, and the local treatment of phagedena is the same as already set down for that complication, attacking chancroid (p. 498). There is one important difference, however ; namely, that the phagedena attacking syphilitic chancre may be kept up by the general debilitating influence of syphilis upon the patient's vitality, and consequently, in these cases only, the antidote to that influence, mercury, given internally, has excep- tionally a favorable effect in retarding the progress of phagedena. Internal treatment of syphilitic chancre is the same as for early syphilis, and treatment should be commenced in all cases where the diagnosis is undoubted. It has a marked beneficial effect upon the duration of the chancre. Where there is the least shadow of a doubt, no mercury should on any account be administered, until an eruption has cleared up the diagnosis. (/".) SypHiLmc Bubo. — The term " syphilitic bubo " has been applied to the indolent enlargement and induration of those lymphatic glands receiving the absorbents from a syphilitic chancre, not to the other glandular enlargements occurring in the course of syphilis. Syphilitic bubo consequently may occur in many different situations, according to the position of the chancre. They are usually found in the groin, be- cause syphilitic chancre more often occurs on or around the genitals Phagedena, although it destroys the induration, does not protect the patient from the subsequent development of his syphilis, any more than does the cauterization of » syphilitic chancre. SYPHILITIC BUBO. 529 than elsewhere. Thus the inguinal glands are affected in chancre of the perns, urethra, groin, lower part of abdomen, scrotum, thighs, perinsBum, buttocks, anus, or rectum— the submaxillary in chancre of the lips or mouth, the preaural in chancre of the face. In like manner the subhyoid, post-cervical, axillary, epitrochlear, or other gland, may be the seat of syphilitic bubo. With syphilitic chancre of the genitals, the cluster of glands in the groin becomes enlarged and indurated, not a single gland but a group, which group, since Ricord, has become classical under the name of "pleiad." The pleiad consists of one gland larger than the rest, -with one or two or half a dozen smaller glands, nearly all equally indurated on either side. The induration in some cases is not very strongly marked. They rarely become very large, varying from the size of a pea to that of a marble, and they retain their round or oval shape. They are freely movable under the skin, usually each distinct from the others. There is rarely any pain even on pressure, though slight tenderness may exist at first. This pleiad of indolent indurated glands may be (direct) unilateral, on the same side with the chancre or crossed, or (usually) bilateral, the glands on the same side with the chancre being most markedly affected. This induration of the glands exactly resembles, in its woody, ivory- like feel, the induration of the chancre, but in some cases is more soft and elastic, like cartilage or India-rubber. The induration appears dur- ing the second week of the existence of chancre. Fournier records, as unique, a case in which the induration of the ganglia was not detected until the twenty-seventh day after the appearance of chancre. Some- times instead of the usual pleiad there is but a single indurated gland, perhaps as large as a nut. Another variation is the development of a single enormous syphilitic bubo, as large as an egg, on one or both sides. These were found by Bassereau on dissection to consist of an agglomeration of many separate glands matted together by large in- durated lymphatic cords, an4 tough, thickened layers of connective tissue. Occasionally a hardened lymphatic trunk may be traced from the induration of the chancre, to the indurated glands. In strumous subjects the glands are apt to be very largei, and to partake of the strumous degeneration as well as specific induration. Submaxillary and axillary syphilitic bubo often consists of one very large, hard gland. The glands constituting syphilitic bubo usually reach their full development in from one to three weeks. They then remain stationary for several weeks or months, occasionally for over a year. They are habitually present when the first general eruptions appear, and may at this time undergo a sudden increase in size and induration. Sometimes, on the contrary, without known cause, the glands speedily return to their natural size, and all induration disappears. Suppuration of syphilitic bubo takes place so rarely that it may be said practically never to occur. But the syphilitic as well as the healthy 34 530 si: f mme. gland is subject to inflammation from injury, friction, or from inflammation of the chancre, and then suppuration may come on. Strumous glands also may degenerate, mat together, and slowly suppurate. When a syphilitic bubo suppurates, its pus is never auto-inoculable. With suppuration, there is of course pain in the afi'ected gland. With " mixed chancre," suppurating bubo is not uncommon, and even virulent bubo may occur. Pournier thinks that pus once formed in a syphilitic bubo is more capa- ble of absorption than in any other form of bubo. Syphilitic bubo bears no relation to the number or size of the chancres. Large buboes often become adherent to the skin. In three hundred and sixty-eight cases of syphilitic bubo, Bassereau saw suppuration in five per cent. Syphilitic bubo is so constant an accompaniment of syphilitic chancre, that practi- cally it may be said to occur invariably. Fournier, in analyzing two hundred and sixty-five cases of syphiHtic chancre, found ganglionic induration absent in five. Two of the individuals were very fat, and pos- sibly the ganglia existed, but could not be found. The causes of the absence of induration in the glands are believed to be occasionally phagedena of the chancre (Fournier), the excessive smallness of the lym- phatic glands in some fat people (Ricord) ; finally, in those rare cases where indurated chancre occurs a second time in patients who have had syphilis, the glands may not indurate. Syphilitic, spontaneous bubo [buhon d'emhl'ee) does not exist. For diagnosis of syphilitic bubo, see Diagnostic Table. Treatment. — ^The treatment of syphilitic buboes is that of early syphilis, but treatment has indeed little or no effect upon them, as they often persist long after the early cutaneous eruption has disappeared under treatment. Inflammation and strumous complications are to be met appropriately. iff.) Syphilitic Ltmphitis is a specific induration of the lymph-ves- sels and surrounding cellular tissue. Hard, smooth, and knotty cords are perceptible under the skin of the penis, feeling like the vas deferens, varying from the size of a knitting-needle to that of a goose-quill. They are insensitive to pressure, and the skin over them is not red. Starting in the induration of the chancre, they often do not reach to the root of the penis, but may extend to the ganglia. Sometimes, but rarely, the surrounding induration includes the blood-vessels. There may be one or more of these cords on one or both sides of the penis. Lymphitis, when present, generally precedes adenitis, coming on shortly after the indura tion of the chancre. It melts away usually during the disappearance ol chancrous induration, lasting from three weeks to six months, and more. Rarely inflammation or suppuration may occur, but the pus is never auto-inoculable. If the chancre be mixed, so may be the lymphitis. Rollet states that syphilitic lymphitis occurs in about twenty per cent, of cases. No special treatment is necessary, except what may be re- quired for inflammatory complications. DIAGNOSTIC TABLE. 531 CHAPTER IV. STPEILI8. UIsgBostic Table of SypMitio Oliancre, Chancroid, Herpes, and Ulcerated Abrasion.— Of Syphilitic Bubo and the Bubo of Chancroid.— Of Syphilitic LympMHs, and the Lymphitis of Chancroid.— General Syphilis.— Secondary, Tertiary, Malignant, Irregular, and Intermediary Syphilides.— Prognosis of Sypliilis. — Duration. — ^Influence of Gout and Scrofula upon the Course of SyphiliB. — The Ten General Characteristics of Syphilides. — Concomitant Symptoms of Secondary Syphilis. — Secondary Incubation, SyphUItic Fever, Alopecia, Indolent Glandular Engorgement, Sore-Throat, Analgesia. The following table is intended to serve as a summary of the broad, classical characteristics of syphilitic chancre and chancroid, with their accompanying buboes, as well as for the differential diagnosis of syphilitic chancre, chancroid, herpes, and ulcerated abrasions ; of the bubo of chan- croid, and that of sjrphUis ; and of the different forms of lymphitis. Syphilitic Chancre. 1. Nature. — Al- ways a constitutional affection. 2. Cavse. — Sexu- al intercourse with a patient suffering from syphilitic chan- cre, or some second- ary syphilitic lesion of or near the geni- tals, yaccination with syphilitic blood, ac- cidental or designed inoculation of any vehicle containing the syphilitic virus, upon an abrasion of any portion of any tegumentary expan- sion. 3. Situation. — Usually upon or near the genitals, not very infrequent on the head, hands, or nipple. 4. Inclination. — Constant, not less Chancroid. 1. Always a local disease. 2. Sexual inter- course with a patient Buifermg from chan- croid of or near the genitals ; accidental or designed inocula- tion with the secre- tion of chancroid, or that of virulent bu- bo. 1. Sometimes a local disease, some- times a neurosis. 2. Mechanical ir- ritation, friction, as in sexual intercourse ; chemical irritation, as of acrid dis- charges. As a se- quence of cold, fever, or as an essential neurosis. 3. Very rarely 3. Of very fre- encountered except quent occurrence up- on or around the on the genitals, genitals. Ulcerated {Balanitic or other) Abrasion. 1. Always local. 2. All of the causes mentioned for herpes, except the last three. 4. None after ab- sorption of the poi- 4. Kone. 3. Same. 4. 'Soae. 532 SYPHILIS. Syphilitic Oluincre. than ten days, usu- ally three weeks. 5. Commence- ment. — Begins as an erosion or a papule, and remains an ero- sion or ulcerates. 6. Nu mber. — Usually unique or simultaneously mul- tiple ; never multiple by successive auto- inooulation ; never confluent. 7. Physiognomy, {a.) Shape : round, oval, or symmetri- cally irregular. (6.) Lesion is ha- bitually flat, capped by erosion or super- ficial ulceration; or scooped out ; or deep, fumiel-shaped ulcer, with sloping edges. Sometimes the pap- ule is dry and scaly. (c.) Edges : slop- ing and adherent, sometimes promi- nently elevated. {d.) Bottom: smooth, shining. (e.) Color: som- b re, darkish red, gray. Chancroid. son. Ulcer usually fully formed on the second or third day ; very rarely com- mences later than the seventh. 6. Begins as a pustule or ulcer, and invariably remains as an ulcer. 6. Usually mul- tiple, both simulta- neously and by suc- cessive auto-inocula- tion ; often conflu- ent. 7. (a.) Shape : round, oval, or un- symmetrioally irreg- ular, with border de- scribed by segments of large circles. (5.) Always true ulcer, excavated, hol- lowed out. Ulcerated {Balanitis or other) Abrasion. (c.) Edges : sharp- ly-cut, abrupt, often undermined. (d.) Bottom : un- even, warty, irregu- lar, without lustre. (e.) Color : yel- low, tawny, false- 5. Begins as a group of vesicles, rarely as a single vesicle, and remains as an ulcer. 6. Generally mul- tiple, simultaneously and by successive crops of vesicles ; sometimes confluent. 5. Begins as an abrasion or fissure, and remains as an ulceration. 6. Generally mul- tiple and confluent 7. Shape : irreg- ularly rounded, with borders described by segments of small circles left by the different vesicles. (i.,) Ulcer usually superficial ; some- times in solitary her- pes there is but one vesicle, and the ul- cer is absolutely cir- cular (Eoumier) ; in this case there are no neighboring patches of vesicles to clear up diagnosis. The base and gen- eral physiognomy of herpetic ulceration are, in other respects, similar to those of chancroid, but of less virulent aspect. 1. Irregular, of any shape, otherwise resembling superfi- cial chancroid ulcer, DIAGNOSTIC TABLE. 533 Syphilitic Chancre. or black, lesion some- times livid and scaly, occasionally scabbed. (/.) Secretion : slight, sero-sanguino- »ent, unless irritation provokes inflamma- tion and a supply of pus. 8. Bisiory. — ^Not found on patients who have had syphi- lis previously. Chancroid. membranous - look- ing, s ometim es bright. (/.) Secretion : abundant and puru- lent. Ulcerated {Balaniiic or other) Abrasion. 8. Found indiffer- ently upon all. 9. Jnoculability. — Not auto - inocu- lable without great difficulty, unless irri- tated, and secreting thick pus. 9. Readily auto- inoculable, produ- cing characteristic chancroid ulcer by the third day. 10. Course. — 10. Eapidly pro- Slowly progressive, grcssive, cicatriza- eicatrization slow. tion slow. 11. Sermbility. — Rarely painful. 12. Induration. — constant, parchment- like, and very faint, or cartilaginous and extensive, terminat- ing abruptly, not shading off into parts iround, almost in- sensitive to pressure, movable upon parts beneath the skin, and not adherent to the 11. Often pain- ful. 12. Absent in type-cases. An in- duration may be caused by irritants or by inflammation. It is boggy, not elas- tic, sensitive to press- ure, shades oif into surrounding tissues, is adherent to parts around, disappears promptly on healing 8. Found by pref- erence upon patients with long prepuce and tender balano- preputial mucous membrane, often showing marked ten- dency to return monthly, fortnightly, or at irregular inter- vals after lack of cleanliness, a ca- rouse, or unusual sexual intercourse. 9. Sometimes au- to - inoculable with great difficulty, when secreting thick pus, producing abortive pustule, not charac- teristic chancroid ul- cer. 10. Does not usu- ally tend to get much larger than the size at which it started ; limitation and cica- trization rapid. 11. Stinging heat at commencement. 12. Inflammatory induration,' capable of being produced by the same causes as in chancroid, and be- having in a precise- ly similar manner. 8. Found indiffer- ently upon aU on the action of efficient causes. Most com- mon on patients with long, tight prepuce, who are not cleanly in their habits. 9. Same. 10. Same. ful. 11. Usually pain- 12. Same. 53i Syphilitic Chancre. latter. Induration may disappear in a few days, usually out- lasts the sore, and may remain for years in the cicatrix. 13. Transmission to Animals. — Not transmissible. 14. Phagedena. — May occur rarely. 15. Bubo. — Sy- philitic bubo con- stant. 16. Lymphitis. — Syphilitic lymphitis possible. 17. Prognosis. — For local conse- quences good, but syphilis follows. 18. Treatment. — Local treatment but slightly cfFectiTe. SYPHILIS. Charicrmd. of the sore, or before that time. 13. Transmissible with difficulty. 14. Much more common. 15. In about two- thirds of cases glands are unaffected, in the other third inflamma- tory or virulent bubo occurs. 16. Inflammatory or virulent lymphitis possible. 17. For local con- sequences more se- rious ; no after-ef- fect. 18. Local treat- ment curative. Herpes. 13. Not transmis- sible. 14. Very rare, if at all possible. 15. Glands are very rarely involved. Inflammatory bubo may occur, virulent bubo is impossible. 16. Inflammatory lymphitis alone pos- sible. 17. Good in all respects. 18. Same. Ulcerated {Balaniiie or other) abrasion. 13. Not transmis* sible. 14. Same. 15. Same. 16. Same. 17. Same. 18. Same. Syphilitic Bubo. 1. Naiure. — It is a specific aSection, with peculiar characteristics. 2. Frequency. — It is a constant symp- tom attending syphilitic chancre. 3. Number of Glands involved. — In those regions where multiple glands are found, it is generally poly-ganglionic ; these may be unilateral or bilateral in the groin, rarely matted together into one large mass, but, when so, the latter retains the characters of indolence, etc. 4. Date of Appearance. — It develops during the first or second week of syphilitic chancre. 5. Si2e. — The glands are usually only slightly enlarged. 6. Induration. — The glands are specifi- cally indurated, feeling like cartilage or wood. ' 7. Evidence of Inflammation. — None ; Bubo of Chanjn'oid. 1. It may be simple (inflarmuatory) such as might attend any inflammatory lesion, or virulent. 2. It is a complication occurring about once in three cases. 3. TTsually consists of a single gland in any region of the body. In the groin it may be bilateral. It is never a group of small, movable glands. 4. There is no fixed period of appear- oe. 5. The gland is greatly enlarged. 6. No hardness except infianunatory. 7. Every appearance of inflammation DIAGNOSTIC TABLE. 535 Si/pJdlitic Bubo. Ihe glands are freely movable among the tissue. The skin is neither adherent nor red, nor is there any pain. The most prominent feature of the swelling is its in- dolence. 8. Ta'mination always in resolution, ex- cept in occasional cases, where, from sim- ple inflammation or strumous degeneration, suppuration ensues. 9. Auto-Inomlability. — In oases of sup- puration the pus is not auto-inoculable. The abscess does not become a chancre, or a chancroid ulcer. It does not extend, and never becomes phagedenic. 10. Natural duration is a few weeks or months. 11. Prognosis gooi. as far as local re- sults are concerned, but the patient invari- ably has syphilis. 12. Local treatment ineffective, except for complications, general treatment of doubtful efficacy, but sometimes service- able Bubo of Chanrroid. The gland becomes fixed (peri-adenitis), the skin adherent, the part feels hot, there 13 pain, the skin reddens, the prominent features ore those of inflammation. 8. Termination occasionally by resolu- tion, usually by suppuration. Virulent bubo invariably snppurates, and becomes an open chancroid ulcer. 9. When the bubo is inflammatory, the pus is not auto-inoculable ; where it is viru- lent, the pus is invariably readily auto-in- oculable. Such an abscess becomes a true chancroid, and may extend or become pha- gedenic. 10. Natural duration is a few weeks, or many mouths, as a chancroid ; possibly years, if it becomes phagedenic. 11. Prognosis good for inflammatory, less so for virulent bubo, especially if it becomes phagedenic. In neither case does syphilis follow. 12. Local treatment useful and necessary to avert suppuration, cure chancroid left by virulent bubo, and lessen complications. Mercury harmful. Anti-syphilitic treatment absolutely useless. HyphiUiic Lymphitis. 1. Occurs only in case of syphilis, and has peculiar characters. 2. Feels hard, like the vas deferens, of the size of a knitting-needle, or of a goose- quill ; no pain, on erection, or on handling. 3. Skin uncolored. 4. Termination by gradual resolution. Very rarely there is suppuration ; but, in such cases, the pus discharged is not auto- inoculable. 5. Treatment unnecessary, and of little effect, except in case of inflammatory com- plication. Bymphitis of Chancroid, 1. Exists as simple inflammatory lymphi- tis, or in virulent form ; the former liable to complicate any inflammatory affection, the latter found only with chancroid. 2. Some inflammatory hardness. Pain on erection, and on handling. 3. Skin red over inflamed vessel. 4. Termination by resolution or sup- puration. Virulent lymphitis invariably suppurates, in which case the pus dis- charged is auto-inoculable, and the open- ings become chancroids. 6. Local treatment advisable to quiet pain, avert suppuration, or limit extent and severity of chancroids left behind by the suppuration of virulent lymphitis. GENEBAL SYPHILIS. Usage has adopted the name " primary syphilis" for the syphilitic chancre, and its accompanying adenitis and lymphitis. These manifes- 536 SYPHILIS. ations, although tlie expression of constitutional poisoning, are never hemselves general, but always strictly local. A chancre never does nor ;an appear elsewhere than at that point through which the poison first entered the body. Hence inherited syphilis has no primary stage, but is reneral from the start. The adenitis constituting syphilitic bubo in- variably affects the gland or glands in direct communication with the ymphatic trunks coming from the chancre ; the other lymphatic glands >f the body, "which may become indolently enlarged, do so only after the econd period of incubation. The latter do not belong to the primary )eriod, but form a part of general syphilis. And so of the lymphitis if primary syphilis, it affects only those vessels passing between the hancre and the syphilitic bubo. Hence, primary syphilis, so far as its manifestations go, is purely Deal. Not so with general syphilis. There is uo organ or tissue of the lody through which it may not manifest its presence by symptoms, or ipon which it may not exercise its power. The lymphatic glands all ver the body may suffer, some habitually more than others. The skin rom crown to sole, the naUs, the hair (the teeth in inherited disease), nd the mucous membranes, especially around the natural orifices, have heir peculiar affections, due to syphilis. The eye and the testicle do lot escape, and each and every viscus is liable to be invaded, as are aU he tissues, connective, fibrous, muscular, cartilage, bone, brain, nerve, nd vessel. Not only this, but the aU-embracing arms of general syphilis aclude the functions as well, any of which may be disordered by it and ach and all of the special senses may be perverted or destroyed — in- luding the sexual appetite. The symptoms of all the forms of local, pecial, or general paralysis of motion or sensation, may be occasioned y syphilis. Finally, the intellect may succumb. Acute and chronic lania, dementia, lunacy, idiocy, all the above, and many more, form a ategory of symptoms comprehended under the one term general yphilis. General syphilis has been arbitrarily divided into a secondary and ertiary stage. For convenience of description and treatment, such a ivision is a good one, and will be retained in this treatise. Secondarij syphilis includes all the earlier affections of the tegumen- ary expansions, cutaneous and mucous, and many of the lighter affec- ions of the eye, testicle, and other glands, with some of the varieties f nervous syphilis. Tertiary syphilis follows secondary, and consists of the later and he ulcerative skin-affections, the deeper lesions of connective tissue, jusole, bone, cartilage, and of tne internal organs (visceral syphilis), with he deeper and more serious lesions of the eye, testicle, brain, and all lorbid conditions occasioned by what is known as gummy deposit. The line between secondary and tertiary syphilis is not always well larked, and, although in typical cases the lesions become progressively GENERAL SYPHILIS. 537 deeper, oommenoing as mere efBorescences in the secondary stage, and gradually increasing in severity to the most extensive ulcerations, and destructions of bone and cartilage in the tertiary, yet some of the symptoms, naturally belonging to the secondary group, as the mucous patch and scaly eruptions, frequently crop out in the tertiary stage, while more rarely nodes come on with early syphilis, and occasionally most extensive ulcerative or other tertiary (gummy) lesions appear within the first few months after chancre, perhaps all the lighter secondary erup- tions having been omitted. This latter form, where tertiary symptoms come on in place of the secondary, is called " malignant syphilis." The former variety is known as " irregular syphilis." Inherited and nervous syphilis will be described separately. Certain of the eruptions which occur late in the secondary stage, and early in the tertiary, have been grouped by Hardy ' under the title of " intermediary syphilides." The distinction drawn between secondary, intermediary, and tertiary syphilitic symptoms, is useful as a guide to treatment. Mercury as a rule is advantageous in proportion to the near- ness of the symptoms, for which it is given, to the primary lesion (chan- cre), while iodine is nearly a specific for the later manifestations. The intermediary symptoms require both medicines combined. Secondary syphilis lasts often a year, sometimes two, or more. Tertiary syphilis (except as malignant) does not commence till after the expiration of at least one year from the appearance of chancre. It may never show itself, or may appear after a period of health of many years, often five or ten, sometimes as late as fifty-two (Fournier). There can be no absolute certainty about the dates of syphilis, or about what symptoms will appear. The whole secondary stage may be skipped under treatment, some late tertiary ulceration alone evidencing the fact that the patient had general poisoning at all. Case XLYIIL— In the fall of 1872 a robust-looldng patient presented himself in a state of mental distraction, about an ulcer on his glans penis, not auto-inoculable, which had been pronounced lupus by his physicians, and for which extirpation, by a cutting operation, had been proposed. The ulcer was as large as a half-dime, eaten out deeply, with abrupt edges, hard base, etc., inguinal glands unaffected— in short, a typical tertiary ulcer. The patient was married, and had had a healthy child. His wife also was healthy. The ulcer had commenced as a hard spot, which fissured and ulcerated without much pain. The patient had not been untrue to his wife. The ulcer had existed for eight months, gradually increasing in size. Ulceration had been arrested once by caustic ap- plications, but the cicatrix had shortly reopened. When told that the sore was syphilitic, the patient, on the authority of his physicians, laughed at the idea. He said that he had had chancre eleven years before, without suppurating bubo ; that this chancre had been pronounced syphUitic by a reliable surgeon, and that he had taken mercury in pills for a while. He was an inteUigent patient, and a close observer, and he declared positively that he had never had any eruption, or any symptom due to syphilis after his chancre, so far as he was aware. He stated, in further corroboration of his view, that during the sun> > " Maladies de la Peau," Paris. 538 SYPHILIS. mer (a few months previously), after the ulceration had existed for some time on his penis, he had had an attack of iritis. For this he had consulted an oculist, who, learning that he had once had a chancre, gave him mercury and iodide of potassium, the latter in gr. vijss doses, until it upset his stomach, so that he was obliged to fall to a lower dose, and, as he triumphantly asserted, although the eye got weU after a while, yet the ulcer advanced steadily, " I taking as much iodide of potassium as the stomach would bear. Why, then, should not the ulcer have improved had it been syphilitic ? " It was m^nly on this account that the patient's former physicians had concluded that this ulcer must be lupus, since it could not be syphilitic, and evidently was no cancer. The patient was answered that his ulcer was syphilitic, and had not gotten well, while his eye was under treatment, because he had not taken a large enough dose of the iodide of potassium. Local treatment was at once suspended, the patient was put upon a diet of rioe-and-milk, with ten-grain doses of subnitrate of bismuth four times daily. No medicine was used except a saturated solution of iodide of potassium in water, aa § j. Of this he took drop-doses at first, and ran it up by drops, largely diluting it before it was taken into the stomach, and using it only after meals, No change in the ulcer oc- curred until gtt.-xv doses were reached. Improvement was rapid at gtt.-xix doses ; at gtt.-xx, the stomach rebelled, and the dose was reduced to gtt. xv, and then advanced to gtt.-xvii. In six weeks the ulcer was cicatrized, thus establishing the diagnosis. This case illustrates at once so many important points necessary to be considered in connection with syphilis, that it has been reported at length. Syphilides. — The most conspicuous symptoms of general syphilis affect the skin, and are known as syphUides, or syphilo-dermata. The prominent primary lesion characterizing the cutaneous affection gives it its name, and in syphilis most of the confusing epithets of dermatology may be dispensed with. Thus, if a papule be the prominent lesion, or a vesicle, or a pustule, the affection is not necessarily called a lichen, or eczema or impetigo, but a " papular," " vesicular," or " pustular syphi- lide," as the case may be ; adding " general," or " in groups," according to the physical distribution of the lesion. Ulcerated syphilides, again, are spoken of as superficial or deep, serpiginous or perforating, making the nomenclature of syphilis exceedingly simple, since the words them- selves describe the affection. Prognosis. — As to the character of the general syphilis, which is to follow upon a given chancre, the pecuKarities of the individual have more to do with it than any thing else, excepting of course judicious treatment. Certain authors have advanced that phagedenic syphilitic chancre is followed by severe syphilis. The condition of the patient, allowing him to have phagedena, it is fair to presume, is also such as will cause him to suffer severely from his syphilis; but it does not necessarily follow, for the cause of the phagedena might have been a local one or one only acting temporarily, and then the succeeding general syphilis might be mild. Nor indeed does Diday's idea prove trustworthy, that the length of incubation of the chancre, or the length of secondary incubation, portends the character of the general syphilis which is to follow. There is undoubtedly a measure of truth in this, for, if the quan- PROGNOSIS. ggg tity or quality of the poison absorbed, or the state of the individual, be such as to allow the first local and general manifestations of the disease to be long delayed, it is reasonable to suppose that the whole course of the malady will be mild. The same natural inference may be made with some reason in connection with the mildness or severity of the chancre. But neither of these rules is reliable. Not infrequently we see cases of protracted, severe, obstinate disease attending a chancre of very long incubation. And the syphilide following the chancre which never ulcerates is sometimes more intractable than the same eruption following a large, excavated, ulcerated, primary lesion. Syphilis acquired from a mild case may be severe or mild. The following three cases will tend to demonstrate the fact that individual peculiarity has more to do with the form of syphilis than any thing else : In 1865, in the cutaneous wards of St. Louis Hospital, under Prof. Hardy's care, were two cases, man and wife. The man had severe malignant syphilis, with large gummy deposits in his skin; some of them ulcerating ; all occurring within a few months after chancre. This man had poisoned his wife while he yet carried his chancre. She had a very mild papulo-erythematous syphilide, bearing none of the characters of malignancy. The woman, from whom the man acquired his disease, was sought out and found. She also was a simple case of ordinary mild syphilis. The poison in these three cases was identical, handed directly from one to the other, but the results were so widely different that it would have been hard to convince a layman of their identity of origin. What the idiosyncrasy is which makes syphilis bad in one case and light in another cannot be afiSrmed. Scrofulous and strongly lymphatic indi- viduals, although a little more prone to sufi'er from severe suppurative and ulcerative lesions than others, are by no means the only ones who have severe attacks. The most obstinate and long-enduring cases are frequently found in connection with the gouty diathesis, the predomi- nant eruptions in such cases being scaly and tubercular, and nervous syphilis being not uncommon. Perhaps the best light that can be thrown upon the question of prognosis may be derived, not from the time of appearance, but from the character of the first eruption of the secondary period. If this eruption be scanty and purely erythematous (roseola), or even papular, the case will probably be much more mild than if the earliest eruption were vesicular, or, still worse, pustular, especially if complicated early by iritis. Finally, if extensive tubercular eruptions and ulcerations appear in place of the usual secondary symptoms, the case is one of malignant syphilis, and the prognosis becomes grave. There is no just foundation for the opinion which has been advanced, that syphilis acquired from a secondary lesion runs a more severe course than if it were acquired from contact with a chancre. As far as the virulence of the poison is con- cerned, the converse of the above proposition would theoretically appear 540 SYPHILIS. more probable, for the secretion of a syphilitic chancre seems more readily inoculable than that of secondary lesions. Further, it is certain that as the disease advances its transmissibility by inheritance declines. A syphilitic mother will abort in her early pregnancies, then produce a dead child at or before term ; next a child who may die in a few weeks, with specific eruptions ; then another who may have only mild symptoms of inherited syphilis ; and, finally, in the tertiary stage of the mother, her children may be born healthy, and continue so indefinitely. Youth and strength do not insure a mild attack to a patient with syphilis, nor does age or debility necessarily imply a severe one. Excesses of every sort, of wine, of women, of work, are liable to intensify the type and dtiration of existing syphilis. Climate also seems to have some influence. Treatment throws confusion into the natural order of appearance of the eruptions, postpones their outbreak, lightens their character, shortens their duration, and, in the most favorable cases, almost prevents them entirely. All local irritations tend to call out eruptions at the points irritated, and to maintain them there. A child born with inherited syphilis may give no evidence of his malady until he is vaccinated, whereupon an eruption may speedUy appear, become general, and be attributed to the innocent vaccination. A blister in the same way, even upon an adult, may call out dormant syphilis. Not infrequently a cold, great heat, any excess, a fatigue, an irritating or sulphur bath, friction, electrization, may be the exciting cause calling dormant syphilis into action and occa- sioning an eruption. Patients who work much with the hands are more liable than others to eruptions of the palms. Perspiration upon over- lying portions of skin often intensifies a given eruption at such points, as under the female breast, around the umbilicus, between the scrotum and the thigh. Lack of cleanliness around the anus and under the pre- puce is a powerful predisposing cause to mucous patches, while the use of tobacco chewed or smoked is proverbial for its power of originating and maintaining the same lesions in the mouth. A mucous patch of the tongue is often occasioned and indefinitely prolonged in a syphilitic sub- ject by friction of that member against the rough edge of a tooth, and the suction of a baby on the nipple calls out mucous patches there. A knowledge of all these facts is of great importance in making a general prognosis. Bad hygienic surroundings materially aggravate and prolong syphi- litic manifestations, to such an extent, indeed, as often to render specific treatment absolutely unavailing or even harmful, until the patient is removed from such surroundings. Dttration of Gen:ekai, Stphujs. — ^There is no disease so protean in its form as syphilis. " Age cannot wither her, nor custom stale her infinite Tariety." Syphilis finds expression through every tissue. Its symptoms simulate DURATION. 541 Uiose of a vast number of other diseases, and some of its forms may be so obscure as to bafBe accurate diagnosis without the assistance of the touchstone treatment. So true is this, that it has passed into a proverb among certain of the less well-informed of the profession, in face of an obscure disease, " If you do not know what to do, treat the patient for syphilis." The unscientific looseness of such a course needs no com- ment ; but the existence of the proverb is the best argument to substan- tiate the protean type of sjrphilis. Only minute and careful investiga- tion into the more obscure manifestations of the disease can lead to accuracy of diagnosis, which is of more importance in this than perhaps ' in any other malady. Hence the difficulty of saying when syphilis has ended, or indeed of deciding that it ever does end, since it so often per- manently modifies the diathesis of the individual who has suffered from it. Syphilis may occur in so mild a form that the patient may never know he has it ; or, again, with such intensity that extensive lesions of the skin, bone, and other tissues, may come on within the first year, with paralytic symptoms of great extent and severity. Syphilis may mani- fest itself as a mild eruption after chancre, disappearing possibly without treatment, and then (exceptionally, it is true) lie latent for many years, as long as fifty-two years,' to reappear with characters due only to syphilitic disease. In Foumier's case, a gentleman of seventeen had acquired chancre, followed by some secondary eruptions, which were pronounced syphilitic. No further symptoms had appeared until the age of sixty-nine — fifty-two years after the chancre — when he had suffered from syphilitic caries of the upper jaw. At seventy-two he applied to Fournier for a gummy tumor of the thigh, which got rapidly well under the iodide of potassium. Now, in this case, had the patient died at the age of sixty-eight, he might, with seeming justice, have been reported as an instance of cure, for over half a century would have intervened since his last syphilitic symptom. This one case gives at a glance the practical answer to the whole question of the duration of syphilis. Every physician of any consider- able experience with syphilis can recall analogous cases, though, perhaps, less striking. Syphilis, once acquired, stamps its impress upon the indi- viduality of the patient, and becomes a part of him, and no power on earth in a given case can say when that impress disappears. A half- century may pass away and the trail of the serpent be still visible. This is a fact, and as such must be recognized. It is of vast practical impor- tance, and to shut our eyes to it would be folly. That we do not so shut our eyes, even those of us who believe in an early and radical cure of syphilis, is sufficiently shown by the avidity with which, in doubtful cases of skin or bone disease, the history of the patient is carefully inquired into for a record of pregxisting syphilis, which, if found, no 1 Fournier, "Notes sur un Cas de Gomme syphilitique survenue 65 ans aprbs le D6but de VAffeotion," Paris, 1870. 542 SYPHILIS. matter how distant, makes the diagnosis, establishes the treatment, and often leads to a cure. Yet, in spite of this assertion, who shall say that sjrphilis may not be cured? Occasionally cases are seen where syphilitic chancre is acquired a second time, followed by crops of secondary eruptions, and surely in these cases the old syphilis must have been cured, or the new one could not have appeared. Yet in some of these cases tertiary symp- toms have been present when the second chancre was acquired, but this again only coincides with the evidence furnished by clinical observation : namely, that the virulence of syphilis disappears in the late tertiary period ; that dining this period neither the blood nor the pathological secretions will infect a healthy subject with the disease, and that such patients may be the parents of perfectly healthy children, who never manifest the faintest sign of syphilitic poisoning. The necessary con- clusion, then, is this ; that while symptoms which can depend upon no other disease than syphilis may crop out at any period during the life of a patient, who has once had syphihtic chancre, yet the virulence of the disease and its contagious properties do die away in time, what are left being more properly sequelae in the received acceptation of that term. The above is the possibility of the duration of the effects of syphilis, and must be recognized by every intelligent physician who wishes to accept facts and desires to view syphihs in a practical light. The proba- bility of the disease in most cases, however, is that its manifestations will disappear finally after a few years, and this under intelligent man- agement becomes almost a certainty. Syphilis is no longer the terrible scourge it proved itself in the fifteenth century. It is rarely fatal except in the visceral form, and the majority of patients escape this stage entirely. It is hardly too much to state that, of the two diseases, gonorrhoea and syphiUs, the former sends more patients to the tomb than the latter. Neither kills directly ; both do so by their sequelag. The classical mode of death as resulting from gonorrhoea is through stricture, to fatal bladder and kidney disease ; and, whatever the ratio of deaths to attacks may be in the two diseases, it is highly probable that more deaths actually occur from gonorrhoea as their first cause than from syphilis. Syphilis, again, has the advantage of being a manageable disease. Its symptoms yield to treatment far more readily than do those of any other chronic malady, and it is precisely in that period where the disease is most destructive to tissue and to life, the tertiary stage, that remedies are the most brilliantly effective. Syphilis, as encountered in the higher walks of life, is a mild but terribly lurking and insidious disease. It may escape attention altogether. Many ladies come by it honestly, but never know they have it. Children develop some obscure symptoms ; the significance of which escapes not only the parents but also the' DURATION. 543 family physician ; and even a man may get chancre, followed by some light eruption, consider it of no importance, and get well spontaneously, marry, and have healthy children, himself remaining entirelv free from any evidence of the disease, and dying in a green old age. Practically what the physician wants to know is this : during what time are symptoms liable to recur before that long latent period may be expected, which is to terminate all manifestations of disease, and in which the patient is certainly well, probably cured ? Or, still more practically, the question may be put : If a patient presents himself with syphilitic chancre, at what period may he safely marry ? Roughlj', and on the average, this last question may be answered by saj'ing, after about two and a half years, or to be safe regarding mar- riage, one year after the disappearance of the last syphilitic symptom, treatment having been continuously kept up, and being continued until after the birth of the first child. This may be said, because well-managed syphilis usually ceases to relapse in about that time. Those patients most often do badly, other things being equal, who follow irregular and uneven courses of treatment, now pushing medication to excess, in the hope of killing the disease, which is impossible, now giving up all treatment in despair. It is very rare for bad symptoms to appear upon a patient who falls into the hands of a conscientious physician, one who recognizes that the disease cannot be jugulated, that the eliminative and not the abortive treatment must be followed, and who quietly and steadily pursues the enemy through its periods of repose, as well as during its moments of eruption, confident that, by mildly and persistently keeping up this treatment by extinction, he will triumph at last over the disease. In mild cases so treated there may be but one faint erup- tion, or perhaps but a few little spots, with epitrochlear, glandular in- duration and a few mucous patches, to mark the disease, the whole of the symptoms only lasting a few months after chancre, and the patient's after-life being healthful. This, however, is the exception. Ordinarily some mild symptoms continue to crop out from time to time, for per- haps on an average two to three years, after which comes the period, be it cure or not, during which the patient bears all the marks of health, is unable to communicate the disease, and reproduces healthy offspring. Finally, there are exceptional examples where late tertiary symptoms appear after long years of latency, as already observed ; of malignani syphilis which is controlled with difficulty by treatment ; and, of other inveterate specimens of disease where relapse after relapse follows through long series of years, perhaps in spite of a continuous intelligent treatment. These last cases may be mostly ranged under two heads : 1. Those living in bad hygienic surroundings, and giving themselves up to excesses of every sort. 544 SYPHILIS. 2. Patients possessed of a strong tendency to gout, or of decidedly scrofulous diathesis. Inplttence of Gout and Sceofdxa upoit the Couese of Syphi- lis. — Both gout and scrofula may exercise a disturbing influence upon the course and the manifestations of syphilis. In the rheumatic or gouty subject the cutaneous symptoms partake of the gouty type. They are apt to be dry, erythematous, papular, tubercular, scaly, of a par- ticularly livid red, of great chronicity, leaving much pigmentation be- hind. Certain purely gouty eruptions are almost indistinguishable from similar ones produced by syphilis, and these, when occurring upon a patient vrho has had syphilis, give rise to great difficulties of diagnosis, and are most often mistaken for syphilides and treated as such, either without effect or until they spontaneously disappear, when the specific medication gets the credit of the cure. Such gouty eruptions are the dry, papular patches or single papules about the hands, on the palms or back, upon the feet or elsewhere ; scaly patches, generalized papular and scaly livid eruptions on the extremities or back, especially such as occur during the spring or fall, and during the heats of summer (from the acridity of the perspiration). The different forms of psoriasis, as seen upon an individual of the gouty habit, possess many of the charac- teristics belonging to syphilitic eruptions, and often lead to error. These eruptions which have been just mentioned do not itch (as a rule), and their diagnosis (when found upon a syphilitic patient), from inspec- tion alone, is always difficult, sometimes impossible. Treatment may be required to solve the problem. Syphilides on a gouty patient get well quite promptly, while other eruptions are not sensibly affected by anti- syphilitic remedies. Besides this simulation of syphilis by certain gouty eruptions, whether they occur on a patient who has had syphilitic chancre or not, the gouty diathesis tends to make the type of syphilis an obstinate one. During the employment of treatment, and in spite of it, in some such cases, a new eruption will crop but, while the tendency to relapse, and to the recurrence of scaly, papular, and tubercular patches is sometimes disheartening. Finally, the gouty diathesis seems to predispose to the development of nervous symptoms in syphilis, both of the rheumatic order in early disease (pain), and to lesions of bone, of fibrous tissue, and, later on, of nerve-substance, such as furnish the different forms of paralysis. Scrofula, on the other hand, leads to moist eruptions in syphilitic poisoning, the vesicular, pustular, early and late ulcerative. Most of the lymphatic glands become involved, but they are usually not so markedly indurated. The eruptions are often slow in coming out, and slow in getting well. The cicatrices of ulcers are not so liable to be deeply pigmented ; they are often somewhat irregular, puckered, ridged and drawn like the scrofulous cicatrix, unlike the round, depressed, GENERAL CHARACTERISTICS OF STPHILIDES. 545 smooth, thin, glistening, non-adherent, characteristic cicatrix of syphilis. The type of the whole disease is apt to be slow, chronic, pustular, ulcer- ative, inveterate, often attended by destructive bony lesions. Again, in a syphilitic patient, a gland may suppurate, and then ulcerate with all the appearances of struma about it, and yet yield only to anti-syphilitic treatment. Genbeai Chaeaoteeistios of Stphilides. — All the syphilitic affec- tions of the skin have certain general characteristics which stamp them as a class. Every mark is not possessed by each eruption, yet the majority belong to each and every syphilitic lesion of the skin. They are usually well marked, and may be grouped under ten heads : 1. Polymorphism of the initial lesion. 3. Rounded form of the patches of eruption, and of the ulcers. 3. Livid color, like the meat of raw ham, then coppery (pigmented), then gray, then white. 4. Absence of pain and itching. 5. Earlier eruptions superficial and generalized, usually symmetrical. f). Later eruptions in groups, involving the cutis vera. 7. Scales white, usually not adherent, superficial. 8. Crusts greenish, black, irregular, thick, adherent. 9. Ulceration with abrupt edges, adherent, not undermined, slug- gish, and bleeding easily. 10. Cicatrix rounded, depressed, thin, non-adherent, white, smooth at first, often pigmented, then clearing ofi' from the centre toward the cir- cumference. To these special characteristics may be added for the earlier out- breaks, the general accompanying phenomena of syphilitic fever, alopecia, headache, osteocopic pains (worse at night), analgesia, ansesthesia, indolent lymphatic ganglia, iritis, sore-throat, and mucous patches in, upon, or around the natural orifices : 1. Polymorphism. — This applies to the earlier and generalized erup- tions. With other cutaneous diseases, it is the exception to have an eruption composed of many elementary lesions ; with syphilis it is rather the rule. An erythematous syphUide is usually also at the same time partly papular. The papular furnishes examples of erythematous spots, and very often some vesicles, some pustules, and some scales, and so of the other generalized eruptions. This is partly accounted for by the fact that the elementary lesion often develops in successive crops, and there- fore shows during its different stages as an erythema, a papule, a vesi- cle, a pustule, a tubercle, or a scaly spot. One lesion, however, always exists in excess, and from this lesion is the eruption named — as, papular syphilide. 3. Bounded Form. — In a generalized eruption the groups of ele- mentary lesions are gathered into rounded clusters, but this is more spe- cially shown in the later circumscribed syphilides, be they groups of 35. 546 SYPHILIS. papules, vesicles, pustules, tubercles, or indeed ulcerations. The ten- dency to a rounded form of the group is marked. 3. Color. — The color of the syphilides is not a frank, inflammatory red, but a vinous, empurpled redness, resembling, when well marked, the raw meat of ham. This color is found also in many of the gouty, papu- lar eruptions, and in psoriasis, rarely with other eruptions. The color of the syphilides passes by pigmentation from the dusky, violet-red, into what is known as copper-color, and from there on sometimes, by a deep pigmentation, to brown or black, the skin around the lesion being usually also pigmented to a certain extent. This pigmentary coloration some- times lingers for years, but usually clears off after a few months, disap- pearing first centrally, the clearing off extending peripherally in all direc- tions. Finally, the spot becomes brilliantly white. 4. Pain and Itching. — ^The syphilides are not accompanied by any itching or pain ; neither the eruptions nor the ulcers ordinarily furnish any disagreeable subjective sensations. Occasionally there are some heat and prickling with an eruption as it is coming out, but it never amounts to actual itching. Syphilitic ulcerations are also free from pain, except as occurring upon dependent portions of the body, where the imperfect circulation tends to set up some inflammation around or in the throat, where the constant motion seems often to lead to the same result. This absence of subjective phenomena is of great importance in diagnosticat- ing syphilitic eruptions. Errors, however, are liable to occur vrith gouty and scrofulous eruptions, most of which are also entirely devoid of pain or itching. Other features, however, distinguish the latter. Sometimes eruptions are seen which, although evidently syphilitic, are yet attended by itching. In such cases an attentive inquiry will usually disclose the cause of the exceptional peculiarity. The patient may be fovmd to have a naturally irritable, itchy skin, a pruritus which always troubles him, and which the syphilitic eruption by no means relieves. He may be afBicted vdth urticaria along with his specific eruption. Not uncommonly, in hospital patients, prurigo from pediculi coexists with some svphilitic exanthem. Case XLIX. — In a curious ease observed at the Charity Hospital of this city, the patient had chancre and gonorrhoea. He took by mistake an overdose of copsuba for his gonorrhoea, whereupon copaibal roseola developed, which itched terribly, causing the patient to leave the marks of his nails on many parts of his body. The copaibal erythema was just subsiding when a syphilitic roseola declared itself, the marks of nails were still upon the patient's body, and he believed that his present eruption was the same one he had been suffering from, and consequenfly asserted positively that It itched. Obervations, how- ever, proved the contrary, for, as the syphilitic roseola developed, and the copaibal ex- anthem decreased, aU itching ceased. Contrary to the rule, the earlier syphilitic eruptions of the scalp are usually attended by itching. 5. The earlier eruptions are distributed habitually all over the body, and are superficial, mainly congestive in character. There is no GENEKAL CHARACTEKISTICS OF STPHILIDES. 547 alteration, nor any destruction of tissue, as proved by the fact that the earliest eruptions (erythematous and papular) leave no scars. Those coming a little later leave faint scars (pustular and vesicular). The de- velopment tends to be symmetrical, the eruption coming out on the flanks and sides of the thorax, the forehead, along the edge of the ha'ir, on the sides of the nape, and the margins of the nostrils, on the palms and soles, etc. 6. The later eruptions are grouped; tubercle, pustule, or ulcera- tion, whatever be the lesion, it is now no longer generalized, but gathered into groups ; and that the lesion is deep and there is destruction of tissue, are shown by the depression of the cicatrix. These lesions usually leave a scar whether they ulcerate or not, and this distinction of leaving cicatrices without previous ulceration is enjoyed by no other class of eruptions save one, the scrofulous. A tubercular non-ulcerated lupus will also leave scars, but such scars are the irregular, stretched, burn-like cicatrices of lupus, and not the round, depressed, white scars of syphilis. 7. The scales on the cicatrices, and on the patches of scaly syph- ilitic eruptions are thin, white, non-adherent, lamellar, very different from the dense, thick, imbricated, adherent scales of psoriasis. 8. The scabs formed on syphilitic, ulcerative, rupial, and pustular lesions are rough and adherent, dark-colored, of a greenish black, some- times loosened by an underlying accumulation of pus, but more often seemingly set into the skin, and tightly adherent. They may be of light color where the lesion has been pustular, but, light or dark, the green shade is rarely totally absent, and is often brilliantly marked. 9. Characteristics of Ulcers. — With the exception of the chancre and of the ulcerated mucous patch (both of which may vegetate, and are always liable to be elevated instead of depressed), the ulcerations of syphilis resemble chronic, indolent ulcers. They are rounded or oval, with abrupt edges cut away like those of a chancroid, the base is cov- ered with the yellowish, false-membranous-looking deposit, sometimes bluish, like boiled sago. The edges and base of the ulcer are usually hard, and the former generally, but not invariably, firmly adherent, and not undermined as in the ulcerations of scrofula. These ulcers do not bleed easily, are generally atonic and sluggish, and usually entirely painless. Apparent exceptions to the rule in regard to pain are often due to the dependent position, or other cause sufficient to excite inflammation, or to the situation of the ulcer over a bone, the periosteum of which latter is suffering from painful syphilitic disease. 10. The cicatrices of such syphilitic lesions as have destroyed tis- sue, whether there has been any surface ulceration or not, are generally rounded, very thin, depressed, smooth, shining, and non-adherent. They ire usually at first uniformly pigmented, of a coppery hue, more or less ieep (nearly black in brunettes). This pigment clears off from the centre to the circumference until only a dark border is left, which some- 54S SYPHILIS. times lasts for months, but finally the whole cicatrix acquires almost a pearly whiteness. Cicatrices over bone may adhere if they have been connected with bone lesions. The cicatrices left by an ulceration par- taking' of the nature of both syphilis and scrofula (p. 544) are often com- plex, that is, a scar irregular, uneven, bridled on its surface, contracted in parts, not much pigmented, perhaps with a vein running across it, and often adherent at points ; possessing, in a word, some of the charac- ters of a strumous cicatrix added to those due to syphilis. These com- plex cicatrices are best marked about the neck, where glands have suppurated on strumous subjects who are also syphilitic, and are not very uncommon after rupia. CoNCOMiTAi^'T SxMPTOiis OF Secosdaet Syph tt . ts . — ^The phenom- ena which most frequently precede or accompany the first cutaneous out-breaks are syphUitic fever, indolent engorgement of the lymphatic glands, headache, osteocopic pains, alopecia, and sore-throat, with mucous patches, and perhaps iritis. A few words will serve to describe these symptoms. They follow the period of secondary incubation. SECONDAEX rNCTTBATION. Primary incubation (as already described, p. 513) extends from the moment of suspicious contact to the appearance of the chancre. Then primary syphilis is ushered in ; but now there is another period of rest, wherein the disease seems to be purely local, for there are no general symptoms. This period dates from the appearance of the chancre to the appearance of general symptoms. It invariably exists whether treatment be commenced or not, and has been named the period of secondary incubation. Primary syphilis may, and often does, extend through this whole period, and even longer, but still it is a period of incubation, for the general organism shows no sign of suffering until a lapse usually of many days. The shortest length of period of second- ary incubation yet reported is twelve days (Rollet) ; that is, twelve days elapsed after the appearance of the chancre before any general symptoms became evident. Rollet observed it again of one hundred and thirty days' duration. The mean length of the period is forty-six (Diday) or forty-seven (Rollet) days, as established both by experiment and clinical experience. This period may often be lengthened materially by the intervention of early treatment, but even then it is customary for some slight eruptive disturbance to appear about six weeks after the advent of chancre. SYPHTTiTTIC FEVEE. About a week or more before the appearance of any eruption, while the chancre is perhaps showing signs of getting well, the patient is liable to exhibit more or less marked symptoms of fever, but, as in SYPHILITIC FEVER. 549 nearly all of the symptoms of syphilis, so in this one, tne intensity varies in diiferent cases from nothing upward. The poison of syphilis is at work during the period of secondary incubation, and produces more or less cachexia by directly diminishing the quantity of the red corpuscles of the blood. Grassi, the enterprising apothecary of the HOtel Dieu, by frequently repeated analyses found this diminution of the red corpuscles to vary in diiferent cases from eleven to sixty-five per cent., and noted, also, that the percentage of corpuscles increased under the administra- tion of the iodide of potassium. Some diminution of the red corpus- cles seems to be constant ; but, while it varies greatly in cases where no treatment has been employed, under early judicious treatment the amount of decrease is certainly less. This syphilitic hydxasmia, then, is constant, but it may be so slight as not to be accompanied by any observable fever ; while, again, the amount of febrile disturbance may be excessive. Hence it sometimes appears that syphilitic fever, as such, is entirely absent. Lancereaux believes that it is present in two- thirds of all cases. When present, as distinct fever, it is marked by physical and mental depression, loss of appetite, functional disturbance of the primse. vise, and a temperature running up in the evening, accord- ing to Guntz,' often to nearly 104° Fahr., but falling again rapidly after a few days. The fever may be continuous, or may occur in paroxysms, chiefly toward night, followed by sweating. The type of the fever may be also remittent, or even occasionally intermittent, with regular tertian paroxysms of chill and fever. Again, the fever may be low and typhoid in type. Sometimes it is accompanied by nausea, hebetude, and stupor; or, again, the patient may feel quite comfortable and as vrell as usual, retaining his appetite, or even eating more than his ordinary amount of food — boulimia (Fournier). Whether there be much or little true fever, the hydrsemia commonly announces itself by sallowness of the complexion, with pallid face, pinched features, and sunken eyes. The nervous depression is sometimes prominent, occasioning melancholy, with sad looks, a gloomy view of life, even to a tendency to suicide. The patient exaggerates his sufferings, and is often wofully depressed, complaining of general malaise, fatigue, and feebleness. Paroxysmal or continued neuralgia, vertigo, feelings of faintness, may come on; these perhaps spontaneous, or, again, provoked by movements of the head. Where the hydrsemia is marked, shortness of breath is com- plained of, and palpitation ; a soft, blowing sound may be heard at the base of the heart and in the vessels of the neck. Epistaxis and oedema of the feet, perhaps, occur. With or without these symptoms of hydremia, pain is almost con- stant in syphilitic fever and during the earlier eruptions. This pain usu- ally affects the fibro-osseous system, and is known as osteocopic {boThv- ' " Das syphilitische Fieber," Leipzig, 1873. 550 SYPHILIS. Konreiv, bone-breahing), on account of its peculiar intensity. It as- sumes a multitude of forms, occurring in the nucha, back, loins, be- tween the ribs, constituting a pleurodynia sometimes mistaken for pleurisy, in the shoulders, elbows, knees, and sternum (Baglivi). These pains are movable sometimes, shifting rapidly from one part to another. They may occur only at night, or may be continuous, in which case they are often decidedly worse at night. Pressure sometimes affords them temporary relief, or, on the other hand, evokes them where they are not spontaneous. A diagnostic value has been attached to the fact that pressure over the lower or upper third of the sternum pro- duces pain not otherwise complained of. Among the pains of early syphilis, headache is prominent, often of an excruciating character and usually worse at night. The joints may stiffen and be hard to move, on account of pain. Effusion occasionally occurs in and around them, giv- ing to syphilitic fever the aspect of mild acute inflammatory rheuma- tism. Jaundice may perhaps come on during or just before the outbreak of eruption, rarely lasting over a few weeks, and due to hepatic en- gorgement, or, possibly, as Lancreeaux suggests, to compression of the bile-duct by enlarged lymphatic glands, since this cause is certainly sufficient to produce icterus occasionally in advanced syphilis. The pulse of syphilitic fever rarely reaches higher than 120°. The fever is usually greater according as the eruption is early and abundant. Sometimes it quickly abates and disappears as the eruption comes out, or it may continue and get worse for weeks. Occasionally there are some slight feverish symptoms just before other crops of eruptions which succeed the first general outbreak. The diagnosis of syphilitic fever is made by a study of the history of the case. Treatment is mainly tonic and hygienic ; these means being persist- ently "pushed while the general treatment of syphilis is kept up. Ano- dynes are sometimes required to master the pains. Although Grassi foimd that the number of red blood-corpuscles did not increase under the administration of mercury, yet this remedy, carefully, mildly, but persistently used (never pushed to salivation), usually seems to shorten the attacks, and, if commenced soon after the chancre appears, seems able to prevent the fever altogether. A few words will suffice for the other ordinary concomitants of the earlier general syphUides, alopecia, general indolent glandular engorge- ment, sore-throat, iritis, mucous patches, paralysis, anaesthesia, analgesia, boulimia, jaundice. ALOPECIA. Falling of the hair due to syphUis is of two kinds. Where there are scabby sores on the scalp, and especially in later ulcerative disease, the hair-foUicles, over limited areas, become destroyed, in which case the fallen hair is not reproduced. Ordinarily, however, general baldness ALOPECIA— GLANDULAR ENGORGEMENT. 55I occasioned by syphilis is only temporary. In fact, baldness is not usually produced, but only a considerable thinning of the hair, not only of the scalp, but of the eyebrows, eyelids, whiskers, and, to a degree, of the whole body. This thinning of the hair is due to two causes : (1.) The syphilitic hydraemia, which, like thin-bloodedness from any other acute cause (fever), temporarily impairs the vitality of the hair- papillse, causing the hair to lose its lustre and then to fall out. (3.) A seborrhoea, the sebaceous matter clogging the hair-follicle pressing upon the papilla, ultimately leading to the fall of the hair, and possibly, in some cases, to the atrophy of the papilla. The dried seba- ceous matter mixed with scales may usually be scraped away plentifully from the scalp around the hairs. Treatment. — Although some falling off of the hair is often inevitable, yet the quantity may be lessened by attention to the hygiene of the scalp, shampooing once a week with a little ammonia in warm water (a teaspoonful to the pint) to get rid of the accumulating sebaceous matter, and the use afterward of a stimulating lotion, of which a little may be rubbed upon the scalp nightly. One of the best of these is : 5. Tr. capsici, 3 ij.-v. Glycerini, 3 j. Aquae Cologniensis, ad. § j. M. Where sores infest the scalp, general treatment alone is to be relied upon. IMDOUEH'T GLANDTTLAE BNGOEerEmENT. Coincidently with the first outbreak of general syphUis, sometimes preceding the eruption, more often shortly following it, there is a marked tendency to a general indolent engorgement of the lymphatic glands. This concomitant symptom rarely fails, and it furnishes a diganostic mark of the first importance in all doubtful cases. The enlargement of the glands does not necessarily depend upon the occurrence of an eruption, since it is encountered where close observation fails to detect any neighboring exanthem. This is particularly true of the post-cer- vical and epitrochlear glands. The engorgement of the glands is indo- lent, painless. They are usually of a cartilaginous hardness, insensitive to pressure, varying in size from a small pea to a marble. The coincident indolent engorgement of certain glands is almost pathognomonic of syphilis. These are the post-cervical (posterior chain), markedly two little glands lying high up on either side of the nucha, upon the occipital bone ; a gland over the mastoid process of the tem- poral bone ; and the epitrochlear gland (or glands) on either side, just above and without the inner condyle of the humerus. Other glands may also become indolently engorged, but more rarely ; as, the lateral yc the cervical, the axillary, the inguinal (where the chancre is extra- genital, and where these glands consequently have escaped primary 552 GENEKAL TEEATilEST OF SYPHILIS. infection) ; but the g ands of most assistance to diagnosis are undoubt- edly the post-cervical and epitrochlear, and these should be sought for in aU cases to confirm the diagnosis of general syphilis. SOEE-THEOAT. Sore throat is a concomitant symptom of all stages of general s}'philis. There are three type varieties : 1. A diffuse general redness, vrith or -without ulceration. 2. A certain amount of chronic congestion, and bravrny thickening about mucous patches or atonic ulcers. 3. Destructive ulceration from gummy deposit. The first variety is an early secondary phenomenon, and alone of the three is a concomitant of the early syphilides ; the second may occur along with the later secondary and earlier tertiary lesions ; the third is tertiary. They will be described in connection with the other symptoms. Recently Fournier' has noted, as a concomitant symptom of the earlier secondary period of syphilis, certain aberrations of cutaneous sensibility, such as loss of ordinary cutaneous sensitiveness (aniEsthesia), inability to appreciate the sensations of heat and cold, and complete insensitiveness to pain (analgesia) ; these either general or more com- monly confined to limited areas of skin, notably the extremities. The back of the hand over the wrist is a favorite location. The trouble is a passing one, not lasting more than a few months, and has been observed by Foumier chiefly in women. It is questionable whether hysteria may not often play a prominent part in the causation of these phenomena- Foumier's observations include over a hundred cases. Iritis concludes the group of concomitant symptoms. It will be described later. CHAPTEE Y. OEXERAL TEEATMEX2 OF SYPHILIS. Hygienic, Tonic, Specific Treatment.— SypMIizatlon.— Treatment of Early Syphilis.— Bad Effects of Mer- cury.— Methods of administering Mercun-.—Treatment of Late Syphilis.— JDxed Treatment — Treatment by the Iodides.— Methods of administering Iodine in Syphilis. — Quantity of Iodide which may be required. — ^Duration of Greneral Treatment. The general " treatment of syphilis is hygienic, tonic, and specific. The latter is often inefiective unless aided by the former. Xeither should be depended upon alone. They form component parts of one rational system. '"Annales de Dermatologie et de Syphilographie," tome L, 1869, p. 486. "Surla Syphilis," Paris, 1873. ^ The local and special means required for the different maiiifestations of the disease will be detailed under the heads of the symptoms requiiing them. HYGIENIC TREATMENT. 553 Sygienio Treatment. — The hygienic treatment of syphilis includes all the ordinary laws of health. Regularity of the habits — especially of those of eating and sleeping, and of those involved in the performance of intestinal functions — is all-important. No deviations need be made from ordinary diet. Excesses of any kind are bad, even emotional (fear, anger), and especially excesses in strong drink, in work, in venery. The function of the skin should receive attention through scrupulous cleanliness. Warm baths are more cleanly and relaxing to the skin than cold. If baths be too hot early in the disease, they are apt to call out a more plentiful crop of eruption. Catching cold should be avoided. It is apt to induce and prolong mucous and ulcerative patches about the mouth, nose, and throat. Singing, and loud and continuous talking, are objectionable in subjects having weak throats. Experience has taught that tobacco in all forms, and even highly-seasoned food, is certainly injurious, in irritating and keeping up an outcrop of mucous patches. Air, exercise, and light, essentially necessary to all animal well-being, are particularly so in the case of obstinate chronic or advancing disease. Change of air in some of these cases is essential to the success of treat- ment, as a trip to the country, change from the seaboard to the moun- tains, or from inland to the shore, and then perhaps back again, six weeks being usually long enough in any locality to obtain its maximum effect for good. Case L. — A geDtleman of twenty-four, of fair general health, tall, slight, pale, some- what lymphatic in aspect, applied for treatment of a large lump on the forehead, nasal catarrh, and a yellow ulcer of the soft palate. He had been under treatment for some time for scrofula. Daily local applications had been made to hia ulcer. He suffered no pain. His appetite was excellent. The most scrupulous examination and careful inquiry failed to elicit any history of syphilis, except a urethral discharge coming three weeks after exposure, for which he took capsules ; and a little sore-throat within six months after- ward. He never had been treated by mercury, or otherwise for syphilis, which he was unconscious of having. There was a painful node on the left ulnar, nodes on the tibise ; the bones of the bridge of the nose crackled when touched, and had already begun to sink in. The fluctuating tumor (gummy) on the forehead was painless. The ulcer of the palate was rapidly perforating, and characteristic in appearance. He was put on tonics, cod-liver oil, and the iodide of potassium. Five grains of the iodide produced a profuse eruption of purpura of the feet and legs. On this account he went to the country, continuing his iodide, and with directions to increase it. Within twelve hours after reaching the country, his purpura ceased coming out, he was able to increase the dose of the iodide, and all of his symptoms improved. Within a few weeks the ulcer in his mouth healed, the lump on the forehead greatly diminished ; he had gained flesh and strength, and concluded to return to the city. Shortly after doing so he was obliged to decrease the dose of the iodide ; new crops of purpura appeared daily, his nasal discharge ceased to improve. Again he sought the country, again his purpura promptly ceased, and he went on to recovery. Many equally instructive illustrative cases might be detailed. The rule is positive. Many obstinate bad cases of late secondary and tertiary disease, which fail to respond to treatment in their homes, especially if that home be in the city, make rapid strides toward recovery, as soon as 55i GENERAL TREATMENT OF SYPHILIS. the air and surroundings hare been modified.' Mercury and the iodides will not cure aU syphilis, as many practitioners seem to believe. The old chronic cases, remaining from year to year in our large hospitals, and relapsing endlessly in the damp and crowded tenements of our large cities, are not in need of medical treatment, for this they have and of the best ; but what they need is intelligent hygiene, and with its assist- ance many of them would recover. Tonic Treatment. — ^In the same category with hygiena belongs all tonic and supportive medication. Cod-liver oil, iron, quinine, and all lesser helps, find ample space to vindicate their claims at some part of the treatment of most cases. Without them specific treatment is often unworthy the name. In the hydraemic stage, just before and during syphilitic fever and the earlier exanthemata, as weU as during portions of the later cachexise, these remedies outrank the specifics, and are in- deed occasionally used alone and to advantage, until the general tone of the patient can be elevated ; after which the prompt efficiency of the specifics, intelligently administered, gives them a claim to the title of being the most reliable drugs used in the practice of medicine. There are, however, certain phases of syphilitic cachexia over which no tonics act with the same efficiency as minute doses of mercury, especially corrosive sublimate, in women preferably combined with iron. Specifie Treatment of Syphilis. — But few known remedies have been left untried in the treatment of syphilis. Even condurango, the last startling therapeutical novelty, claimed to eradicate it. The claims of few of these need detain us. Most of the syphilides, especially the earlier varieties, are self-limiting, and will get well under any treat- ment, one might even say in spite of treatment. MUd cases, especially in married women, often go imtreated, unrecognized indeed, and the patients never suffer any considerable inconvenience. It is on cases of this order that anti-mercurialists build their theories, substantiating the latter by reference to cases, in themselves inveterate and malignant in spite of the use of mercury, or perhaps in connection with its improper use. No treatment may be better than over-treatment. The different vegetable decoctions and infusions, of which sarsapa- rilla takes the lead, assist digestion, promote the action of the sldn, encourage the functional activity of the kidney, and please the patient. They may be adjuvants in certain cases, and should be perhaps ranked along with hygienic and tonic means, but they have not merited by their action any right to the term curative in its narrowest sense, since they do not demonstrably postpone relapses or shorten the duration of existing symptoms any more than other hygienic and tonic means. Bumstead speaks favorably of Zittmann's decoction (which also contains mercury), from 3 viij to xvj daily, enough to produce free catharsis in ' We tave repeatedly demonstrated the value of the truth contained in the above lines. STPHILIZATION. 555 some " inveterate cases," believing that it increases the appetite and improves the patient's general condition. To the same order of treatment belong diaphoretics and the action of baths, both useful undoubtedly, but strictly belonging to the class of adjuvants. Of syphilization, that is, the attempt to eradicate syphilis by the rapid, indeed exhaustive reproduction of iilcers upon the patient by the use of pus taken from an auto-inoculable source, usually chancroid, — the process is founded upon an inaccuracy. Its premises are scientifically inexact, for chancroid is not syphilis, any more than is nettle-rash the itch. Its effects are produced not upon the principle similia simili- bus, but upon that which regulates the power that issues and setons sometimes have over certain cutaneous affections. The skin becomes exhausted as to its power of maintaining an eruption. This same effect has been produced by the establishment and maintenance of ulcers with tartarized antimony, a method of treatment named, satirically, " tartar- ization." That an eruption may fade promptly under treatment by syphilization is highly probable, but this is only one of many symptoms of syphilis. Other eruptions and other symptoms are not prevented, and the treatment itself is physically repulsive, painful, and certain to leave more indelible cicatrices upon the integument than would a serious at- tack of syphilis allowed to go untreated.' The specific treatment of syphilis consists in the intelligent adminis- tration of mercury and of some of the preparations of iodine. It is divided, for convenience of description, into — 1. Treatment of early syphilis ; 3. Treatment of late syphilis — mixed treatment. The proper duration of treatment will be discussed at the end of the section. 1. TREATMENT OP EAELY SYPHILIS. General treatment should be commenced as soon as the diagnosis of ' It ia only the recent presence among us of the kind and gentle old man, the apostle of syphilization, Prof. Boeck, of Christiania, which makes it necessary to devote more than a single line to syphilization. Certain desperate cases in a neighboring city were undertaken by him, and so decidedly benefited that a well-known surgeon of that city, in reporting the case, announced his faith in the so-called " duality of syphilis " shaken. But, granting any amount of improvement in any number of severe cases, although it might establish the value of continuous and prolonged cutaneous irritation as a means of combating severe forms of syphilitic disease, it could not estabUsh the identity of the poisons of syphilis and chancroid, any more than could tartarization, employed with suc- cess, be held up as an argument for the identity of tartar-emetic and the syphilitic virus. In a case (personal) of obstinate tuberculo-ulcerated syphilide, attended by acute ataxic symptoms in the lower extremities, where immense doses of iodide of potassium with a small amount of mercury failed to effect any marked or speedy relief, a certain advantage (by no means as marked as in Boeck's cases) seemed to be derived from the establishment and maintenance upon the breast of the patient of six large ulcers. They were kept open with the utmost difBculty, by means of large wooden buttons strapped down over them, and were occasionally sprinkled with tartarized antimony. The remedy caused pain, and the amount of benefit derived from it was not sufficient to justify it» long continuance. 556 GENEKAL TEEiTMENT OF SYPHILIS. syphilitic chancre is made. There is no object in waiting for an eruption. By so doing, valuable time is lost. Still, early action is only justified by an absolute certainty of diagnosis. In all cases of doubt the honest surgeon must hesitate, and many cases are doubtful at first. In all such it becomes the duty of the surgeon and of the patient to wait for abso- lute proof of its presence before treating a disease which possibly may not exist. By following the opposite course the surgeon perhaps throws doubt and discontent, sometimes even torture, into the whole subse- quent life of the patient, who is constantly alarmed by every pimple, every ache, every unusual feeling he may have through life, fearing it may be the beginning of the long-delayed onslaught of his imaginary foe. A few days of a mercurial treatment m some cases will disturb the regular development of symptoms, perhaps prevent their appearance altogether in a form which would be readily recognized, and, in face of such a case, if the diagnosis of the nature of the chancre had been doubtful, how much more so would be that of the subsequent syphilis ! Hence the rule in all cases of doubt : Do nothing, but frankly tell the patient that he must wait ; or, if he has not the grace to appreciate pure honesty, and must have something to do while waiting, give a placebo while studying the nature of the sore and awaiting developments. As soon, however, as the diagnosis " syphilis " is satisfactory, commence general treatment. In the early manifestations of syphilis mercury is specially potent. Under its kindly influence the chancre heals, the early eruptions fade. If given continuously and intelligently from the first, syphilitic fever rarely amounts to more than a little pallor, with occasional osteocopio pain, and the early eruptions instead of being general are more or less discrete. The iodides have but little power over early syphilis, al- though they are sometimes preferred during syphilitic fever, especially if it run high. A mild mercurial, however, is better, but with it the tonic and hygienic treatment should be vigorously combined ; and, if mercury have a depressing effect, it should be discontinued until the latter means have brought up the patient to a point where he can tolerate the more powerful drug. Mercury properly administered may be taken for years without any injury to the individual, or to his constitution, either immediate or remote. It has no connection as a cause with the appearance of severe tertiary forms of syphilis. Accumulating expe- rience derived from more accurate observation has established this truth beyond cavil, although the ancient superstition as to the injurious after- effects of mercury stUl measurably taints popular belief.' ' The sn-eeping assumptions and broad assertions of a recent author of a pretentious volume in folio (" Ueber die WiAungen des Queclisilbers auf den menschlichen Organis- mus," Dr. Jos. Hermann), which would seem to ascribe all possible evils, and especially the symptoms of syphilis, to the effects of mercury, are too little substantiated by the facts adduced to call for any discussion here. BAD EFFECTS OF MERCURY. 557 Bad Effects of MEKcrET.— Not very rarely a patient is found who cannot take mercury, or who bears it badly even in minute doses, and in any case it is a depressor of vitality if given too freely. Patients are now and then encountered, in all stages of syphilis, who are thrown at once into a condition of hopeless mental and emotional depression as soon as they begin to come under the influence of mercury. This curi- ous phenomenon has been noticed again and again by the authors, and has been patiently and critically studied in order to differentiate it from the mental and emotional depressions caused by the syphilitic virus. Mercury will depress the spirits and give an otherwise buoyant disposition the most languid and distressingly desponding tendencies. No words can describe the awful gloom that settles down on an indi- vidual upon whom mercury exercises this peculiar power. One form of the remedy produces it as well as another ; striking relief is afforded, obviously, by discontinuing the drug, or, what will often answer, lessen- ing the dose. These symptoms may be observed before mercury has produced any effect upon the mouth or gums. The other bad effects produced by mercury are salivation and diar- rhoea with griping pain. The well-known poisonous effects of the stronger mercurials (bichloride, biniodide, bicyanide, etc.) render it un- necessary to discuss death from an overdose of one of the latter class. The general intelligence of modern practitioners renders it equally unnecessary to more than allude by name to mercurial tremor and mer- curial cachexia, neither of which could occur except after an inordinate, unjustifiable use of the drug, although mild tremors are noticed some- times after mercurial baths. (For the irritating effects of mercury used locally, see Inxtnciton.) Salivation. — Salivation is harmful. It should not be aimed at. The greatest effect that it is allowable to produce by mercury is to " touch the gums," as it is called. When the gums are touched there will be an increased flow of saliva, a faint coppery taste in the mouth, some ten- derness of the gums, tongue, perhaps of the whole buccal cavity. Press- ing the teeth firmly together causes slight pain, while a little swelling of the gums and a faint reddish line at the neck of the teeth may' be noticeable. Sometimes ulceration along the edges of the tongue or gums, or on the inside the cheek, is caused by mercury, while there is still no tenderness about the mouth, nor a very markedly increased flow of saliva, but this is rare. The mouth should be inspected before com- mencing a mercurial course, so that the condition of the teeth and gums may be known. A patient with ragged teeth covered with tartar is not in a fair condition to test the therapeutic effect of mercury ; his gums, naturally tender, will become affected long before his point of true toler- ance is reached. Tt is, therefore, wise, in commencing a mercurial course, to send the patient to a dentist, with injunctions to have the tartar entirely removed from his teeth, both to make the observation of the 558 GENERAL TREATMENT OF SYPHILIS. effect of mercury more accurate, and to remove one source of local irri- tation capable of keeping up mucous patches. The quantity of the drug necessary to produce an effect upon the gums varies with each individual ; minute doses will occasion it in some cases having special idiosyncra- sies ; others may take enormous doses before the symptoms yield or the gums become affected. The point of saturation or " tolerance " of a given patient can only be learned by close observation of the symptoms just described. After this we have his gauge, and can temper his treatment according to the urgency of his symptoms. Should salivation acciden- tally occur, or be encountered in practice, it requires treatment. The effect of mercury is by no means increased by keeping a patient sah- vated ; on the contrary, the disease is not benefited, while the patient is positively injured. The cause of salivation is special idiosyncrasy with a small dose of mercury, or no idiosyncrasy with large doses. A mouth kept dirty or containing bad teeth is more apt to suffer. The influence of cold and wet during a mercurial course seems sometimes (though very rarely) capable of inducing it. Bumstead ' mentions a patient who became " profusely salivated a month after the cessation of a mercurial course as a consequence of exposure to the rain." Symptoms. — In sahvation the salivary fluids flow freely, sometimes to an enormous extent, the breath is fetid, the metallic taste is very marked, the gums are sore, perhaps bleeding, the teeth feel too long for the patient to shut his mouth, tapping lightly upon them causes pain, the tongue swells, showing marks of the teeth, the lips and cheeks may also become tumefied. Often there is febrile excitement with mental depression, the lymphatic glands in the vicinity become swollen and painful. The teeth may fall, or portions of the soft or bony parts necrose, in extreme oases. Articulation is indistinct and painful, deglu- tition almost impossible. The above is a description of a severe type case of mercurial stoma- titis. Between this and the mildest increase in the salivary flow with " touching of the gums," the affection assumes all shades and varieties of intensity. The patient should be cautioned to report for inspection on the advent of the earliest of these symptoms, that possibly impending salivation may be averted. Treatment. — Salivation may often be kept off by the administration of large doses of the chlorate of potash during a mercm-ial course, and that, too, without interfering with the effects of the mercur3', as Ricord has shown,' but it is better to hold this remedy in reserve for exhibition, in case symptoms of mercurialization should suddenly run high. During salivation, or any sore mouth from mercury, ten to twelve grains to the ounce, of chlorate of potash in water, or any bland fluid, should be kept constantly on hand (warmed), and with it the patient should repeatedly ' Op. at., p. 602. ' " Le9on3 sur le Chancre." METHODS OF ADMINISTBRINa MERCURY. 559 rinse his moutli and throat. At least one drachm, and not more than three, of the same remedy daily should be introduced into the patient's circulation, either through the stomach, if he can swallow, or by the rec- tum. A mild solution of carbolic acid or of Labarraque's solution, or water rendered pink with a little permanganate of potash, should be occasionally used as a gargle, where there is great fetor of the breath. These means will generally promptly overcome salivation. In all other respects the treatment of salivation is symptomatic. An anodyne or a laxative may be required — the physician selects the one with the use of which he is most familiar. Nourishment must be kept up by hot broths, milk, and soft articles of light food, until a subsidence of the swelling allows the patient to swallow solids. Diarrhoea with griping pains is apt to come on in many patients who are fairly under the influence of mercury. If kept up, the patient loses appetite, runs down, and fails to derive benefit from his mercurial course. When any mercurial shows signs of disagreeing by the pro- duction of these symptoms, it is better to lower the dose, if the syphi- litic lesions are under control ; otherwise, to change the mercurial prepa- ration for a milder one, putting the patient at the same time upon a rice-and-milk diet, with lime-water and moderate doses of bismuth, or to administer the mercury by some other method — inunction, fumigation. Opiates and astringents may be combined with the mercurial, to prevent its irritating eifects, but it is better to avoid them if possible, or in any case to try first the means above suggested. Methods of administering Mercury. — The effects of mercury are produced no matter how the drug is employed, hence the choice of a method depends mainly upon the ease of its administration, the prompti- tude of its action, or upon the desire to produce or to avoid some local, useful, or disagreeable effects. It is on this account that, for treating general syphilis, the method by the stomach is the best. Since it is necessary to continue the use of mercury for a year, unremittingly, at the very least, it becomes at once apparent that the docility of the pa- tient is taxed severely to keep him under treatment at all, and common- sense avers that the ordinary patient will take his medicine steadily by the mouth, in many cases where he would absolutely refuse to continue it by any other method — as by the hypodermic injection, inunction, fu- migation. All of these methods have their value in the rapidity of their action, and from the fact that they spare the stomach, but, for prolonged, regular treatment, the latter organ must be relied upon. Even the advo- cates of other methods do not propose them for continuous use, but only to combat symptoms — calling the disappearance of an eruption a cure of syphilis, and the next eruption a relapse. ' Frequent warm batha and the exhibition of diuretics are useful for patients under any mercurial course. They hasten the elimination of the drug, thus warding off evil effects, without interfering with the therapeutic action of the remedy. 560 GENEEAL TEEATMENT OF SYPHILIS. Among the methods in common use for the administration of mer- cm-y at the present date, five require mention. They are, in the order of their respective value to the practitioner : 1. By the stomach. 2. Local. 3. Endermio (inunction). 4. Fumigation. 5. Hypodermic. 5. Hypodermic Injections. — ^In favor of this method it may be said that eruptions, iritis, and lesions relievable by mercury, seem to yield very rapidly during its employment, as a rule. The method em- ployed is that of Lewin,^ more or less modified. From one-sixteenth to one-eighth of a grain of sublimate, with perhaps a little morphine, dis- solved in fifteen minims of Tvater, is injected, once or twice daily, under the skin — preferably of the back below the scapula. The objections to the treatment are sufficient to condemn it, unless in exceptional cases, where a speedy action of the drug is required, or where the patient can- not or will not swallow. Abscess sometimes follows the puncture, and a hard, painful lump of chronic inflammation occupies the seat of the in- jection, as a rule, for a length of time. Salivation is not uncommon. 4. Fumigation. — This method is an excellent one, but not practi- cably applicable. It requires an expenditure of time and care, such as the ordinary patient will not continue to give it for a long time. It is useful where prompt and kindly action of mercury is aimed at. Im- provement of svmptoms sets in rapidly after the baths are commenced. Salivation is rarely induced. Fumigations may be taken daily, where the patient is robust and bears the treatment well, or at longer intervals. Depression, headache, faintness, tremors, occasionally salivation, or di- arrhoea, attend this mode of treatment, when the patients are impression- able. Langston Parker" has done much to develop this form of treat ment.' The simplest method of thorough fumigation is the following: The apparatus for a local fumigation of the throat (Fig. 132) is all that is required in the way of special machinery. The patient undresses for retiring. The lamp and tin, and mercurial to be volatilized, are placed in position beneath a cane-bottomed chair. The patient, naked, sits upon the chair and wraps himself and the chair completely in a couple of thick blankets, drawing the latter snugly about his chin. A ■ " Behandlung der Syphilis mit suboutaner sublimat-injection. ^ " On Sypliilitic Diseases," London. ' Mercurial fumigations are administered in most of the Turkish and Eussian bathing establishments in all large cities; but it is the universal experience of physicians that the proprietors of these establishments are prone to tamper with patients, and invariably fail to carry out instructions received from the physician. Otherwise the facilities of such establishments of mingling steam with the fumes of mercury are unequaled. In these institutions, where the head is also immersed in the fiimes, the black oxide ia the most suitable mercurial to he employed — from one to two drachm doses. FUMIGATION. 561 pan of steaming, boiling water is now placed under the blankets. As soon as the confined steam has rendered the body warm and slightly moist, the spirit-lamp under the chair is ignited. The bath lasts from fifteen minutes to half an hour. Profuse perspiration usually comes on. After fifteen minutes, if the patient is uncomfortable, the light may be extinguished, but remaining in the fumes five or ten minutes longer is of advantage. The patient now wraps one of the blankets around him and lies down, without wiping off the mercury until he has cooled. A more complete apparatus is that of Maury, of Philadelphia (Fig. 131). It is attached to the gas-burner by a rubber-pipe. There are two pans ; one for water, one for mercury. Of the different mercurials generally used in fumigation, calomel is the best. About a scruple is enough for a bath; the diminution or increase of this dose is regulated by circumstances. Calomel is better than the other substances used, because it volatilizes promptly with a heat Fis. 131. easily attained by a spirit-lamp, and whatever of the fumes escapes into the room is not irritating to the fauces. The red oxide of mercury also volatilizes without reduction. All the other substances in common use, metallic mercury, mercury with chalk, the gray oxide, the black oxide, the binoxide, the yellow oxide, the bisulphuret, are exactly the same thing; they all reduce first, and then the metallic mercury volatilizes. 36 562 GENERAL TEEATMEKT OF SYPHILTS Pure metallic mercury boils at 662°, and is apt to sputter on the appli- cation of dry heat before it volatilizes. It takes considerable heat to vaporize it. When the red sulphuret of mercury is employed, the fumes are those of sulphurous acid and metallic mercury ; the former is often irritating to the pharynx and lungs, and the preparation should not be used without circumspection. 3. Inunction. — Sigmund, of Vienna, is the present apostle of the " inunction cure of syphilis," a method of very ancient origin. Inunction is, perhaps, of all, the best means of exhibiting mercury. It spares the stomach, and rarely salivates, and though, in special cases, it may pro- duce any of the bad effects of mercury, yet it is, undoubtedly, of all methods the least apt to do so. The only objections to its continued use are that it requires time and care for its proper application, is not cleanly, and may give rise to a local eczema. Should this eruption occur, it is treated with soothing ointments. The best preparations to use in inunction are the oleates of mercury. They are found in the shops of three strengths, five, ten, and twenty (sometimes thirty) per cent, of the peroxide of mercury, combined (chem- ically) with oleic acid. They are rather expensive. The five-per-cent, preparation resembles Knseed-oil ; the twenty-per-cent. is thick, pasty, j^eUowish. The disagreeable odor may be corrected by the addition of a few drops of oil of roses. The twenty-per-cent. preparation is actu- ally eighteen and a half per cent., a little more than one-third the strength of strong mercurial ointment, which contains fifty per cent, of mercury — ^the others in proportion. Twenty-per-cent. oleate irritates the skin, but not as much as mercurial ointment. It is more cleanly, and seemingly capable of much more thorough and rapid absorption. The five-per-cent. oleate may be rubbed daily upon the same portion of integument in many individuals without producing the least irritation. Choosing one of these preparations, according to the irritability of the skin and the effect desired, preferably the twenty-per-cent., the patient with his own fingers rubs it gently into any convenient portion of the skin until the proper dose has been used, and it has mostly sunken into the integument. The scrotum is to be avoided, and a different portion of integument chosen each night. Absorption is most rapid through the soft skin of the flexures of the joints. After the friction has been made, the part is covered with a bandage, to preserve the clothes, for twenty- four hours, when the spot is washed with soap and warm water, and a new inunction is made elsewhere. The dose for an inunction of the twenty-per-cent. oleate is about 3 j, of the others, proportionately more. Mercurial ointment — more dirty, less effective, less expensive — may be used in the same way, at a dose of 3 C -j at a Motion. Another excellent endermic method ' of giving mercury is, to spread out upon a fold of thick bandage mercurial ointment, or better, twenty- * Kno^fD as Teale's method. USE OP MERCURY BY THE STOMACH. 563 percent, oleate over a space about as large as the palm, and to bind this around the arm, forearm, leg, thigh, body, in succession, keeping the mercury against the thinnest portion's of the skin. Such a bandage may be worn twenty-four, forty-eight hours, in some cases indefinitely, for weeks without washing the spot. It should be studiously inspected, however, and removed at once on the advent of itching or the appear- ance of any erythema. When it is removed, the surface should be washed with soap and warm water. 3. Local Use of Mercury. — This will be referred to in connection with the different lesions. The local application of mercury alone, or (in ulcerated lesions) in combination or alternating with iodoform, has a positive beneficial (local) influence. Powders, solutions, oleates, ointments, all have their merits. 1. Mercury ly the Stomach. — This means must be adopted in the vast majority of cases, and it is only in examples of rare idiosyncrasy that it is objectionable. As already stated, the general action of mer- cury taken by the stomach is not so rapid as by other means. It may, however, be so taken for any length of time, is very little troublesome, can be continued while traveling, and without making the patient conspicuous to his friends. Several forms of mercury have proved themselves by experience to be especially adapted to prolonged use by the stomach in syphilis ; they are the protiodide, the bichloride, blue-pill, and gray powder ; the latter has been used chiefly with infants. Calomel is useful in those cases where it is desirable to bring the patient very rapidly under the full influence of mercury. Administered in one-twelfth-graih doses every hour, it will often " touch the gums " in twenty-four to forty-eight hours, and with safety, for its prompt discontinuance on the first appearance of signs of salivation prevents the development of the latter. These prep- arations leave little to desire. The gray powder is least irritating to the stomach, blue-pill next, then protiodide, and most acrid the bichlo- ride. Their power over the disease is, however, not at all dependent on their irritating properties, and, though this or that susceptibility or irritabUity may render the choice of this or that preparation advisable, yet for the great majority the protiodide is the best. It is well borne by most stomachs, and is sufficiently powerful. The American protiodide is of irregular strength, and very apt to be highly irritating when used in effective doses. The best preparation known is the imported one (French), preferably as found put up in sugar-coated granules, one-fifth grain each, by Gamier and Lamoureux. In using this preparation it is best to commence with one granule after each meal (three daily), and to add one granule every third or fourth day to the daily dose (not to each dose), until either the metallic taste is complained of, or some slight in- testinal irritation is felt, or until three granules can be taken at a dose. It is rare to find a patient who will support more than three. On the 5 6 J: GEXEEAL TREATMEKT OF SYPHILIS. advent of any irritation at the mouth, or in the intestine, the dose is to be slightly decreased. 'V\Tien the proper dose is reached (two or three granules), it is steadily maintained. If the mercurial course has been begun early, no eruption may appear, or only a few scattered papules, some glandular engorgement, and a few mucous patches which will rarely escape an attentive observation, somewhere between the second and the sixth month. Should a more positive outbreak appear at any time dtiring the mer- curial course, instead of increasing the dose by the stomach, it is better to resort to inunction or fumigation, in addition to, or in place of, the regular treatment, until the eruption disappears, and then to continue steadily with the granules of the protiodide without intermission for at the very least one year. Instead of employing inimction, if the stomach be powerful, on any given outcrop of eruption the bichloride may be substituted for the granules at a dose beginning at one-twentieth of a grain, in a bitter menstruum, increasing until the symptoms yield, or some disagreeable result of merourialization seems imminent, carrying the dose to one-eighth or one-sixth of a grain.* The common solution in tincture of bark (or the elixir) is as good as any that can be desired : 5 ■ Hydrarg. bichlorid., Ammonii sesquicWorid., aa gr. jss-iij. Tr. cmchonse CO., | iij. il. S. Teaspoonful, largely diluted in water, after eating. Or the old Xew York Hospital formula — • • 5. Hydrarg. bichlorid., gr. It. Tr. ferri sesqnichlorid., §j. S. Ten drops in water after eating — may be exhibited with good effect in anaemic cases where the stomach is not weak, as in the earlier outbreaks attended by syphilitic fever, where a tonic is particularly required — in some cases indeed to the total exclu- sion of mercury. When it is deemed advisable to give the bichloride in pill-form, it may be combined with reduced iron, as in the following: Hydrarg. bichlorid., gr.j. Ferri redact., Sjss. Gum. tragacanth., 1 Glycerini, i M. F. pil, No. XT. In anaemic women the New York Hospital formula is a good one, in which blue-pill gr. ij is combined with gr. j of the dried sulphate of iron in pUl-form. The quantity of either ingredient of the pill may be increased if circumstances require. Finally, the gray powder (hydrarg. ' Muriate of ammonia is frequently added to solutions containing the bichloride, to increase the solubility of the latter, where large doses are glTen. A saturated solution of hydroehlorate of ammonia dissolves seventeen times more bichloride than simple water. MIXED TREATMENT. 565 cum cret&) may be employed, increasing from two-grain doses, It is very mild in its action. TBEATMENT OP LATE SYPHILIS. This includes the use of the iodide of potassium. The iodides are rarely of value in the early stages of the disease. They are often given instead of mercury during syphilitic fever, but their action is probably purely tonic, and not at all specific in such oases, since their administra- tion does not have any appreciable effect over the duration of the early syphilitic exanthemata. The iodides are useful early in cases of pre- cocious syphilis, where lesions of bone, nervous manifestations, or deep ulcers, come on shortly after chancre. As soon, however, as the cutaneous lesions of syphUis show a marked tendency to aggregate into patches, and especially to remain long chronic, as scaly or tubercular thickened patches, or, indeed, mthout eruption, after the first year of treatment, the iodide should be used with mercury in the form of treatment called mixed. Again, all lesions certainly or presumedly gummy, ulcers, gummy tumors, deep lesions of bone, of brain, of viscera, require the iodide in large excess, often with- out the addition of mercury, until the symptom is controlled, then again in combination and in reduced dose. Mixed Treatment. — There are many methods of employing the mixed treatment, of which but three require mention : 1. When the two drugs are mixed in the same prescription. 3. When they are given separately at the same or different hours of the day. 3. When the iodide internally is combined with inunction. 1. Mixing the two drugs in the satne prescription is the best method for prolonged use. Either ingredient of the prescription may be raised or lowered according to the requirements of the case. The following " syrup of the biniodide " is at once palatable and efficient. Ammonia in some form is generally added to prescriptions containing the iodides, under the idea that it improves and intensifies their action. 5 . Hydrarg. Tjiniod., gr. jaa. Ammonii iodid., 3j. Potass, iodid., 3 ij. SjT. aurant. cort., gj. Tr. ejusdem, 3j. Aquse, ad. |iij. M. S. Teaspoonful, largely diluted with water, after eating. The iodide of sodium may be substituted for the iodide of potassium, and the sesquichloride for the iodide of ammonium, in the above, and the dose increased according to the requirements of the case. A pre- scription in common use and based on high authority, wherein the bichloride of mercury is given with iodide of potassium in solution, 566 GENEJUL TREATMENT OP SYPHILIS. althougli undoubtedly effective, is unohemical, and no better tban a fresh combination of the biniodide with the iodide of potassium. The bichlo- ride in contact with the iodide of potassium is decomposed and becomes biniodide. The mixed treatment may be carried out in pUl-form, where only small doses of the iodide are required. Wliere the dose is large, solutions should invariably be used. Ordinary pUls containing iodide of potassium are difficult to keep, on account of tendency to deliquesce. They may be kept, however, in bottles with tight rubber stoppers. A piU contain- ing five grains of the iodide with one-sixteenth of a grain of the bin- iodide is not inconveniently large. Such piUs should be taken during, or immediately after, a meal. For convenience of administration, where only small doses are re- quired, Dunton has prepared three sets of " compressed pUls," which keep perfectly well, and form an elegant preparation. They contain simply the biniodide of mercury with the iodide of potassium, in the pro- portion of one-twentieth of a grain to three grains, one-sixteenth of a grain to four grains, one-twelfth of a grain to five grains. 3. Where the drugs are given separately the iodide is administered in water or in syrup, the niercury in piQ, syrup, in any of its forms, at a suitable dose. Usually a mercurial piU is taken once or twice daily, and a solution of the iodide given at separate hours. This plan presents no advantages, and is more troublesome than the ordinary mixed treat- ment. 3. Iodide internally combined with inunction (or even fumigation) is an excellent method of treatment, especially in old, chronic, inveterate cases, where the stomach must be spared as much as possible for food, but where the mild, efficient action of mercury seems to be required. Treatment by the Iodides. — The more purely gummy any lesion, the more certainly wiU it yield to the iodides. Hence, these preparations are particularly suited to the treatment of the late manifestations of syphilis. No agent in medicine is more brilliantly effective than the iodide of potassium, promptly and unsparingly used, in cases of rapid, destructive, gummy ulceration, as of the throat, nose, skin, or in sudden, violent attacks of nervous syphilis. Unfortunately, however, the iodides do not seem to have very marked curative virtues, gummy deposit often melts like snow under their use, but other symptoms appear after a time. Hence, however strong a weapon the iodides may be, mercury is more powerful in ultimately controlling the disease, and we are accustomed to resort to it in late cases, as well as early, to exercise a curative action, by keeping off subsequent so-called relapses. The Bad Eitects of the Iodides are four, and are most apt to appear when the diuretic action of the drug is absent or deficient. The kidneys would seem to be the natural channels for elimination of the iodide ; w^hen it is retained, iodism results ; when it attempts to escape by the BAD EFFECTS OF THE IODIDES. 567 skin or mucous expansions, unpleasant symptoms are more apt to ac company its administration.' The bad effects of the iodides are : 1. Possible indirect causation of salivation. 2. lodism. 3. Irritation of mucous membranes. 4. Cutaneous eruptions. 1. Salivation. — Indirectly the iodide of potassium may cause saliva- tion, since it dissolves and renders active mercury which may be lying dor- mant in the tissues, causing its elimination. Hence, some care is neces- sary in commencing a course of iodide of potassium after a course of mercury, especially where the patient is known to be sensitive to the action of the latter drug. Indeed, the efficient action of the iodide over late symptoms has been ascribed to its power of liberating, rendering active, mercury already in the body. This position is unsound, since cases of tertiary disease, which have never been treated by mercury, yield promptly to the iodide. Bumstead quotes a striking case.' In this coun- try we rarely encounter patients with syphilis who have not taken mercury. 2. lodism. — A peculiar poisonous effect is produced iipon some pa- tients by the use of iodine, especially in the form of iodides.' The symptoms are general irritation of the nerves, with depression ; the ears ring, the head aches, neuralgic pains are felt deep in the bones and muscles. There is more or less general torpor, with physical and mental depression. This affection is rare. It may occur from the least touch of iodine, or large quantities may be required to produce it. It occurs with or without irritation of the cutaneous or mucous expansions. 3. General irritation of more or less of the mucous expansions of the body, with perhaps some nervous phenomena, headache, pains in the bones (iodism). In mild cases this takes the form of " catarrh," or a simple cold. A sharp coryza sets in, with sneezing and a plentiful watery discharge from the nose, perhaps with reddened conjunctivae and streaming eyes. Bumstead mentions, in rare instances, loss of vision, due apparently to sub-retinal effusion. The lining of the frontal sinuses may be hypersemic and swollen, occasioning considerable pain. The fauces and mucous lining of the lungs participate in these hyperaemic and secretory changes occasionally. The symptoms sometimes reach a high grade, from swelling and oedema. A marked increase of the sali- vary flow is observed. ' The supposed power of iodine, long administered, to cause atrophy of the testicles (the breast in the female), and abolish sexual vigor, is purely hypothetical. Temporary diminution of sexual appetite seems occasionally to depend upon the internal use of iodine, but the abolition of the power, or atrophy of the testicle, never — although syphilie may undoubtedly cause both the latter. " From Gazette des Bdpitaux, January 28, 1860. ' One physician in this city stated to me that the least contact even of tincture of iodine with the stin gave him symptoms of iodism. Another physician was at one time always disagreeably affected in a nervous way by touching his tongue to any solution con taiuing the iodide of potassium. — Ketes. 568 GEXEEAL TREATMENT OF SYPHILIS. The stomach and intestines suffer less often than the nasal and bronchial membranes, if the precautions are observed of never giving the iodides soHd, except in small quantity, during or immediately after a full meal. When a large quantity is given, it must always be in solu- tion largely diluted, and taken upon a fuU stomach if possible. A neglect of these precautions not infrequently produces pain in the pit of the stomach, loss of appetite, griping, diarrhoea. !Mild attacks usually subside even with a judicious continuance of the remedy. But in rare cases the symptoms are so violent that the drug has to be discon- tinued. The iodide of sodium is much less irritating to the stomach and intestines than the iodide of potassium. Its effects upon the skin seem also to be less marked ; but, on the other hand, its therapeutic action does not appear to be as prompt or effective. This irritation of the membranes, when not subsiding rapidly enough upon suspension of the remedy, may be hastened away by diuretics and diaphoretics. 4. Eruptions cavsed hy the Iodides. — Three forms of eruption are encountered upon patients taking the iodides and produced by the drug. In patients where the elimination by the kidney is rapid and thorough, generally neither iodism nor any eruption is encountered. The eruptions are, in the order of their relative frequence : acne, ery- thema — more or less modified— purpura. 1. ^cne. — A few pustules or papulo-pustules of acne (simplex or indurata) generally appear during a course of the iodides. Their favorite site is about the forehead, cheeks, shoulders, back, buttocks, and extensor aspect of the limbs. They are usually unimportant, but sometimes they occur in profuse crops, covering nearly the whole body, and are then painful and unsightly. With acne may be associated large tuberculo-pustules and boils. 2. Erythema. — Iodic erythema, as commonly observed, covers the slopes of the nose and portions of the cheeks and forehead. It is fol- lowed by branny desquamation. It may occur upon other surfaces, iso- lated or in large patches, particularly on the forearms. It is sometimes attended hy papulation. Papules may appear, not acneic and not sur- rounded by erj'thema. The erythema may run on to eczema about the face and scalp. Mercier ' mentions a case where in the same patient, on two occasions, small doses of the iodide of potassium produced a severe eruption of eczema rubrum over the whole body. Another form of vesico-pustular (bullous) eruption occurs, but is exceedingly rare.' It is very severe. Slight erythema usually precedes the development, all over the body, of patches, more or less large, of bullse, some of them umbilicated, of th^ size of a split-pea to nearly that of a penny. They quickly become purulent. They are accompanied by burning pain and 'Quoted by Bumstead, from V Union Medicale, February 11, 1860. ' The authors have eDcountered one very striking case. BAD EFFECTS OF THE IODIDES. 569 itching, and disappear rapidly upon discontinuing the iodide, to reap- pear if the drug is again exhibited. 3. Purpura may be caused by large, sometimes by moderate doses of the iodides ; chiefly in debilitated, anasmic subjects, suffering from syphilitic cachexia and tertiary lesions. Case L. illustrates this point, where the patient was surrounded with every comfort, eating vegetables, not overworked, or seemingly in any way scorbutic. The best-marked cases of purpura hasmorrhagica, in the authors' axperience, are encountered in connection with advanced tertiary disease, as in giving large doses of iodide for nervous syphilis. Iodic purpura rarely gets above the knees. It is accompanied by some oedema. It may occasionally reach the thighs, or be seen upon the hands. It often ceases to appear upon discontinuing the drug, or change of air. The exhibition of cod-liver oil, astringent preparations of iron, and other hygienic and tonic measures, are indicated. All of the bad results of iodine disappear when the drug is discontinued. The acne and erythema may be moderated by plentiful warm baths and a diuretic (half-drachra doses of acetate of potash), which hasten elimination somewhat and pre- vent bad effects, without interfering with therapeutic action. Method of administering Iodine in Syphilis. — Only certain iodides, of those in general use, are valuable as controlling syphilitic manifesta- tions. These are, the iodides of potassium, sodium, ammonium. The first is preferable, if it can be borne, the iodide of sodium is milder, the iodide of ammonium is more diiEcult to take, and is rarely used alone. It may be conveniently combined with the iodide of potassium, the action of which seems to be increased by any ammoniacal preparation ; of which the favorites are the muriate and the carbonate. In selecting an iodide, the prepa'ration of sodium should be commenced with where the primm vim are in an irritable condition. Inflammation of these organs contraindi- cates the use of iodides.' The iodine may be given pure in small doses. Dunton's compressed pills of iodide of potassium, containing gr. v each, may be used if taken with or immediately after food. Not more than gr. v of solid iodide should be taken at a single dose, for fear of irritating the stomach. When given alone, the iodides are best combined with tincture of bark or of gentian. 5 . Potass, iodidi, 3 ij. Ammonii iodidi, 3j. Tr. cinchonse CO., § iij. M. S. Teaspoonful, largely diluted with water, after eating. When a considerable quantity has to be taken for a long time, it is Dest to order the concentrated solution : ' In certain oases, where it has been impossible to administer iodides by the stomach, the authors have obtained excellent effects by using them in the rectum. As much as half-drachm doses daily have been given dissolved in an ounce or more of beef-tea. The stomach is spared in this way for food, but usually the rectum revolts after a time, espe- cially if the solution of the iodine be too concentrated. 5tt, GE^-DRAL TBEATMEXT OF SYPHILIS. 5. Potass, iodid., AqusB, aa q. s. Commencing at fire drops, largely diluted, after eating, go on until the symptoms yield, or the remedy disagrees. Quantity of Iodide which raay he required. — There is practically no limit to the proper dose of the iodide of potassium, except an improve- ment of the symptoms. A taste may produce iodism in some eases, in others the symptoms faU to yield until enormous doses have been reached. An old patient, -whose mouth, fauces, and nose, formed one vast, ulcer- ated cavity, a hospital case, who was accustomed to enter the Charity Hospital, stay till he was nearly well, and then leave until the progress of his disease forced him back — ^this man took daily for eleven days, having been rapidly run up to this amount, two ounces (nine hundred and sixty grains) in the twenty-four hours. He developed only a few scattered pustules of acne, but, after eleven days, when the destructive disease in the throat had been stayed, the stomach began to suffer, and the dose ?ras decreased. His throat went on improving under the diminished dose. It is not uncommon to see patients, with open, advancing ulcera- tion, who have been taking perhaps twenty-grain doses of iodide of po- tassium for weeks without benefit, in whom another five or ten grains added to the dose clears the ulcer, arrests its progress, and induces rapid cicatrization. Hence the rule : in all cases where the diagnosis is cer- tain, of a late, tertiary, syphilitic symptom requiring iodide of potassiima, continue increasing the dose until the symptom yields, or the patient will bear no more. The advantage of hygiene in connection with the administration of the iodides is illustrated by Case L. DITEATION OF TKEATHEITT. Treatment of syphUis, according to the experience of the authors, should last at the very least two years — one year with mercurials, one year with mixed treatment — and this in cases which show only the mild lesions of glandular engorgement, a few papules or roseolar patches, mu- cous and scaly patches in the mouth, and sore-throat. To this class be- long nearly all cases treated steadUy and conscientiously, continuously from the first. It is the rare exception to find such patients showing bad symptoms during their treatment, or developing serious lesions after- ward. In other words, those cases do badly most often which are irregularly and spasmodically treated, and those cases are most apt to be prolonged and obstinate, and indeed to crop out in severe lesions at late date after chancre, which have not followed a continuous, persistent, prolonged, mUd mercurial course at the start. Hence there are two classes of cases to be discussed : 1. The patient who comes with syphilitic chancre. 2. The patient who comes with a late, obstinate form of disease, after perhaps years of apparent health. DURATION OF TREATMENT. 57J 1. The patient who comes with chancre should be gently urged with a suitable mercurial, until his " dose " is found. His " course " should now be based upon a dose a little lower than this, which should be con- tinued steadily, until some reason to change appears. Should an erup- tion crop out, the remedy is changed and slightly pushed and maintained steadily, inunction being added, until the eruption has disappeared. Tonic and hygienic measures are observed throughout. In bad cases, with frequent outcrops, this mercurial course may be prolonged eigh- teen months, twelve may be sufficient. Where tertiary symptoms ap- pear early, the iodide of potassium must be added to the mercurial. After this, mixed treatment is commenced, and is to be continued one year, eighteen months, or more, until at least six months have passed after the appearance of any symptom due to syphilis. Then the patient should be put for a while upon a tonic, and finally allowed to give up treatment. This is the treatment by extinction, and although it is impossible to say of any given patient that he will never have a relapse after having faithfully followed it, still it is so rare as to be almost phenomenal, when a case so treated develops any very serious lesions due to syphilis, later on in life. What symptoms do appear, if any, generally yield promptly to the mixed treatment, while it is rare for extensive, pure, gummy lesions to develop. 3. "Where the patient first comes for treatment with serious or oh- stlnate disease which has come on at a late period after chancre, there will be found to blame, either : 1. The gouty constitution. 2. The scrofulous diathesis. 3. Intemperance, excess, or misery — ^in short, bad hygiene ; or, 4. A short mercurial treatment, at first, perhaps, carried to salivation, which, in the treatment by extinction, is always to be avoided. The proper course to pursue with such a case is to adopt a treatment suited to the lesion, mixed or iodide alone, and to use it, aided by hy- giene, until the lesion has disappeared, then to commence a course of mixed treatment, and continue it mildly for a year or more, watching for relapse ; fiinally, to terminate with a mild, pure mercurial course, ex- tending over six months or a year at least. This seems to be the most beneficial course, but in old, obstinate cases it will not always prevent subsequent outbreaks. In such cases the main reliance is in tonics, hygiene, and the symptomatic treatment of the outbreaks. It must be remembered that mercury has power, more or less marked, over all shades and dates of syphilis. It is useful in the tertiary stage, although undoubtedly not so useful as in the secondary. 572 SYPHILIS OF SKIN AND MUCOUS MElTbEANES. CHAPTEE VI. SYPHILIS OF SKIN AND MUCOUS MEMBRANES. Sj'philides, Secondmy and Tertiary. — The Secondary SypMides.— Concomitant Symptoms on Mnconfl Membranes. The SypHUJDES are those manifestations of general syphilis found upon the cutaneous enrelope. There are two groups, the secondary and the tertiary. Those occurring in secondary syphilis are: 1. Roseola ; 5. Bullous syphilide ; 3. Papular syphilide ; 6. Vesicular syphilide ; 3. General pustular syphUide ; 7. Squamous syphilide ; 4. Pigmentary syphilide; 8. Tubercular syphilide. With these occur on the mucous membranes : 1. Erythematous patches ; 3. Mucous patches.; 2. Ulcers ; 4. Scaly patches. These are all general eruptions, except the pigmentary and scaly syphUides, and they belong to the group called secondary, about in the order in which they are given. Thus the roseola and papular syphilide always appear early ; the tubercular and scaly syphilide always late. The former require mercury alone for their removal ; the latter demand a mixed treatment, a combination of the iodide of potassium with mercury, to insure the most prompt and effective action. The syphilides which belong to the tertiary stage of the disease are : 1. Ecthyma; 4. Tertiary ulcerations ; 2. Rupia ; 5. Gummy tumor. 3. Groups of pustules ; With these occur on the mucous membranes : 1. Mucous patches ; 3. Deep chronic ulcers ; 2. Scaly patches ; 4. Destructive gummy ulcerations. These (tertiary) affections, it will be noticed, are none of them gen- eralized. They all occur in patches. They wiU be considered later. The concomitant symptoms of the group are affections of the bones, of the larynx, of the internal organs, and nervous syphilis. SECOBTDAEY SYPHILIDES. 1. Roseola. — This is an erythema, or simple redness, occurring in small, flat patches or blotches of irregularly crescentic or circular form ROSEOLA. • 573 and slightly indented margins, each blotch varying from the size of a split-pea to that of a copper penny. Occasionally the blotches become confluent. Instead of being flat, the patches of eruptions may be raised above the level of the surrounding skin by the presence of minute papillse upon the reddened area. The patches of roseola resemble exactly what would be an exaggeration of the mottling (marbling) of the integument, which any fair-skinned individual may observe faintly upon his own person by exposing the abdomen to cold air for a few moments. This erythema is the lesion proper, but, following the rule of polymorphism in syphilitic eruptions, it is customary to find other lesions besides the erythema, such as pustules leaving scabs in the hair, and pustules and papules elsewhere, scattered through the eruption, especially about the head and face. The patches of erythema at first disappear entirely upon pressure ; but, where the eruption has been in- tense or of long duration, a faint, tawny, yellowish-brown stain is left after pressure (pigmentation), which indeed outlasts the eruption and is removed only by time. A small amount of fine desquamation attends the disappearance of the eruption in well-marked cases. This exanthem is usually the first to appear after chancre, generally at about six weeks, sometimes three weeks, occasionally after several months, but rarely after the fourth. Its advent usually coincides with the secondary engorgement of the lymphatic glands. It often comes on slowly, and may never be observed by the patient until his attention is attracted to it by his physician, or it may be called out rapidly by the heat of a bath, by a cold, or other exciting cause. If the patient have had no syphilitic fever, he is less likely to have noticed the eruption. When it comes on slowly, the chest and flanks are first invaded, and an inspection of these surfaces with the light shining obliquely across them will reveal sometimes the beginnings of a roseola, as yet invisible to casual inspection. In rapid cases twenty-four hours are sufficient to cover the whole body with the eruption, including even a few blotches on the palms and soles. In perhaps the majority of cases the eruption is confined to those portions of the skin covered by clothing, the hands and face escaping, or being so faintly marked as not to attract atten- tion. When roseola comes on early, it lasts from one to six weeks ; when, however, it first appears some months after chancre, it usually lasts several months. Treatment greatly influences its duration. Relapse occasionally occurs. Diagnosis. — Patients with syphilophobia are apt to mistake the natural marbling of the skin produced by cold for syphilitic roseola. Heat causes this marbling to disappear. Non-specific roseola is attended by some positive febrile symptoms, often by nausea, disappearing when the eruption comes out. The latter runs a rapid course. It is more frankly inflammatory than the syphilitic roseola, and occurs chiefly in 5H SYPHILIS OF SKIN AXD MUCOUS MEMBEANES. children. Copaibal roseola is frankly inflammatory, usually itches,, sometimes excessively. The history shows the ingestion of copaiba (of which the urine smells), and abstinence from the balsam effects a speedy cure. Urticaria occurs in raised patches, and itches greatly. The concomitant symptoms distinguish measles. The non-inflammatory character of syphilitic roseola, its lack of itching, and the accompanying indolent engorgement of the lymphatic glands, render its diagnosis easy. When itching is complained of with syphilitic roseola, pediculi, urticaria, or some accidental eruptions are to be suspected. " {See Case XLIX.) General treatment alone is required. 2. Papuiae Stphuxde. — ^This eruption may follow a roseola, or a roseola may be transformed into a papular eruption, or the latter may be the first eruptive outbreak observed after chancre. The papules con- stituting the initial lesion may be miliary in form (like those seen on the spots of roseola), in which case they are often early surmounted by a minute vesicle. The papule is often larger, but acuminated, or it may be broad and flattened (this is a common form), about the size and shape of a split-pea (lenticular) ; or, finally, this last form of papule is some- times greatly exaggerated, reaching the size of a penny. The type varieties, then, of papule in the earlier general papular syphihde are two, the acuminated and the flat. The general characteristics of the eruption are the same in each. The papular syphilide is superficial and preco- cious. The color at first is rosy, but soon darkens to the purplish hue of syphilis. Pressure removes the color at first, but later some pigmenta- tion occurs, and then pressure is no longer efiective. This final tawny coloration often outlasts all prominence of the papule. Desquamation sets in early. Fine scales become detached, especially around the base of each papule, forming a sort of little rufiled border of white. Biett considered this circular desquamation of the base of the papule of great diagnostic value. It occurs, however, occasionally, in the case of large non-syphUitic papiiles. Sometimes the desquamation is so considerable over closely-grouped broad papules, that a diagnosis with squamous syphilide becomes difficult. One form of papular syphilide is peculiar : Broad flat papules appear, scattered irregularly, especially seen about the face, forehead, and neck, and on the scalp. Each papule is covered by a thin, yellowish, superficial scale, like a scab, raised at the borders, and distinctly depressed centrally. The raised edge is sometimes dis- tended by a slight amount of serum, the whole looking like a flattened, partly-desiccated bulla. Sometimes each lesion is surrounded by a reddened (livid) areola. Shortly the large superficial scale becomes detached, the papule pales, flattens, disappears, and leaves no scar. The papular syphilide, though general, is usually most marked at the back of the neck, on the forehead, back, and flanks. There is no pain or itching with this eruption. Scabs in the hair are likely to PAPULAE SYPHILIDE. 575 .coincide with it, and the indolent, engorged, post-cervical and epitrochlear gatiglions are rarely absent. The eruption may come before the third week from chancre, or after the fourth month. Its duration is from three to eight weeks, it may be prolonged for months by the recurrence of suc- cessive crops of papules. Diagnosis. — A papular syphilide is liable to be confounded with two eruptions only. (1.) When the acuminated papules are few, and scattered about the temples, and oyer the forehead, they greatly resemble a form of acne seen in middle age upon rheumatic subjects. The syphilitic eruption may be usually distinguished by a certain amount of pigmenta- tion around the older papules, a feature not observed in acne. (2.) The flat papules, few in number, livid in color, and attended by no itching, situated over the backs of the hands, wrists, forearms, and sometimes extensively over the body, and constituting one of the forms of lichen planus seen on rheumatic subjects, are very liable to be mistaken foi syphilitic lesions. The patches, however, are more irregular in shape and size, and often present a slight umbilication (without desquamation) at some period of their course, which, together with the history and lack of concomitant phenomena, serves to distinguish this affection from a syphi- lide. With the papular syphilide are apt to coexist scabs in the hair, engorged ganglia, perhaps patches of erythema and pustules occasionally, and pretty certainly mucous patches, erythema or ulceration of some mucous membrane, especially that of the fauces. Small, circular red- dened spots on the palms and soles are also a very constant accompani- ment of a generalized papular syphilide. These are attempts at papu- lation aborted by the thickened epithelium. They appear as circular depressions, reddened centrally and partly deprived of epithelium, which latter is undermined at the edge of each depression as a whitened, fringed circle. Several of them may usually be found on each palm. An exactly similar condition is sometimes seen on the palm after an attack of lichen urticatus of the extremities. The severe itching attend- ing the latter eruption insures against error of diagnosis. This affec- tion of the palms is sometimes described as syphilitic psoriasis. It is more justly an aborted papular syphilide, or results from previous small patches of erythema. It may be found when there is no other syphilitic eruption upon the surface. Its appearance is characteristic, almost pathognomonic of syphilis. Iritis sometimes accompanies a severe out- break of syphilitic papules. Treatment. — A general papular eruption requires only general treat- ment. When the papules are conspicuous upon the face or hands, their disappearance may often be greatly hastened by local applications Any mercurial ointment is useful, rubbed into the papules. Ungt. hydrarg., red oxide of mercury ointment, and dilute citrine-ointment (3 j-ij to the § j), are all efficacious, but the most prompt results are obtained from one of the following : 576 SYPHILIS OP SKIN AND MUCOUS MEMBRANES. 5 . Hydrarg. ammoniat., 3 ss- 3 j. M. Cerat. benzoat., §j. Or— 5. Hydrarg. oxid. flav., gr. xx to 3j- M. Cerat. benzoat., |j. and perhaps best of all the five-per-cent. oleate of mercury applied nightl}'. The white ointment, on aocoimt of its color, may be used for the face, the yellow for the palms — the oleate for_ either. These local mercurial applications are useful in all the dry syphilides, and (mitigated) in the ulcerated forms of disease as well. 3. Geneeai Pustulae STPHiLtDB. — There are three varieties of generalized pustular syphilide belonging to secondary syphilis : (a.) Superficial pustules complicating other lesions. (b.) General syphilitic acne. (c.) Superficial ecthyma. (a.) Superficial Pustular SypMlide. — "With a roseola, or papular syphilide, or occurring alone, there may be some superficial pustules scat- tered on the scalp, or along the forehead, or about the upper lip, at the base of the nose, at the labial commissures, or, indifferently, over any part of the body, more or less thickly. The pustules are small, supei^ ficial, ephemeral, without any hardened or elevated base ; they often run together and dry up, forming scabs — brown, rough, uneven — like those seen in impetigo. The patches always tend toward a circular arrangement. Instead of drying up under the scabs, slight ulceration may take place, with, not infirequently, vegetation of the surface by the excessive growth of granular tissue. This feature is especially notice- able at the angles of the lips, or around the base of the alae of the nose. Indeed, any moist, ulcerated surface may granulate, the feature being an epi-phenomenon, and not essentially a characteristic of syphilis. Occa- sionally, in syphilis about the labio-nasal furrows, the lips, and chin, minute, dry, irregular, papular prominences occur in rows and segments of circles where there has been no previous moist surface. These warty excrescences rarely get larger than the head of a pin ; they are of a dead gray color, sometimes pigmented. They last several weeks, then dry up and disappear without leaving any cicatrix. Hardy has de- scribed the eruption as " syphilide granuleuse." There is nothing about the slight pustular eruption above described characteristic of syphilis, except the pigmentation of the skin in th brown areola which forms about the scabs, and the tawny, vinous- red color of the skin left after the fall of the latter. A very faint, cen- tral depression marks the spot of the pustule, and from this central de- pression the clearing up of the pigmentation begins, progressing cen- trifugally. The eruption may relapse, several crops appearing succes- sivelj', especially on the scalp. (5.) General Syphilitic Acne. — ^This eruption occurs scattered over GENERAL PUSTULAR SYPHILIDE. 577 the scalp, face, and the extremities, the lower rather than the upper, or it may cover the whole body. Each pustule is distinct, and out of most of them grows a hair. They are not prominent, usually small, often but little larger than a grain of millet, occasionally quite large. Each sepa- rate pustule rests on a reddened base, which itself never suppurates, the pustule being superficial. Each pustule grows slowly, taking from two to three weeks to develop and break, and then the fluid hardens into a dry scab. The hard base of the pustule has meantime been getting brown, and becoming surrounded by a copper-colored areola. When the scab falls, the elevation constituting the base of the original pustule remains as a papule, with a faint central depression. This pap- ule becomes gradually absorbed, leaving a purplish, pigmented discolora- tion, which is very slow to disappear. Sometimes a slight, superficial ulceration remains. This is followed by a minute, round, white, de- pressed cicatrix, very different from the puckered scar of ordinary acne. General syphilitic acne rarely appears before six months after chan- cre, being later than the superficial pustular syphilide, and earlier than the superficial ecthyma. It may appear very early, indeed as the first eruption, but it is beheved to indicate a bad form of syphilis, especially if accompanied by iritis. Syphilitic acne lasts ordinarily about two months, but this limit may be greatly prolonged by successive crops of eruptions. Diagnosis. — The coppery areola distinguishes syphilitic acne from other varieties, but where the eruption appears late, and is confined to the forehead, temples, and face, it is sometimes hard to distinguish it from the simple acne occurring late in life on gouty subjects. (c.) Superficial JEJcthyma. — This eruption is constituted by red- dened patches upon which pustules develop. The latter may be um- bilicated, much resembling variolous pustules. The pustules vary in size from that of a pea to (occasionally) nearly an inch in diameter. They are round, either scattered or collected into groups, in which latter case they may run together (confluent). The pus is thick, often bloody, and there is a dark-red areola (afterward coppery) around each pustule. The pustules do not repose on a hardened base. The crust is rough, dark brown, with a greenish shade, and underneath it there is ulceration. The latter heals under the scab, leaving a slight cicatrix (often pitted, like the scar of vaccinia), which for many months retains its purple, coppery color, gradually whitening from the centre. Syphilitic superficial ecthyma is found anywhere on the body, often on the scalp. It occurs in bad cases of syphiUs, especially where cachexia comes on early. It rarely appears before about the close of a year from chancre, and may be delayed a couple of years or more. On the other hand, it occasionally comes on as the first eruption, within some weeks after chancre, accompanied by early cachexia, not yielding readily to treatment, and often followed by extensive ulcerations. 37 578 SYPHILIS OF SKIN AND MUCOUS MEMBKAlsTlS. Diagnosis. — "WTien febrile symptoms accompany the outbreak of syphilitic ecthyma, as they sometimes do, and the pustules are umtili- cated, the disease is not uncommonly mistaken for variola— an error to be avoided by a study of the history of the case, the course of the erup- tion, and the absence of other symptoms of variola. Cachectic ecthyma may be confounded -with the syphUitic. The former appears in chUdren and the aged, chiefly on the legs, is more purulent, more inflammatoiy, less or not at aU pigmented, and has no accompanying history of syphUis. The superficial ecthyma of secondary syphilis differs from the so- called ecthyma of tertiary syphilis, in that the latter has an elevated, hard, empurpled base, ulcerates deeply, leaves a considerable, depressed scar (not pitted) ; is, in short, a gummy infiltration of the skin, ulcerat- ing superficially. All the pustular syphUides have the common charac- ters of lack of pain and itching, and the presence of the areola, first of vinous-red, then of copper-color, from the pigment. Treatment is general. Locally very mild mercurial applications are serviceable. 4. PiGMENTAET SxPHELEDE. — This syphilide has been described by Hardy.' It appears between the foiuth and twelfth month. It consists of a coffee-colored pigmentation of the skin, without elevation of the surface and without desquamation. The size of the spots varies from that of a silver five-cent piece to a quarter of a dollar. The borders of each spot are irregular, many of the patches run into each other. The intervening skin seems whiter than normal. This eruption occurs chiefly at the sides of the neck, perhaps ex- tending down over the breast. It may be found elsewhere. Lymphatic patients, with white, fine skin, chiefly women, are subject to it. Diagnosis. — In pityriasis versicolor there are desquamation, itching, and the parasite constituting the affection may be readily demonstrated by the microscope. Freckles are smaller and more generally distributed, never confined to the neck. Remarks. — This eruption is sometimes, possibly always, simply a pigmentation left behind by a roseola. It is often very faint, so that it can only be seen by viewing the neck sidewise with the light shining across it. It is found in some patients who deny any previous eruption upon the site occupied by the pigmentation. It may last one or two months or indefinitely, and is entirely uninfluenced by treatment. It is rarely detected by the patient, and is of little importance, except as an additional means of diagnosis in obscure cases, since it only occurs on syphilitic patients. 5. BuiiOFS Stphujde. — A syphilitic pemphigus upon adults has been observed in a few cases (Bassereau, Zeissl) occurring among the secondary symptoms, confined to the palms, soles, backs of the fingers, '"Le90iis sur la Scrofule et les Scrofulides et sur la Syphilis et les Syphilides," Paris,1864, p. 175. VESICULAR SYPHILIDE. 579 and bends of the elbows, and relievable by mercurials internally. This eruption, so common in inherited syphilis, is of the utmost rarity in adults. 6, Vesictloab Stphzlidb. — This is a rare form of syphilitic eruption. There are three varieties : {a.) Varicelloid syphilide ; (5.) Syphilitic eczema ; (c.) Syphilitic herpes. (a.) Varicelloid Syphilide. — This form comes early if at all, before the sixth month after chancre. Small, red, perhaps slightly elevated spots appear as large as a pea. Upon these arise one or more pointed, round, or umbilicated vesicles, surrounded at their base by a dark-red areola afterward becoming brown. The contents of the vesicles quickly become purulent and dry up into a greenish-brown, adherent crust. This scab falls in about a fortnight, leaving a purplish discoloration, which slowly disappears. There are usually but few spots of eruption, scat- tered over the face, limbs, and body. Successive crops of vesicles may prolong the eruption for several months, and ordinarily some other early syphilide coexists with it. Diagnosis. — When there is considerable syphilitic fever, there is danger of confounding this eruption with varioloid. This may be avoided by observing the color of the patches, the areola around them, the course of the affection, and concomitant symptoms. (5.) Syphilitic Eczema. — This is a vesicular eruption, not very common, appearing chiefly on the trunk and extremities, rarely on the face. The vesicles are small and acuminated, scattered or tmited into patches. When scattered, each vesicle is surrounded by the character- istic areola ; when in groups, the surface from which they spring is of a vinous-red, which coloration extends slightly beyond the border of the patch. The vesicles behave in two different manners. After remain- ing a while translucent, they may dry up, the liquid being reabsorbed; slight desquamation follows, the brown areola pales and no scar is left : or the vesicles become purulent, break, and little darkish scabs form (iso- lated and not confluent as in eczema) ; the scabs separate slowly and the brown stain disappears, leaving no scar. The eruption, in itself slow, is made more chronic by relapse. Diagnosis. — In ordinary eczema the vesicles are small, ephemeral, and break quickly, leaving an oozing surface or a confluent scab. The eruption itches, and there is no coppery areola. (p.) Syphilitia Herpes. — The patches of syphilitic herpes are situated on a base of specific color. The vesicles are of different sizes, from a grain of millet to a pea. They are arranged in irregular groups or describe circles or segments of circles. The vesicles last about a week, are succeeded by little scabs or by a fine desquamation. After these disappear, the color pales and no scar is left. Successive crops of erup- tion are the rule. 580 SYPHILIS OF SKIN AND MUCOUS MEMBRANES. Diagnosis.— GoloT, areola, and slowness of development, distinguish tHs eruption from ordinary herpes. The circinate form does not pro- gress centrifugally, as do other forms of circinate herpes. Treatment of the vesicular syphilides is general. 7. Squamous Stphujde.— Nearly all of the eruptions of syphilis go through a desquamative stage, and thus a patch of eruption, which is essentially papular, tubercular, or pustular, may finally become scaly, and, remaining so for a considerable time, pass for a squamous syphilide. So also does pityriasis occur in syphilis, as of the scalp vrith early alopecia; sometimes in little patches along the margin of the scalp with the other syphilides ; again, with syphilitic cachexia, furfuraceous des- quamation of the scalp, or even of the whole body, may be encountered, with a dry, rough skin. In none of these cases, however, can it be aflBrmed that pityriasis is an essentially syphilitic lesion. It is rather a local consequence of general blood deterioration, and may be induced by many causes other than syphOis. There are, however, two varieties of essentially scaly syphUide where the scale is the prominent lesion from the first. These are — {a.) Syphilitic psoriasis, including lepra ; (b.) Palmar and plantar psoriasis. (a.) Syphilitic Psoriasis. — This eruption occurs in two varieties — as a guttate or difFused psoriasis, and in the circinate (leprous) form. The characters of the eruption are the same ia both. They may be met together on the same subject. The patches vary from a split pea to a penny in size — or much larger ia the circiaate or gyrate form — ^have (as a rule) the deep syphilitic color, are but slightly elevated above the surface, not papulated. The scales are white, very fine, not adherent, not imbricated (as in true psoriasis). After a few weeks the scales faU. They may be replaced by others, finer than the first, and thus several desquamations occur. Finally, the color pales, and the darkened spot disappears, leaving no cicatrix, provided the eruption has not been a mixed one (tuberculo-squamous), which form does leave scar from inter- stitial absorption. The circinate form starts as a circle, or segment of a circle, inclosing healthy skin, does not generally increase in size, and lasts from a few weeks ia the earlier variety, to some months in the later, where there is more interstitial thickening of the skin, S\-philitic psoriasis does not appear before six months from chancre, and may come on after an interval of many years. It may coexist with other syphUo dermata. Scaly syphilides, appearing before six months from chancre, are usually the remains of previous papular eruptions. Syphilitic psoriasis appears upon the trunk, the members, the face, and along the forehead at the edge of the hair. It shows no tendency to locate at the elbows and knees, like non-specific psoriasis. The later its appearance after chancre, the longer does it tend to remain. Diagnosis. — When not associated with other specific lesions, syphi' SQUAMOUS SYPHILIDE. 581 litic psoriasis is often difficult to distinguish from non-specific scaly disease. Much light is thrown upon such cases by a study of the pre- vious history, on such points as the well-known inveterate tendency of ordinary psoriasis to relapse, its tendency to outbreak in the spring and fall. Neither eruption itches (usually), and both have the same livid redness of color under the scales, but ordinary psoriasis tends to cluster about the elbows and knees, and upon the scalp ; its scales are thick, imbricated, tightly attached, and lying in several layers, so that it is difficult to scrape them all away and get down to the livid redness of the patch beneath, and, when the scales are all rudely rubbed off, the patch is very apt to bleed. Common lepra, where the scales come off in patches, is usually much more extensive in its distribution than the syphilitic variety, and often of indefinite duration, -which the syphilitic is not. In syphilitic psoriasis the scales are more lamellar, finer, less adherent, not imbricated, or in thick layers, while the duration of the eruption is not so great. Finally, anti-syphilitic treatment has a marked and often rapid effect in the one form, while it does not modify the ordinary variety. The circinate form in some of its stages exactly simulates ordinary ring-worm, but the diagnosis may be made by the absence of spores, and by ■watching the course of the eruption, vchich, in syphilis, remains stationary, vrhile in ring-worm a progressive centrifugal enlargement is observed. {b.) Palmar and Plantar Psoriasis. — This eruption consists of rounded, livid colored patches on the palm or sole, slightly prominent, hard, covered by adherent, grayish scabs. The patches may be isolated or confluent, and may reach a large size, extending up to the wrist, or malleolus. Deep fissures may form upon them, caused by motion of the parts. These may bleed and occasion enough pain to restrict move- ment of the fingers. At the limits of the patches there is usually a characteristic livid areola. This eruption differs from the small circular depressions of the palm with an undermined circumference of white, hard epithelium, left by the papular or erythematous syphUide of the palm, and already described (p. 575). Palmar psoriasis comes on latei in the course of the disease, is often of more considerable extent, and lasts for several months, sometimes for several years. Diagnosis. — The diagnosis with ordinary psoriasis is difficult, unless other concomitant symptoms lend their aid. Ordinary palmar psori- asis is of a higher color, and not so circular in its figure. It generally itches, has no marked areola, and is pretty sure to coincide with other patches of psoriasis (perhaps at the elbows and knees). Scaly patches confined to the palm or sole always excite a suspicion of syphilis, and call for a profound study of the patient's general condition and history. A patient may have had syphilis and still have psoriasis later, not due to specific disease, and no error is to be more carefully guarded against 582 SYPHILIS OF SKIU AND MUCOUS MEMBKA2JES. than that of imagining that, because an individual has once had syphilis, all his subsequent eruptions must necessarily be due to the continued action of the virus. The touchstone treatment quickly reveals the fallacy of this supposition to the intelligent practitioner. Scaly patches, which continue for years in spite of well-directed treatment, are not syphilitic. Treatment. — Old, obstinate cases of syphilitic psoriasis require local (tar, mercurial ointments) as well as general measures. 8. Gejteeai, TuBEECUiAE Stphiude. — Tubercular eruptions are well on the boundary-line of tertiary syphilis. They are more frequently grouped than discrete, and often leave cicatrices without previous tJcer- ation. Still the eruption does occur in a discrete, general form, and may be ranked as a late secondary or early tertiaiy symptom. The tubercle is a large papule, involving the thickness of the skin. A subcutaneous, gummy tumor is not a tubercle. Tubercular eruptions, generalized or in groups, are rarely seen early in syphilis. A generalized papulo- tubercalar eruption may come on at four or five months, but groups of tubercles rarely appear before a year after chancre, and they may come on at any indefinite date. Bassereau notes a case at forty years. The farther from chancre the eruption appears, the more certain is it to be a patch of tubercles and not a general eruption, and the more marked in such a patch is the tendency to ulceration. There are two forms of this eruption ' (a.) General tubercular syphilide ; (5.) Tubercular syphilide in groups. (a.) General Tubercular Syphilide. — The lesion in this eruption is a solid, round, oval, pointed, or flattened tumor, about as large as a pea, at first shining and of a deep red, then of raw-ham or coppery color. They are scattered irregularly, or lie so as rudely to describe circles or segments of circles. Sometimes the eruption is confluent in spots, in which case the skin between the lesions is similarly colored. After a time a superficial scale covers each tubercle ; this becomes detached, and then the little tumor sinks away without ulceration. A slight, de- pressed, and pigmented spot marks for a time the site of the lesion, which also finally disappears, leaving no trace, or perhaps a very super- ficial cicatrix behind. This scar is the result of interstitial absorption of the substance of the true skin, and does not necessitate previous ulceration. Diagnosis. — The general tubercular syphilide appears over the whole body, perhaps more prominently on the face and forehead. Its characters are so marked that it is hardly possible to confound it with any other afiection. Treatment is mixed, with local mercurials. (5.) Tubercular Syphilide in Groups, — The lesions in this eruption are usually smaller than in the disseminated form, otherwise the same GENERAL TUBERCULAR STPHILIDE. 583 description applies to them. They may be no larger than a grain of millet, but they seem to involve a considerable thickness of the true skin. They may be assembled into irregular groups of rounded contour, or form circles, segments of circles, figures-of-eight. Sometimes each tubercle continues distinct from its neighbor, or they may run into each other, forming a continuous raised -welt, inclosing healthy skin, or a roughened, thickened, livid patch. In the circinate form the first tuber- cles undergo absorption, and are replaced by others circumferentially, causing the ring to grow larger centrifugally, as in ringworm, except that the tubercles which have disappeared usually leave little, smooth, round cicatrices behind, first livid, then white. Patches of very small tubercles leave no scar. Groups of tubercles may occur anywhere, but the forehead, cheeks, lips, and nose, are favorite sites. Groups of syphi- litic tubercles, in the period of decline, become covered by a fine desqua- mation, and, as each patch lasts a considerable time (from a few weeks to several years), the eruption goes by the name of tuberculo-squamous syphilide. Such patches show the tubercular character of the eruption more strongly at the border where fresh tubercles are springing up, while toward the centre of the patch many round, white, smooth, thin cicatrices show where tubercles had previously existed. Such patches are encountered mainly about the forehead and nose. This scarring without ulceration is caused as follows : The syphilitic tubercle is due to a diffuse hyperplasia of small cells in the substance of the true skin. These cells, which partake of the nature of so-called gummy exudation, grow at the expense of the natural tissues, and cause the atrophy of more or less of the substance of the latter, even while there is apparently an hypertrophy, as evidenced by the little tumor called a tubercle. When, however, the adventitious, newly-formed cells go into atrophy, and are absorbed during the progress of the eruption, then, not only does the tubercular prominence disappear, but the scar left attests the atrophy and absorption of the true elements of skin-tissue, which took place dur- ing the deposit of the morbid material. This element is of diagnostic importance. In only two eruptions — the tubercular (non-ulcerated) syphilide, and the tubercular (non-ulcer- ated) scrofulide in groups (i. e., tubercular non-ulcerated lupus) — is this important feature observed, and the mechanism of the formation of scar is the same in both eruptions. Groups of syphilitic tubercles may soften rapidly and ulcerate, but then the aifection becomes frankly tertiary in type (se^ p. 595). The course of this syphilide is always slow, its dura- tion being extended by successive crops of tubercles. Diagnosis. — It is perhaps possible to confound the circinate form of tubercular syphilide with ringworm, but the greater infiltration of the skin, and usual existence of scars, deeper color, and absence of spores, should protect the practitioner from error. Patches of syphilitic tuber- cles on a livid base are very apt to be mistaken for non-ulcerative lupuSi 584 SYPHILIS OF SKIN AND MUCOUS MEMBKAlfES. In this latter affection the tubercles are flatter, softer, partially translu- cent, less livdd ; there is some swelling of the subcutaneous, ceUular tissue ; the cicatrices upon the patches are puckered, irregular, often ridged with flat, tight, adherent, shining portions, resembUng somewhat the cicatrix of a bum, usually with a few veins running over the surface. Treatment of the tubercular syphilides is mixed, with, locally mercu- rials. CONCOMITAITT SYMPTOMS ON MtTCOTJS MEMBEANES. The affections of the mucous membranes found in secondary syphihs are four : 1. Erythema ; 3. Mucous patches ; 2. Ulcers ; 4. Scaly patches. 1. Ebtthesia. — The hyperemia of mucous membrane seen in sec- ondary syphilis usually attacks the fauces. It generally comes on from three to eight weeks after chancre, and looks and acts a good deal like the erythema occasioned by ordinary cold. It often extends backward into the pharynx and upward into the posterior nares, possibly occa- sioning a Kttle deafness, especially if the tonsils become engorged, as is not infrequently the case. The nasal mucous membrane is sometimes similarly affected, occasioning symptoms of ordinary catarrh. It occa- sionally extends downward into the larynx, resulting in slight catarrhal laryngitis, with hoarseness and some cough, occasionally temporary loss of voice. Diday ' mentions an aphonia occurring early in syphilis, where the voice is not visibly affected, except in the higher notes (in singers), which cannot be sounded. A few days of mercurial treat- ment restores the voice. The lesion is evidently hypersemia. Erythema of the fauces is often attended by oedema of the sub-mucous tissue. Faucial erythema usually accompanies the earliest outbreak of cutaneous syphilis. The tendency to the formation of ulcers or mucous patches upon the erythematous surface is great ; but, if these do not form, the diagnosis of the affection is not revealed by any special characteristics it possesses, unless it be that the inflammation is less frank, the color more dusky, and the complaints of the patient less urgent than they would be from a similar amount of hypersemia dependent upon a cold. The syphilitic erythema is sometimes seen in patches, and may be punctate. Ricord, in his " Iconographie," gives a plate (XV.) of an erythema of the glans penis coinciding with a cutaneous roseola, and this phenom- enon, by no means common, may be occasionally observed. Bumstead? noticed it in a case prior to the detection of any cutaneous symptom. The erythema of the throat may resolve, or (more frequently) ulcers or mucous patches appear. ' Oaiette Medicale deLyon, 1860. » Op, dt, p. 677. ERYTHEMA AND ULCERS OF THE THROAT. 585 Treatment. — The early erythematous sore-throat, if severe, requires local in addition to constitutional treatment. If swelling and pain are considerable, inhalation of steam and hot fomentations around the neck are soothing. Lactucarium, codeia, or an opiate, is often useful to quiet pain and prevent coughing. The patient should be advised to talk as little as possible, if there is any hoarseness. Flaxseed-tea, containing chlorate of potash in the strength of gr. v-x to the ounce, is useful in tablespoonful doses every hour or two. Saline laxatives, if the inflam- mation runs high. Gargles are not of much service if the throat is pain- fully inflamed. Hot milk as a gargle is soothing. 2. Ulcers. — Ulcers superficial in character, round, oval, or irregular in shape, are found upon the mucous membranes early in secondary syphilis. They are very frequently encountered in connection with the erythema above described. Their favorite seat is in the fauces, upon the tonsils, on the half-arches, on the soft palate and uvula, along the sides and tip of the tongue, especially if there be a rough portion of projecting tooth, against which the tongue rubs, on the inside of the cheeks, very often at the angles of the lips, inside the lower lip, under the tongue, along the fraenum, etc. ; in short, any portion of the mucous membrane of the buccal cavity may be affected, even the gums. These little ulcerations are usually superficial in character at first ; if they become deeper, the border thickens, grows red and angry, and a dirty-white pellicle covers the lesion. If they remain superficial, the mucous membrane seems to have been rubbed off, leaving a raw surface, smooth, glistening, red at its edges. Salt, pepper, etc., on the food occasion sometimes a stinging sensation at the abraded points. The surfaces of these ulcerations are prone to become aphthous, covered by a grayish-yellow exudation. Ulcerations of similar character may aflbot the nasal and genital mucous membranes in both sexes, especially if the parts are not kept perfectly clean. , The superficial ulcers appear early and late during the whole course of secondary syphilis. Lack of cleanliness, the use of tobacco, imperfect teeth, etc., are efficient exciting pauses. The ulcerated surfaces some- times vegetate, i. e., become covered by exuberant granulations. Deeper ulcers in secondary syphilis may depend upon continuance and extension of the foregoing variety, from continued irritation (a pro- jecting tooth, use of tobacco) ; or result from ulceration of mucous patches. The favorite seat of such deeper ulcerations is on the tonsils. The whole of the fauces may become brawny around them, dusky in color, thickened. The ulcers themselves have raised, sharply-cut bor- ders, yellow, unhealthy bases, and bear a strong resemblance to ordinary chancroid. They are encountered also at the angles of the lips, inside the cheeks, on the tongue, and are found upon the preputial mucous membrane, and about the anus, extending up into it. They often lead to considerable destruction of tissue in a slow, chronic way, eroding 586 SYPHILIS OF SKm AND MUCOUS MEMBRANES. the whole tonsil, or at the anus destroying tissue and resulting ulti- mately in stricture. This ulcer and ulcerated chancroid are the most frequent causes of so-called syphilitic stricture of the rectum. The ulcers above described belong to secondary syphilis. They com- mence superficially and not from within, and are thus distinguishable (as well as in their march) from gummy ulcerations of mucous mem- branes belonging to tertiary disease. The symptoms of ulcerations of the fauces usually complained of are sore-throat, perhaps difficulty in swallowing, and ofter pain under the jaw, caused by sympathetic swelling of the submaxillary glands. That erythema and ulceration of the other mucous membranes, oesophagus, stomach, intestine, bladder, urethra, etc., may occur in secondary syphilis, although highly probable, is not proved. Symptoms from these quarters are uncommon. Tertiary ulcerations are known to affect these membranes. Treatment is general and local. (See after Scait Patches.) 3. Mtrcotrs Patches. — The mucous patch is a lesion peculiar to syphi- lis. It is a round, oval, or oblong, pale or rosy, moist spot, usually elevated above the integument, sometimes flat or even depressed. The surface is slightly, sometimes heavily, furred, especially in the mouth. This lesion occurs plentifully about all the mucous orifices, especially around the anus, throat, mouth, and in the preputial cul-de-sac. It may develop upon the site of an existing chancre, converting the latter into a mucous patch. The true skin may also be covered by mucous patches, chiefly in regions where two surfaces of skin lie in contact, especially if they are also habitually moist ; under the female breast, on the scrotum, or upper part of the thigh, between the toes, at the umbilicus. They are seen also at the edges of the naUs. The soft skin of babies is peculiarly subject to mucous patches. Mucous patches vary in size, from the head of a large pin to that of a penny, or become larger if several run together. When occurring upon the skin, they are occasion- ally dry, vp^art-like (condylomata), elevated considerably above the sur- face. Sometimes upon the skin they scab over. Condylomata are seen to best advantage about the anus, perinseum, and scrotum ; but even upon the skin the whitish moist pellicle, resembling furred mucous membrane, may cover them. The surface of a mucous patch either upon the skin or mucous membrane may granulate, forming a prominent vegetating surface. Mucous patches around the anus and genitals, especially in the preputial culrde-sao (vagina in female), are very con- stantly attended by the formation of a viscid, badly-smelling secretion, which, in its turn, if not removed, irritates the skin, causes itching, and may excite a plentiful outcrop of vegetations, lack of cleanliness being the immediate cause of these latter, which themselves are accidental, and not in any sense syphilitic. Mucous patches subjected to friction, or left dirty, are apt to ulcerate. Such ulcerations are seen about the MUGOtJS PATCHES. 587 anus, extending perhaps into the rectum, along the sides of the scrotum from friction, between the toes, where they may become very painful, at the angles of the lips, on the tonsils. The secretion of mucous patches is contagious, and when they are present on the lips, or anywhere within the buccal cavity, the patient cannot be too urgently warned of the possibility of spreading the disease among members of his own family, by kissing or using the same spoon, cup, pipe, etc., as other members of the household. Mucous patches of the mouth are often of irregular shape, owing to the irritation of friction against the teeth. At the angles of the lips, and on the dorsum and sides of the tongue, they are often more or less fissured. The whitish pellicle on the surface is thick and adherent, sometimes covering the whole patch, sometimes having a ciroinate distribution. The buccal patches are usually flat, sometimes slightly depressed. Upon the tongue they may vegetate, while extensive ulceration upon the tonsils is not unusual. In connection with such ulcerations, the tonsils swell, there is a good deal of inflammatory thickening and induration around, swallowing may become painful, the submaxillary glands en- large. Since the use of the laryngoscope, mucous patches have been re- peatedly seen within the larynx ' and trachea." They do not become large in these situations, or secrete much, and they disappear in a few weeks, even without treatment. Symptoms are hoarseness, perhaps aphonia, no pain, cough, or ex- pectoration. Mucous patches come on with the earliest syphilides. They appear upon the skin, usually in connection with the papular syphilide, espe- cially the broad, flat variety. They may outlast several crops of different eruptions, and they relapse (especially about the lips, tongue and tonsils) with more pertinacity than any other symptom of syphilis. They occur late along in the secondary and even in the tertiary stage of the disease, but become gradually less and less prominent, until finally they pass over into the scaly patch of mucous membrane, so closely resembling the mucous patch in some of its features. Nothing is of more importance in the prevention of mucous patches than thorough cleanliness, nothing more active as an exciting cause (upon a syphilitic patient) than local irritation, prominently the use of tobacco, smoked or chewed (for the mouth), or snufi'ed (for the nose), the retention of a naturally irritating secretion from lack of cleanhness (for the anus and genitals). Mucous patches do not leave cicatrices un- less they have ulcerated deeply. Treatment is general and local. {See after Scalt Patches.) 1 Gerhardt and Eoth, "Virohow's Archiy.," xsi., 1861. Tiirok, Ziessl, "Const. Syphilis." 2 Sledel, " Jenaer Zeitschrift fiir Medizin," 1866. 588 SYPHILIS OF SKJN AND MUCOITS MEIIBRAITES. 4. ScAiiT Patches. — These patches, sometimes described as mucous patches, and sometimes as psoriasis, resemble mucous patches to casual inspection, but are found on closer observation to differ. They appear on the inside of the cheeks, especially near the angles of the mouth, and on the sides, tip, and dorsum of the tongue. They are rotmded or irreg- ular in shape, often gyrate on the back of the tongue. They are flat, smooth, shining, and of the bluish-white color of skimmed (city) milk. When mild, they are not at all sensitive. When severe, they become whiter in color, and the epithelium, whose thickening constitutes the le. sions, cracks in places, causing pain. A portion of the epithelium may grow out from the surface, hard, white, adherent, feeling like cartilage. These patches are epithelial hypertrophy. The scales are very firmly adherent, so much so that it is often impossible to scrape them off, and very rough handling fails to provoke bleeding. The patches may be- come confluent and cover the greater part of the dorsum of the tongue, making it feel stiff and uncomfortable for the patient. These patches sometimes occur along with the true mucous patch, but usually they appear later in the course of the disease. They may be found at any time, even during tertiary syphilis, and often remain long after all other symptoms have disappeared. They are sometimes seen in inherited syphilis. Smoking is an eflicient exciting cause. They are rebellious to internal measures, and are more effectively treated locally. They indicate a continuance of the syphilitic diathesis. Treatment. — ^Ulcers, mucous and scaly patches of the mouth and fauces often require other local measures in addition to those advised for erythema of the fauces, which latter are equally serviceable in cases of ulcer, where the accompanying inflammation runs high. The local measures most efficient are removal of aU local sources of irritation, which alone are often capable of keeping up the trouble in spite of the best-directed general treatment, such as stumps and ragged edges of teeth ; disuse of tobacco, chewed or smoked, and of strong drink, stimu- lating or highly-seasoned food; a mouth-wash containing chlorate of potash, or tincture of myrrh, carbolic acid, or Labarraque's solution, the latter, if there be any offensive odor ; careful cleansing of the teeth and gums with a soft brush. These measures, combined with internal treat- ment, are often all that is required. Where, however, a speedy effect is desired, direct topical applications are indispensable. One of the most efficient of these is the vapor of mercury. The best way of using this powerful agent is as follows: Direct the patient to procure at a tin-store a piece of tin ten inches long by three and one-half broad. This should be bent to a right angle at two and one-haK inches from either end, or at a convenient distance for the action of a flame from a low (tin) spirit-lamp placed beneath the table, formed by bending the ends of the tin (Fig. 132). Upon this " table " the powder to be inhaled is scattered, the inhala- SOEE THROAT— LOCAL TREATMENT. 589 tion being made by holding the mouth over it, or preferably a piece of paper twisted into a cone, the large end receiving the fumes. The powder found most efficacious is calomel, of which gr. J-ij rubbed up with two grains of chalk, to prevent too rapid volatilization, is sufficient for a dose, to be repeated three or four times daily. This method of treatment is often promptly effective where the whole tongue is covered with extensive scaly patches, and where large chronic ulcers exist about the mouth and throat. There is an objection to the treatment, however, which prevents its use in some cases ; namely, the provocation of great irritation of the throat, causing severe and prolonged paroxysms of coughing. Many patients suffer no inconvenience from the inhalations ; others cough con- siderably during and immediately after having inspired the mercurial Fio. 182. fumes ; with others no inconvenience is felt at the time, but after perhaps half an hour a violent paroxysm of coughing will come on. Commencing with a small dose (gr. ■^), no accident need be feared as a rule, while the good effect is often quickly perceptible. There are many other valuable local applications in general use. Sulphurous acid diluted (Shillitoe) is the best, used ( 3 j-ij- 1 j) in spray with an atomizer. Bumstead speaks favorably of a saturated solution of nitrate of silver applied in spray accurately with the atomizer, and in conditions of subsiding acute inflammation praises the undiluted tinct- ure of cimicifuga prepared from the fresh root. Where there are ulcers, angry and inflamed, the topical application of tannin in glycerine ( 3 ss-j to the | j) is often efficient. For isolated scaly mucous or ulcerated patches frequent light applications of nitrate of silver or sulphate of copper are beneficial, but the best local applica- tion is the acid nitrate of mercury. A veri/ minute quantity of this caustic is carried to the surface to be medicated upon a glass rod. The application is painful, and the patient is allowed to rinse his mouth at once with cold water. Mucous patches and kindred ulcerations about the anus, scrotum, preputial cul-de-sac, toes, etc., are treated by scrupulous cleanliness, soap 590 SYPHILIS OF SKIN A^sD MUCOUS MEMBRANES. and water being followed by Labarraque's solution in water, one part to four or eigtt, and the washings frequently repeated. Any of the last-named caustics are useful, especially if any of the patches have ulcerated. Otherwise, no treatment is better than dusting the surfaces, after washing and drying, with a powder of equal parts of calomel, oxide of zinc and iodoform (or using dififerent proportions of these ingredients), and keeping contiguous surfaces apart by the interposition of dry lint. Even the vegetations, which spring up around and upon the surfeces of mucous patches, will usually subside under this treatment. If a mucous patch granulates too exuberantly, it should be burned with nitrate of silver or nitric acid. This completes the study of secondary syphilis, with the exception of certain lesions, which are more conveniently considered under sepa- rate heads in connection with tertiary lesions of the same tissues or organs ; as in affections of the eyes, ears, naUs, joints, tendons, testicle (p. 433), nervous affections, certain forms of all of which may be found during the secondary period. CHAPTEE Vn. SYPHILIS OF SKiy AXD MUCOUS MEMBBAXE3. The Tertiary Syphilides. — Concomitant Symptoms on Mncous Membranes. The results of tertiary syphilis, as seen upon the tegiunentary ex- pansions, are most advantageously considered in connection with the lesions of the same structures encountered in secondary syphilis abeady discussed. Tertiary is a far graver form of syphQis than secondary. Its presid- ing genius is destruction, the tendency of its lesions is to softening and ulceration, and the medium through which these changes are effected is a substance known as gummy material, either diffused through the tis- sues, or collected into circumscribed tumors. This gummy material is a specific neoplasm analogous to tubercle, cancer, lupous deposit, etc. It is an hyperplasia of cells, which have not generally the vitality to become organized. They grow at the expense of the tissue in which they are formed, and, after reaching a certain stage of development, undergo a retrograde metamorphosis, and either become absorbed gradually, without solution of continuity of the tissue in which they are deposited, or break down in mass, occasioning abscess or ulceration — ^in either case leaving indelible cicatrices behind. Certain of the new formations due to tertiary syphilis become organized, leading to permanent thickening, sub-perios- teal exostoses, pachymeningitis, chronic laryngeal thickenings, etc. TERTIARY SYPHILITIC CACHEXIA. 591 Tertiary symptoms rarely appear during the first two years after chancre. After that period they may come on at any indefinite time, having been observed as late as fifty-five years. The appearance of ter- tiary phenomena (unlike the secondary) is rarely marked by the occur- rence of any preparatory or accompanying febrile excitement. Cachexia is apt to accompany them, but even this is often lacking, and, except for the visible lesion upon the skin, the patient may consider himself in per- fect health. Tertiary lesions of the skin and mucous membranes are rarely attended by any considerable heat, burning, itching, or pain — in fact, are usually devoid of any sensitiveness whatever. The course of tertiary affections is generally slow, occasionally terribly rapid. Some- times they yield promptly to treatment, sometimes they are particularly rebellious, lasting for years. As a rule, however, skilfully-directed and long-continued treatment masters them, but it cannot restore lost parts, or remove the indelible injuries sometimes left by the ravages of the disease. Tertiary sypMlitiG cachexia requires a word of description. It oc- curs at times independently of any visible or tangible lesion ; or, again, may accompany any of the recognized forms of tertiary disease. It is probably always due to some physical change (amyloid, gummy) in the blood-making organs or the viscera, or to some nerve-change, rather than to any specific poisonous effect of syphilitic virus — since at this, the ter- tiary period of syphilis, the virus has lost its transmissibility, and seems to have worn out its intensity by lapse of time, while none the less the changes it has instituted upon the organism continue in full force. Syphi- litic cachexia is attended by loss of appetite and strength, and by gen- eral anffimia. The sufferer becomes mentally depressed. He looks thin and pinched. The skin is tawny, dry, dirty-looking, without lustre. The hair thins, the epidermis exfoliates excessively, occasioning a more or less general furfuraceous desquamation. The heart and vessels of the neck exhibit the ansemic murmur, the pulse is small and rapid, and some anasarca is apt to be observed. Sleep is disturbed, and mental activity lessened. The patient may be nervous and fretful, or very de- spondent ; occasionally he keeps cheerful. This general condition indicates great depression of the vital force. It sometimes resists treatment effectually, so that none of the so-called specifics are of any avail. It calls for tonics, and change of life and air, and, if not relieved, becomes progressively worse, either carrying off thr patient or favoring his death by some intercurrent malady. The exist ence of syphilitic cachexia with other syphilitic lesions always demands careful hygienic and tonic as well as (or perhaps rather than) specific treatment. 592 SYPHILIS OF SKIN AND MUCOUS MEMBRANES. TERTIAEY SYPHILIDES. The tertiary lesions of the integument are : 1. Ecthyma. 4. Tertiary ulceration. 2. JRupia. 5. Gummy subcutaneous tumor. 3. Pustular syphilide in groups. With these occur on the mucous membranes : 1. Mucous patches. 3. Deep chronic ulcers. 2. Scaly patches. 4. Destructive gummy ulcers. 1. Ecthyma. — ^In tertiary syphilitic ecthyma there is gummy infil- tration of the true skin. After a few days a pustule appears on the top of the solid elevation. This grows rapidly and breaks, or is scratched off. The matter dries up into a dark-brown scab, perhaps containing a shade of green. Underneath this pus forms, increasing the thickness and roughness of the scab, while the solid portion of the lesion increases also in size, and becomes surrounded by a livid areola. The scab grow- ing from beneath may finally become larger than the ulcer, but the livid areola and the interstitial thickening of the skin extend usually beyond it. Often the scab is depressed, let-in, as it were, inlaid into the skin, and firmly adherent to it. If removed, an ulcer, with sharp-cut edges and pultaceous floor, is found, very closely resembling a chancroid. This form of deep ecthyma may occur separately or in groups; in the latter case giving rise to a scabbed patch of irregular form, under which there is ulceration, which may become circumscribed and heal under the crust, or, rarely, advance as a serpiginous ulcer. The favorite seat of this eruption is the lower extremities. It may occur anywhere upon the body. The duration is often many months, by successive crops of ecthymatous pustules. An indelible, often deeply- depressed scar results, which remains of a livid color long after the fall of the scab, and is bronzed more or less in different subjects. Blanching commences centrally, until finally the cicatrix is of a pearly white, per- haps surrounded by a faint ring of pigment, which is slower in disap- pearing. Mixed treatment is the most valuable. 2. RuPiA. — ^The lesion in rupia is a bulla, quickly becoming pustular, the pus usually mixed with blood. It may be a flat pustule. It varies from the size of a pea up to (in bad cases) a penny. It rests usually upon a flat base surrounded by a red areola. The pustule breaks in a few days or dries into a crust, under which ulceration progresses. New supplies of pus are furnished from beneath, while the ulceration pro- gresses slowly at its circumference. Thus the first crust becooies lifted up by the formation of a slightly broader layer of scab beneath, and, this process going on for weeks or months, finally a prominent, rough, oyster-sheU-like scab results, marked by concentric layers, of a blackish- PUSTULAR SYPHILIDES IN GROUPS. 593 brown color often shaded with green. A new bullous ring may form outside the crust, and, in drying, rapidly increase the size of the latter. These scabs may grow to over an inch in height and reach enormous lateral dimensions, especially if the ulcerations under several buUte have become confluent. Pressing upon the crusts will usually cause pus to ooze out from the side. The scabs may remain on until cicatrization has occurred, and then, falling, leave a purple, depressed, slightly irregular spot, which behaves like the spot left by deep ecthyma, finally becom- ing white. On the other hand, the scabs sometimes become detached, leaving an indolent ulcer with sharp-cut borders of chancroid-like aspect, and tending to extend superficially but not in depth. Rupia is found upon all portions of the body, scattered or in groups, and may coexist with other tertiary or late secondary lesions (patches of tubercles, scaly patches). It is believed to indicate a bad general condition. Treatment is mixed, combined with a large share of tonics and hygiene. 3. PtrsTULAE Stphilidb in Geottps. — In this affection a red spot first appears. Upon this a group of small pustules develops. These become confluent and break, their secretion drying up into a thick, greenish crust. Outside of this the purple color forms an areola, as in the other varieties of syphilitic ulcer covered by a scab. The ulcer extends slowly and the scab keeps pace with it or falls oflF in part, show- ing a granular (perhaps fungous), unhealthy ulcer beneath, secreting a sanious, plastic pus, which readily reconcretes into scab. The scab so formed is broken up, granular, cracked, and not prominent as in rupia. New pustules at the circumference slowly tend to increase the size of the patch. After a time it becomes limited, the scab contracts and dries up, the areola becomes more bronzed ; finally the scab falls, leaving the characteristic scar, which whitens very slowly, especially on the lower extremities. Instead of healing under the scab, the ulcer may become serpiginous, extending superficially but not in depth. These patches occur singly or several at a time upon any part of the body, but preferably upon the face, scalp, neck, and breast. Diagnosis. — The pustular syphilide in groups is liable to be con- founded with the pustular scrofulide in groups, both having the same general character. The scab of the latter, however, is black or light colored, not greenish ; the borders of the ulcer are irregular, fringed, undermined ; in the syphilide, smooth, sharp-out, abrupt, adherent. The chancroidal aspect of the base and the coppery areola are only marked in the syphilitic affection. The color of the scrofulide is paler. The cicatrix of the syphilide is smooth, depressed, thin, violet ; at first bronzed, then white ; of the scrofulide, irregular, prominent in parts, perhaps puck- ered, adherent ; violet at first, then pinkish white. Treatment is mixed, with iodide in excess, 38 594 SYPHILIS OP SKIN AXD MUCOUS MEMBRANES. 4. Teetiaet ULCEEATioirs. — The sypbilitic ulcer appears in two varieties : (a.) Superficial ulceration, stationary or serpiginous. (b.) Deep, destructive ulceration. Probably aU ulcers encountered in syphilis, even in the very super- ficial forms seen in secondary syphilis, are due to the softening of the so-called gummy exudation, since this exudation is nothing more than aborted connective tissue — connective tissue gone astray under the influence of the syphilitic poison. In fact, aU the lesions of syphilis, external or internal (except the purely congestive), are dependent upon this cell hyperplasia ; but the longer after chancre it occurs, the more prone it is to collect in considerable masses, to form rapidly, and to soften and disintegrate promptly, thus breaking down into ulceration and sweeping away any tissues in which it may happen to have been depos- ited. This considerable collection of newrformed, lowly-vitalized ceU- hyperplasia, infiltrated through the structures of the true skin or in- volving the subcutaneous tissues as well, is always the precursor of syphilitic tertiary ulceration, {a.) Superficial Ulceration, stationary or serpigioioiis. — This form of ulcer may commence as rupia, ecthyma, or a crop of pustules, the ulceration, naturally occurring under the scabs of these lesions, in- stead of healing slowly, either shedding the crust and remaining indo- lent and superficial, or progressing in a serpiginous manner. Often, however, the precursory lesion is the tubercle ; a group of which, hard, shining, livid, indolent, varying in size from a small pea to a small nut, after remaining a while stationary, soften, inflame, and ulcerate. This ulceration has the syphilitic characters — sharp-cut, prominent, hard, adherent borders, a smooth, indolent, false-membranous bottom. There is habitually no pain. An ulcer so instituted may remain long stationary, but usually gradually becomes serpiginous, i. e., creeps over the surface. The advance may be centrifugal in all directions, or along a narrow track in curves, inclosing healthy portions of skin ; or, what is most common, advance may take place in one direction, while the oppo- site edge of the ulcer is cicatrizing. Unless kept off by dressings, such ulcers are constantly more or less entirely covered up by thick, uneven, greenish scabs. The procsss of repair announces itself by a limitation of the ulcer, a flattening of its sharp borders ; the base becomes red and granular, ap- proaching the appearance of a healthy ulcer, and cicatrization goes on, the scar passing through the usual transformations of the syphilitic cica- trix. This scar may be somewhat uneven, owing to the different depths to which the ulcer has penetrated at different points. Several patches of superficial ulceration not infrequently coexist upon the same individ- ual, usually in different stages, whUe cicatrices — some white, some bronzed some purple, — show that the disease is already of long standing. DEEP ULCEKATIVE SYPHILIDE. 595 Treatment is very effective, usually, in this form of ulcer, which is not necessarily attended by any marked cachexia. Untreated, successive outbreaks prolong it for years. Relapse is liable to follow a treatment too soon interrupted. The favorite seat of serpiginous syphilitic ulcers is around the joints, on the back, and on the face. Diagnosis. — Occasionally the serpiginous ulcer is mistaken for old phagedenic chancroid. The distinction is made by a study of the history, the position of the lesion, and, above all, the effect of inoculation ; finally, by treatment.' Treatment is mixed, with the iodide of potassium in excess, or, if destruction of tissue is rapid, iodide of potassium alone, in rapidly-in- creasing doses until progress is stayed, and then by diminishing the dose and adding mercury gradually, as in the mixed treatment. Locally, after poulticing, iodoform and mercurial preparations yield beneficial results. (5.) Deep, Destructive Ulcer. — This is a gummy infiltration of the skin appearing in the tubercular form. It occurs by preference upon the nose, the ear, the lip, and the head of the penis. The tubercle is often quite small, and ulcerates so quickly that the ulcers seem the pri- mary lesion; in other cases the tubercles remain some time before softening. A thick, black, rough, greenish crust forms over the ulcer, which continues its ravages beneath, progressing inward, destroying every thing in its track, including cartilage and bone. If the crust be removed, an uneven ulcer is revealed, resembling the deeply destructive, phagedenic chancroid in all its features. Exposure to the air causes the crust to reform. During the whole course of this affection there may be no constitutional disturbance whatever, no cachexia, and locally no appreciable amount of pain or discomfort. This form of ulcer may last for years, with periods of repose and paroxysms of progress. It is not usually so amenable to treatment as the serpiginous ulcer. The whole nose, ear, lip, or large portions of the penis, may be eaten away by it. Its cicatrix behaves like other syphilitic scars, except that it is uneven, from the different depths to which ulceration has progressed, and may be bridged or bridled. Diagnosis. — The diagnosis is with lupus exedens, true cancer, chancroid ; the former for the nose, lip, or ear ; the two latter for the rest of the body, especially the penis. Lupus occurs usually in the youngj gummy ulceration in the old ; lupus has a less livid border, a pure black or light-brown scab. The history throws much light on the subject, and above all things concomitant lesions, exostoses, optic neu- ritis with mydriasis, gummy ulceration of the palate or pharynx. Fi- nally, the effect of treatment is to be invoked. This form of disease, occurring with inherited syphilis, is almost invariably mistaken for lupus exedens, and treated as such, ' This question of the diagnosis of these two forms of ulcer is continually arising in practice. The points have been critically studied on page 486. 596 SYPHILIS OF SKIN AND MUCOUS MEMBEANES. Epithelioma commences as a tubercle or a wart, which remains a long time before beginning to ulcerate ; the borders of the ulcer are everted, knobbed, irregular ; the floor is more uneven, the fetor greater, and the neighboring glands become involved, which very rarely occurs for the other ulcers under consideration. Especially on the glans penis is tertiary, destructive ulceration liable to be mistaken for phagedenic chancroid, and ineffectively treated. There is absolutely no feature among the physical characters of the two ulcers which distinguishes them. Chancroid commences by a pustule, syphilitic ulceration does not ; but this can rarely be verified. There is perhaps something distinguishing in the appearance of the ulcers, which appeals to the practised eye, but it cannot be described in writing. In- oculation is an infallible test, the history of the case is of vast impor- tance, the effect of treatment often absolutely diagnostic {see Case XLVin.). Cauterization is rarely more than temporarily beneficial. Treatment is that of late syphilis. Local applications are not very serviceable. 5. GumiT TuMOB of the Subcutaneous Tissue. — Gummy tumor may develop wherever connective tissue is found, consequently it abounds in and under the skin. In the thickness of the latter it forms a tubercle, under the skin a tumor. In rare instances, gummy deposit in the sub- cutaneous tissue occurs as an infiltration instead of in its usual circum- scribed form. The skin becomes raised, thickened, reddened ; there are little prominences upon it which ulcerate, and then comport themselves like the syphilitic ulcer. Lancereaux ' has weU described this infiltration, and refers to Vidal de Cassis. Gummy tumors appear first as little hard subcutaneous lumps, freely movable over the subjacent tissues, the integument slightly movable over them. They are not sensitive to pressure. As the tumors slowly increase in size (they sometimes remain stationary for months), the skin over them becomes involved, and the tumors attached to the underlying tissues so that they cease to be movable. Now a purplish discoloration of the skin commences ; the tumor, previously hard and painless becomes somewhat sensitive, and softens centrally, the skin breaks down, and a thick, puriform material, not pus, often mixed with blood, is discharged. After discharging, the lesion remains as a characteristic, deep, indolent, syphilitic ulcer, whose edges at first are undermined, remaining station- ary or progressing, and in some cases strongly resembling cancerous ulcers, or, finally, tending to scab over and healing with the characteris- tic scar. Gummy tumor often forms under the periosteum of superficial bones (clavicle, skull, tibia, ulna), grows quickly, and may ulcerate, and behave like the corresponding lesion, subcutaneously situated, the differences being : that it is deeply attached firom the first ; that bone may be felt ' Op. cU. LESIONS OF MUCOUS MEMBKANES IN LATE SYPHILIS. 597 through the ulcer, and that a superficial scale of bone may become necrosed, thus complicating and prolonging the case (carious ulcer). Subcutaneous or sub-periosteal gummy tumor, instead of coming quickly to the surface, may diffuse itself laterally after softening, and occasion- ally burrow a short distance before opening. Subcutaneous gummy tumor may be single or multiple. The most frequent seat is on the buttocks, neck, head, and extremities. They rarely reach a size larger than a nut, but may become as large as, or larger than, an egg, after softening. Their structure, here as elsewhere, is small rounded cells, more or less gelatinous ; granular, intercellular tissue, with a few fibres, fusiform ceEs, and small vessels. The constant ten- dency everywhere is to undergo retrograde metamorphosis, either lique- fying and ulcerating out, or becoming cheesy and going through absorp- tion with or without cretification. Treatment is that of late syphilis, by the iodide of potassium. AFFECTIONS OF MTTCOtTS mBEEBRANES ENCOTTNTBRED WITH TERTIART STPHXLIDES. These are four : 1. Mucous patches. 3. Deep chronic ulceration. 2. Scaly patches. 4. Destructive gummy ulceration. The first three of these conditions have been already described (p. 585). It is only necessary to add further that mucous patches be- come less frequent, and scaly patches (sometimes called " milk-spots ") more common as the distance in time from chancre is increased. The chronic ulcers of the fauces or mucous membrane of the cheeks at or near the angle of the lips, surrounded by more or less brawny infiltra- tion of the neighboring tissues (already described), are found in tertiary as well as in late secondary syphUis. They are similar to some of the serpiginous or stationary chronic cutaneous ulcers, and undoubtedly often depend upon a moderate amount of gummy infiltration of the tissues. A favorite seat for these late gummy ulcers is the posterior wall of the pharynx, high up, often extending into the posterior nares, and encroaching on the upper surface of the soft palate, which is not necessarily involved. To see them it is often necessary to lift up the soft palate with a suitable curved probe, while the mouth is widely opened, or even to use an inverted laryngoscopic mirror. These ulcers have raised borders, are covered by a tough, whitish secretion, are often raw-looking in parts. They are encountered also on the mucous mem- brane of the nose, causing a slight catarrhal flow, and accompanied by the occasional discharge of bloody scabs from the nose, or " hawked up " in the morning while clearing the throat. When the ulcers are extensive (serpiginous), they indicate long-standing, inveterate disease. Their presence may occasion pain in swallowing, and perhaps in breath- ing. 598 SYPHILIS OF SKIN AND MUCOUS MEMBRANES. Treatment. — Any of the local means detailed at page 588 may be resorted to with advantage, except the caustic preparations last men- tioned, which should not be applied over a large surface. Great clean- liness, constant gargling with chlorate of potash, tannin and glycerine used with a brush, and sulphurous acid in spray, leave little to be desired in the way of local applications. The mixed internal treatment, with a preponderance of the iodide of potassium, is slowly but surely curative. Local measures are of secondary importance. Where the nose is in- volved, it is difficult to maintain cleanliness without the use of the nasal douche. In applying the douche it is essentially necessary to send the stream up through the nostrU which is most obstructed, so that the iluid may readily return through the more open nostril. If this pre- caution be neglected, and the fluid flows up more readily than it can escape, there is danger of some of it being forced into the Eustachian tube, and lighting up inflammation of the middle ear. The posterior nasal syringe and retro-pharyngeal syringe complement the douche. By these two means the cavity of the nose may be thoroughly cleansed with warm water, and subsequently medicated with mUd solutions of borax, chlorate of potash, permanganate of potash (gr. j— | iv), or a strong solution of common salt. 4. Destetjcttve GirMirr ULCEEATiOJr. — This form of ulcer is one of the most serious encountered in syphilis. It may develop as a gummy nodule or as diffuse infiltration of the sub-mucous tissue, or be pri- marily sub-periosteal on the wall of the pharynx, or in the nasal cavity, or on the hard palate. It develops first as one or more deep, rovmd, hard, insensitive swellings, possibly a diffuse infiltration. The mucous membrane may be unchanged in color at first or slightly yellowish, if the tumors are superficial. As the latter grow, the membrane over them darkens in color, becomes cedematous, then softens and rapidly gives way, leaving a deep, irreg-ular yellow ulcer, with distinct loss of substance, surrounded by a line of inflammatory redness. Such ulcers often spread with alarming rapidity, perforating the soft palate or cutting off the uvula within a few days, even hours. The explosion may take place as if by electricity, and twenty-four hours deprive a patient of his soft palate. Deglutition is sometimes painful, sometimes painless, according to whether or not the vilcer is put upon the stretch in swallowing. Any subjacent bone becomes rapidly eroded and necrosed, so that the progress of the ulcer may destroy all the soft and portions of the hard palate, more or less of the turbinated and ethmoid bones, with the vomer and portions of the posterior bony wall of the pharynx, leaving a vast iilcerated cavity to represent what was the fauces and pharynx. The disease may extend inward occasionally and affect the membranes at the base of the brain, giving rise to epilepsy or other nervous phenomena. The voice becomes nasal, food and drink pass forward and out of the nose in swallowing, and yet with DESTRUCTIVE GUMMY ULCERATION. 599 all this the patient may be cheerful and suffer little, often absolutely no pain. The secretion of these ulcers is very foul and has a peculiar odor, in itself suggestive if not pathognomonic. Portions of bone die and are discharged from time to time, or may become encased in new bone during the process of repair. The dead bone, thus remaining encased, acts as a local irritant, and keeps up ulceration and suppuration perhaps long after treatment has removed all progressive disease. When taken early these ulcerations yield readily to energetic treat- ment, later they may prove very rebellious. But Nature accomplishes wonders when repair does take place. Cicatrization binds down any portions of the soft palate which may have escaped destruction, and leaves a characteristic seamed and distorted condition of the pharynx, perhaps entailing a permanent alteration in the voice, sometimes ren- dering the deglutition of fluids difficult, and perhaps only leaving a small opening to mark the site of the uvula. Such a condition of throat is always the result of syphilis, never of scrofula, or so rarely that prac- tically the word " never " is allowable. It has been written that scrofula may cause these throat-ravages in children, because children are found on whom a syphilitic history or parentage cannot be traced, who have ulcers and other evidences of so-called scrofula and destructive ulcera- tion of the soft palate, perhaps not so promptly relievable by the iodide of potassium as similar fresh conditions in the adult. Yet the iodide of potassium is usually given for these cases and with benefit. The following is a good illustrative case : Case LI — A girl, aged sixteen, had, in childhood, ulceration of the throat, which had cicatrized, leavmg the soft palate bound to the pharynx and a permanent cicatricial slit in place of a uvula. She was an orphan, never had had an eruption that she remem- bered, had perfect incisor teeth, had had no interstitial or other keratitis. A chronic destructive disease involved the end of her nose, including both nostrils and part of the upper lip. She had been treated for a long time as a case of lupus, and had derived no benefit therefrom. The destructive ulcer at the end of the nose (although the scab was distinctly of a greenish black, very thick, rough, and adherent), had been burned twice with the red-hot iron without benefit. A few weeks of large doses of iodide of potassium brought about cicatrization. Treatment. — It is rare in the practice of medicine that the surgeon has an opportunity to do good so certainly and so promptly as in com- mencing destructive gummj"- ulceration of the fauces. It is useless and unnecessary to trifle with local measures : only one thing is neces- sary, and that is the iodide of potassium in sufficiently large doses. It should be commenced not at five but at gr. x-xv doses, and run up from there, watching the stomach, until the local lesion yields and the ulcer puts on a bright color. The stomach must be respected, by sub- stituting the iodide of sodium, if necessary, for the more irritating salt, possibly giving it by the rectum. Where the lesion is already old and extensive destructions exist which are still progressing, the same 600 STPHILIS OF THE EYE. treatment is applicable, carried liigli enough to control advance of the ulceration, but not pushed so rapidly. There is no limit to the dose except the production of its effect. A patient at the Charity Hospital, with old disease which had destroyed both hard and soft palate, with most of the bones of the nose, had to be carried up to | ij daily before the desired effect was reached. In all old cases not rapidly advancing, especially where the nasal cavity is involved, advantage is derived from the local treatment, as suggested, at page 588. When the ulcera- tion has been arrested and cicatrization is nearly perfect, discharge, odor, scabs from the nose, are sometimes kept up by a piece of necrosed bone, surrounded by a partial involucrum. No amount of continuation of treatment is of service in such a case. The dead bone can usually be felt with a probe. An operation for its removal, if feasible, wiU be fol- lowed by a cessation of the symptoms. The numerous other manifestations of tertiary syphilis wiU be con- sidered in connection with the secondary forms of disease under sections devoted to the different organs and tissues of the body, as the eye, tes- ticle (p. 432), larynx. CHAPTEE Vm. SYPHILIS OF TEE EYE} The Eyelids. — Chancre, ilncons Patches, GTmimy Tumora, Ptosis. — ^The Conjunctiva. — ^The Cornea. — The Iris. — Mydriasis, Iritis, Varieties and Complications, acquired and hereditary. — Pro°^osis. — Treat- ment. — ^Vitreous Humor, Hyahtis. — Crystalline Lens, Cataract. — Gyditis. — Choroiditis, exudatiye and atrophic. — Ketinitis. — Js'euritis Optica. — ^Paralysis of Muscles. — Periostitis. At.t, the tissues of the eye and its surrounding parts may be affected by syphilis. The influence is either direct or indirect, and the disorders thus induced are usually grave, are sometimes tedious, and are prone to do damage to vision. They can rarely with safety be left to take their own course, and in a satisfactory degree they yield to suitable and early treatment. The imprint of syphUis on the eye may be made during any period of its career. Even chancre has been found upon the superficial parts, while, during the secondary and later stages, a variety of lesions may appear. Hereditary syphnitic taint finds expression in disease of the eye as a frequent occurrence. To give due attention to the various lesions which may occur, I adopt the anatomical order from without inward, both for simplicity and com- pleteness. ' Chapter Till. 13 written by Prof. Henry D. Noyes, M. D., at the request of the authors, who fully indorse the opinions therein expressed. It appears in the first person, as conveying the personal experience and convictions of the writer. THE EYELIDS. QQl The parts wliich we begin upon -will be the Eyelids. Here primary cJiancre has been noticed both in adults and in chil- dren. The sore presents the same appearance as when situated on the genitals, and does not require any special remark as to treatment. If the sore be on the cutaneous surface, it does not greatly endanger the eye ; but, if on the mucous surface, or, as has been seen, on the caruncle, it becomes a serious thing. The accident is, however, so rare that it does not seem worth while to enlarge on the subject. Mucous patches occur both on the cutaneous and conjunctival sur. faces of the lids. I have seen them as large as a three-cent piece, but have not seen any more serious result come from them than a slight catarrhal conjunctivitis. Weak astringent washes, as of alum or sul- phate of zinc, or touching them with a solution of nitrate of silver, gr. v vel X aquse ad | j, is all the needful local treatment. Various forms of secondary cutaneous eruptions may appear on the skin of the eyelids, as upon other parts of the surface, and the eye- lashes and brows are liable to be lost when the hair of the scalp is being shed, but these are incidents which only call for passing mention. Somewhat more important is the fact that gummata develop in the eyelids and adjacent parts. They may grow to be as large as a hazel- nut. In one instance, under my notice, such a tumor appeared in the skin over the lachrymal sac, and, months after the first tumor had dis- appeared, another occurred upon the border of the lower hd. These developments belong to the late stages of syphilis, the tertiary pe- riod ; in the instance above alluded to, several 3'ears had elapsed since the first infection. A mistake is not unlikely to be made in diagnosis of these cases, because cystic tumors, and less frequently fibrous tumors, are of common occurrence in the lids. They, like gummata, usually grow slowly and painlessly. But it is not always true that gummata grow slowly; they may attain considerable size in two weeks. The skin is sometimes thickened, and raised above the surrounding level. The most important local guide in diagnosis is that the swelling involves all the tissues where it is located, and, as it were, incorporates them all into itself. This, in connection with its indolent, painless character, the possible discoloration of the skin, and the constitutional symptoms and history, will guard one against the error of attempting to apply the knife or other instruments to the removal of these tumors. Like other gummata, they melt away under a suitable course of consti- tutional treatment. Drooping of the upper lid (ptosis) is caused by affection of the third nerve, and wiU be alluded to when speaking of paralysis of the motor nerves of the eyeball. CoNJUU-cnvA. — The kinds of inflammation which syphilis may cause In this membrane (meaning the ocular conjunctiva) are : First, sores 602 SYPHILIS OF THE EYE. from primary infection ; second, mucous patches ; and, third, gummy growths. The last belongs quite as much to the sub-conjunotival con- nective tissue as to the mucous membrane. All of the above lesions are rare. The most frequent is an ulceration which I have seen coexisting with mucous patches in the mouth. The common site is near the margin of the cornea, wnere a reddened and elevated spot appears, resembling a severe phlyctenula. It rises higher and is m^ore exten- sive than such eruptions usually are, and it soon presents ulceration. The surface not only becomes excavated, but shows a jelly-like, semi- transparent tissue upon the eroded part — and this may spread to the cornea. The ragged, angry, irritated look of such an elevated ulcer, with the broad thickening of the base, and the large vessels running into it, its encroachment on the cornea, its slow recovery, the pain, lach- rymation, and photophobia which attend it, mark the case as dependent on a constitutional vice. The search for corroborative symptoms of syphilis will usually be rewarded by success. I have seen this lesion oftener in women than in men. The local remedies are : bathing the eye with lukewarm water for short periods, say fifteen minutes four or six times daily ; the use of solution of sulphate of atropia, gr. ij ad | j, dropped into the eye three to six times daily ; pro- tection against strong light by a shade or blue glasses, and the avoid- ance of remedies of an irritating quality. Besides these local means, the constitutional treatment should not be omitted; the only caution to be observed, being to have regard to the state of the general health, and if needful to exhibit tonics as preliminary to, or in connection with, the specific remedies. This caution is not unimportant, because very many of these patients will be found to be in a feeble or cachectic condition, and their diet must often be as carefully directed as their medication. THE CORNEA. In the preceding paragraph the occurrence of the ulceration of the cor- nea in mucous patches of the conjunctiva has been alluded to, and needs no further mention. I have not seen these ulcers go on to perforation. Inflammation of the cornea, as the effect of hereditary syphilis, is a very common disease among children. It usually appears between six months and two years of age, while it may remain latent until the fifth year, or be seen as late as the fifteenth year. It is commonly preceded by cutaneous eruptions, especially about the buttocks, and by glandular swellings. Often the children have coryza, with swollen lips, flattened nasal bones, and badly-formed or perishable teeth. Mr. Hutchinson first called attention to the importance of the teeth as a diagnostic mark ; that the incisors are notched or pointed, or very small, or crooked, or decayed. The canines as well as incisors may be abnormal. The general health is bad, and the whole nutrition perverted. The disease is not violent in its onset. A slight congestion appears THE COKNEA. g03 about the cornea, a little opacity upon its surface. There are moderate photophobia and pain, often no laohrymation. When the disease has deeply involved the corneal structure, the subjective symptoms become intense, and are often most distressing. The alterations of tissue consist usually in opacity and vasculariza- tion. It is rare that iiloeration, except of the minute superficial kind, or suppuration, occurs. The opacity, which at the beginning is faint, soon spreads over the whole surface, and into the depth of the cornea, and becomes more intense. It even affects the posterior epithelial surface, and, because of its extent, is commonly called keratitis diffusa. Of course sight is at once injured, and may be reduced to mere perception of light. The disease may penetrate deeper into the eye, and involve both the iris and choroid. I have under observation a boy, now fourteen years old, who exhibits the effects of inflammation both of cornea and iris and ciliary body — the cornea mottled with diffused and spotted opacities, the pupU closed and adherent to the lens, the tissue of the iris atro- phied so as to be translucent in many places, and the periphery of the iris drawn backward by contraction of exudation and its adherence to the ciliary processes. The duration of these cases, under skillful treatment, is from one to three months when taken at an early period. But the continuance may be much longer if the disease have taken a severe hold before suitable treatment is undertaken. The prognosis as to vision will vary with the severity of the attack, but in general it may be considered favorable. The same disease may occur among adults, but is less frequent, and re- quires no special description. The method of treatment must first have respect to the constitu- tional trouble. By this I mean rigorous attention to food, exercise, and bathing, as well as administration of mercurials. Food in easily-diges- tible form must be given in quantity and frequency which the stomach will permit ; milk, beef-tea, chopped beef or mutton, either roasted or broiled, bread, and eggs, are to be the chief reliance, while sweets and fibrous vegetables are to be excluded. The child should be taken out- of-doors daily, with proper protection from the light by a veil, and a tepid bath should be given every other day. With these hygienic measures the tonic and specific treatment must be combined. It is often advisable to give cod-liver oil, sometimes quinine, or the syrup of the iodide of iron ; while the readiest method of introducing mercury is by putting the blue ointment upon a flannel bandage which shall be swathed around the abdomen. The ointment must be renewed night and morning, and the skin carefully sponged with warm water to pre- vent it from becoming irritable. By this management no unpleasant effects take place and the influence of the remedy is seen in the gradual improvement of the health and appetite. The treatment of the eye 604 SYPHILIS OF THE EYE. consists in fomentation, by compresses wrung out of hot water, for a period of one hour or .two hours at a time, three times daily. The com- presses must be changed as fast as they become cool, and the water must be kept as hot as the hand can bear. This treatment is laborious, but is unequaled in efficacy; sometimes poultices may be more con- veniently used. A solution of sulphate of atropia, gr. ij ad | j, should be dropped into the eye three or six times daily. As the photophobia and acute symptoms abate, the period of fomen- tation may be shortened, until with increasing amendment it may be stopped. It is well to keep up the atropia, so long as any hypersemia remains. Inunction should be persisted in for about two months, unless contraindications forbid. If the skin become fretted, some other part of the body may be chosen for the ointment, or hydrargyrum cum cretd in doses of five grains, administered three times daily. Usually the chief specific remedy demanded is some form of mercury, but in older subjects the iodide may also be required. The extreme importance of using specific remedies in these cases, as well as of guarding them as above indicated, cannot be too strongly insisted upon. THE IBIS. There are two affections of the iris which result from syphilis — paralysis of the sphincter of the pupil, causing mydriasis, and inflam- mation. It is not necessary to say much upon mydriasis. It occurs under two conditions. In one case it is associated with evident paralysis, of one or more of the other twigs of the third pair of nerves. So that, besides dilatation of the pupU, there may be ptosis or divergent strabis- mus, or diplopia. Another case in which mydriasis appears does not present any sign of lesion of the third nerve, so far as other twigs are concerned, but appears to be associated with obscure changes in the brain, or at the base of the skull, which may not at the time declare themselves by noticeable symptoms. Nothing definite can be predicated upon this fact, but it serves to awaken expectation of some disaster which may hereafter arise. It is also true that mydriasis is caused by irritation in the upper part of the spinal cord, or of the cervical sympathetic, and by causes whoUy removed from syphilis. It is a common observation among the insane, and among those called merely nervous. Furthermore, it must be stated that monocular mydriasis, without impairment of any of the other branches of the motor oculi, results from severe use of the eyes, and is attended by paralysis of the accommoda- tion. This happens among miniature-painters, engravers, and such classes of workers. WhUe saying thus much, to guard against error, it must be added that monocular mydriasis occurs from syphilis, unconnected with eithei IRITIS. 605 diplopia or ptosis, (For detail of such a case, see a paper by M6rio, in the British Medical Journal for January 8, 1872, -p. 39, and in the same paper are cases recorded in which mydriasis was combined with ptosis, all other branches of the third nerve remaining intact.) As to the constitutional treatment of syphilitic mydriasis, nothing special need be said. For local treatment the contraction of the pupil may always be temporarily secured by putting between the lids a disk of gelatine charged with the extract of calabar bean. But the remedy has only a temporary effect, and cannot easily be graduated to answer a useful purpose. The faradio current is sometimes used, and Duchenne says he has had success by putting one pole on the sclera and another on the temple, but this treatment is not to be commended. Ieixis. — The most frequent affection of the iris which syphilis pro- duces is inflammation. It has been calculated that about fifty per cent, of all cases of iritis are due to syphilis. The attack may occur within a few weeks or months after primary affection, or it may come among the later phenomena of the secondary stage. Although the contrary has been maintained, there are no marks in the iris by which the syphilitic origin of an inflammatory attack can be asserted. In other words, syphilitic iritis has the same symptoms as other forms of the disease. The tendencies of syphilitic iritis are especially to the formation of plastic exudation, and, when this reaches the exuberance of gummy nodules, it is very rare that such a case is not caused by syphilis. On the other hand, iritis syphilitica may exhibit only serous effusion. The most frequent cases are those in which a moderate quantity of plastic matter is thrown out upon the pupUlary border, and causes adhesions between it and the crystalline lens. A brief enumeration of the symptoms of iritis is as follows : The pupil refuses to expand when the light is obscured, and is apt to be of small size ; the iris-tissue is altered in color, and likewise indistinct in texture ; the color of the pupil is smoky, and not jet black ; perhaps the pupil is irregular, and at its margin may be seen black specks of exuda- tion ; the effect of a drop of a solution of atropia is either not to cause any expansion of the pupil, or to give it an irregular form, the margin being festooned ; there is hyperasmia of the sclera and conjunctiva, in the immediate neighborhood of the cornea, whose depth and extent will vary with the severity of the attack ; there may be chemosis ; there is lachrymation ; the lids do not open fully, and may be a little swollen ; light is offensive; pain is seated in the eye, but more often upon the forehead and temple, or at the vertex and occiput, tracing the course of the supra-orbital branch of the fifth nerve; vision is always impaired, and sometimes is reduced to perception of light. In serous iritis, the aqueous humor will be very dim, and so abundant as to make the anterior chamber unusually deep by pushing back the 606 SYPHILIS OF THE EYE. iris and lens. There are cases in which the whole anterior chamber is occupied by a semi-gelatinous substance, as if a thin and not well-clari- fied jelly had coagulated there. This mass sometimes presents such a similarity to a dislocated crystalline lens as to have been mistaken for it. It consists of exudation of a plastic quality diffused through the aqueous fluid. Its appearance when undergoing absorption is striking, because the lower part of the chamber wiU be murky and clouded, while the upper part will be comparatively clear and display the iris and some of the pupil. In other cases plastic material exudes in nodules upon the free sur- face of the iris, presenting masses like mustard-seeds, or larger bodies, located upon any part of the membrane, but more commonly around the pupil. Sometimes this substance is so abundant as to be precipitated to the bottom of the anterior chamber as hypopyum. These masses are sometimes vascular, and their color is always a reddish yellow. They are correctly called gummata, and have been extracted and found to pre- sent under the microscope the features of true gummy exudation. This material, it must be understood, infiltrates the whole thickness of the iris, and its adhesion to the lens is consequently dense. The reason for impairment or loss of sight is found in the turbidity of the aqueous humor, in deposits upon and proliferation of the epithe- lium of the posterior face of the cornea, and in the obstruction of the pupil. The reason why the pupil in the beginning of iritis is always small is, that the hyperaemia and swelling of the tissue compel the iris to push inward in the only direction in which it can find space. So far from the narrow pupil being due to contraction of the sphincter pupillse, the muscular fibres are reluctant to act because of the sodden condition of the tissue. Inasmuch as a large part of the iris lies in contact nor- mally with the crystalline lens, adhesion between the two surfaces is inevitable, and this is true even when the pupil is well dilated by atropia, as is illustrated in cases of serous iritis. A true picture of iritis cannot be presented without bringing into view complications which often accompany it. The minute opacities above alluded to, which are often found on the inner surface of the cornea, especially on its lower half, are in part pre- cipitations, but also result from participation of the epithelium of the membrane of Descemet in the inflammatory process. The ciliary body and choroid are still more frequently afi"ected. The evidence of the fact is not easy to obtain in the early stages of the inflammation, but all obstinate and persistent cases of iritis pass over into irido-choroiditis. Especially is this true when the plastic exudation is copious, or when the pupil has not been dilated. In old cases the iris sometimes gets a greenish tint or a chocolate brown, its fibres look atrophied, none of the normal tracery can be made out, but a blur over- spreads the surface, and haemorrhages are apt to occur. The vitreous COMPLICATIONS OF IKITIS. 607 humor is hazy — the retina suffers, and often the eyeball becomes soft to the touch, or even reduced perceptibly in size. Vision in these com- plicated cases is extremely bad. The sclerotic hypersemia may not be great, but is persistent, and the globe is both painful and acutely sensi- tive to pressure. Photophobia is often extreme. If complete posterior synechia be the result of iritis, it happens in course of time that an accu- mulation of fluid takes place between the iris and the suspensory liga- ment of the lens, which pushes the periphery of the iris forward and gives it the shape of a ring-cushion. As a result of this condition, the globe in time becomes hard, and secondary glaucoma with excavation of the optic nerve sets in. In such old cases the iris-tissue may have atro- phied so much as to be semi-transparent, while its fibres show like the warp of muslin before the cross-threads are woven in. In other badly-resulting cases, the iris is stuck fast to the lens-cap- sule so completely as to exhibit the convex outline of the lens and to present at its periphery an evident furrow. The attempt to take out a piece of iris in these cases often results in getting away only the front layer of the membrane, while its posterior, deeply-pigmented layer, sometimes erroneously called the uvea, remains adherent to the lens, and frustrates the operation. The formation of a tough fibrous membrane across the pupil, and thickening of the anterior capsule of the lens, are consequences to be naturally looked for in badly-treated or severe cases ; while, as a result of irido-choroiditis, cataract not seldom arises. Iritis may attack both eyes, either in succession or simultaneously, yet is frequently confined to one eye. The description above given applies to acquired syphilis, in its various stages, but iritis occurs as the effect of hereditary syphilitic taint. It indeed may occur in utero, as is shown in clearly-developed symptoms of irido-choroiditis in new-born infants — the pupil com- pletely shut by false membrane, the eyeball reduced in size, the color and texture of the iris abnormal. Hereditary syphilitic iritis usually develops in the early months or years of infancy. I am treating a chUd one year old, in whom, after the disappearance of an attack of keratitis, which was recognized as due to syphilitic taint, iritis began It was not attended by great external hypersemia nor pain, there was very little lachrymation, no swelling of the lids, and moderate photo- phobia ; but the iris was almost concealed from view by a patch of yeUowish-white lymph, which occupied all the anterior chamber, except at the upper outer third. The aqueous humor was so turbid, and the iris so discolored, as to look nearly black. The globe was hard, and the appearance of this patch at first suggested a chronic choroido-iritis, instead of an acute attack. This in reality is a sample of gummy exu- dation, precisely like this form of iritis in adults. 608 SYPHILIS OF THE EYE. Such cases are uncommon, but have been noted by writers. They yield to suitable treatment, but great injury to sight usually remains. The prognosis in iritis depends on the amount of lesion which has been inflicted at the time when treatment is begun. Firm and extensive attachments to the lens, and impUcation of the choroid, prolong the disease, and do more or less injury to sight. Success in dilating the pupil is speedily followed by abatement of symptoms. A very large proportion of cases of iritis, under early and judicious treatment, make a recovery in all respects perfect. Treatment. — This is naturally divided into local and constitutional, and the former is by far the more important. The first and indispen- sable object of local treatment is to secure full dilatation of the pupU : measures to control hyperjemia are next in order ; and, finally, remedies to relieve pain. Under the first head the only effective substance is sulphate of atropia. It has entirely put aside the extract of belladonna, and in only a few exceptional cases does it produce conjunctival irritation, and must be substituted by the alkaloid of stramonium, viz., daturine. The strength of the solution of sulphate of atropia usually prescribed is gr. ij ad | j. It should be ordered in such frequent repetitions as the obstinacy of the adhesions shall compel. Sometimes the instillation of three drops, three times daily, wUl tear some or all of the adhesions ; frequently the same quantity must be repeated six times daily. In obstinate cases the solution may be ordered four times within an hoiir, three times daily, making twelve applications. When the pupil fails to yield to such solicitations, the effect of atropia will often be en- hanced by leeches to the temple, say three to six at a time. When the pupil begins to dOate, the inflammatory symptoms usually decline ; especially is this true of pain. The energy with which atropia is employed is the peculiarity of the modern treatment of iritis, and is the chief ground of success. A word of caution must be interposed as to the liability of bringing on symptoms of poisoning. This effect is not very rare. The patient finds bis fauces extremely dry, and, on inspection, their surface will be found congested and a little cedematous, the pulse is quickened, a mild delirium appears, and, in advanced toxic conditions, violent delirium and dangerous prostration will ensue. AH this results from absorption of the atropia into the general circulation. Some persons experience unpleasant effects of this kind very easily. If the pupU do not expand, even if aided by the application of leeches, I have sometimes resorted to the expedient of procuring a rapid but mild salivation by mercurial remedies, and found that, when the gums were touched, the pupil either yielded to the mydriatic, or the inflammation began to subside without expansion of the pupU. If it should not be deemed wise to employ this treatment, because of the feeble state of the patient's health, the operation of iridectomy is some- TREATMENT OF IRITIS. 609 times advisable. It is not fitted to tiie early states, but rather to the later period of a tedious inflammation. The removal of hyperasmia often ensues when full mydriasis is ob- tained ; but, if this be not so, leeches may be apphed to the temple near the hair ; three to six may be used, and may in some cases need repeti- tion. Care should be observed not to be too free in depleting weakly subjects, and leeches must be regarded as having only a subordinate value. A mild pugative is often needful. Belief of pain is an important item in treatment. Hypodermic injec- tion of morphia may be needed to procure sleep, because it is at night that pain in the eye and head is most troublesome. Moderate degrees of pain are relieved by instructing the patient to rub the forehead with a mixture of extract of belladonna and powdered opium and mercurial ointment. A more efficient topical anodyne is the oleate of morphia (Squibb's), applied with a pencil and allowed to dry into the skin of the forehead and temple. The tincture of iodine applied with a brush is sometimes effectual. So, too, it is often a comfort to heat a folded nap- kin and press it against the forehead. Wet compresses, if of any use, should at the onset be cold, and in the latter stages be lukewarm. In a case of protracted iritis, the prolonged use of -slippery-elm poultices is of the utmost benefit. They may be applied for two hours at a time, three times a day if necessary. The eye must be guarded against ex- cessive light by blue or smoked glasses, although rigorous confinement to a dark room is not good practice, because of its weakening influence on the health. It will be found that feeble and cachectic subjects are more difficult to cure than the robust. If only one eye is involved, the patient should not use the other in any fine work. Exposures to the wind, and smoking, are to be avoided, and no attempt made to use the eye on near objects. The question of constitutional treatment is important to be settled. In former times it was assigned the chief part in the cure. By some, at the present day, it is almost ignored. I have seen a very large number, and, indeed, the majority, of cases of syphilitic iritis recover without being subjected to any of the so-called specific remedies. As above remarked, the facility of cure depends most upon the readiness with which the pupil expands, and can be kept open. I have also said that sometimes the mercurial treatment will bring about prompt resolution when mydriatics fail. I must also say that ■ where the plastic exudation is in large quantity, as when the so-called gummata make their appearance, mercurial inunction, or blue-pill by the mouth, may wisely be employed to aid in the disappearance of the exudation. I have seen entire absorption take place without this rem- edy, and in feeble patients would be unwilling to use it, but would give the vigorous the benefit of it. 39 610 SYPHILIS OF THE EYE. I have no hesitation in stating that the usefulness of either mercurj or iodine to cure iritis is exceptional and not the rule. On the other hand, I must with equal readiness admit that specific constitutional treatment ought to be employed to counteract the poison whose potent influence has induced the iritis. This treatment is aimed at the general disease, and is to be selected and adapted according to the rules which are set forth in another part of this treatise. Accord- ing to this view of the question, a practitioner is not compelled to dose a syphilitic patient with mercurials to protect his sight from the mischiefs of iritis, except under conditions specified, but should steadfastly adhere to that plan of treatment which the general welfare of the system de- mands, and attack the eye-disease with the local remedies which have been designated. I have several times observed patients having iritis in one eye, who have already been brought imder the influence of mercury, to be at- tacked with the same inflammation in the other. This certainly proves that no preventive virtue can be ascribed to the mercury, and argues against the beneficial influence of quick mercurialization in curing the acute attack. In addition to the above remarks on treatment, I should speak of cer- tain peculiar conditions calling for special measures. In cases of iritis serosa, where there is but little plastic exudation, the pupil will dilate readily, but often the pain and redness do not abate. On testing by the finger, the eye wUl be found to be tense and the anterior chamber wUJ be seen to be too deep. Under these circumstances, paracentesis by a broad needle or a Graefe's cataract-knife is indicated. It is not necessary to draw off all the aqueous humor, but the proceeding may need several repetitions, as indicated by the recurrence of pain. The place of punct- ure should be at the margin of the cornea, the instrument should have a very sharp point, and be entered in a plane parallel to the surface of the iris. It should be withdrawn slowly, because a rapid gush of aqueous humor causes severe pain. If, after an attack of iritis has passed away, the pupil should be tied down to the lens by extensive adhesions, relapses of inflammation are likely to occur, and the morbid process is prone to penetrate to the cUiary body and choroid. Hence arise opacities in the vitreous humor and in the crystalline lens. The area of the pupil is sometimes overlaid by a false membrane and the capsule of the lens may undergo thickening. If posterior synechia is complete, that is, if all of the pupillary edge be glued to the lens, an accumulation of aqueous humor sometimes takes place behind the iris, which makes it bulge forward toward the cornea in a series of protuberances or as a complete ring, leaving the pupil retracted. The peripheral parts of the iris sometimes come into actual contact with the posterior surface of the cornea, and the tissue always VITEEOUS HUMOR. QH undergoes atrophy. So great sometimes is the waste of the tissue that in spots it becomes an open mesh-work of fibres through which the light of the ophthalmoscope can be thrown. This has already been alluded to. On the other hand, after iritis, the membrane sometimes becomes greatly thickened by formation of new tissue both in its stroma and on the posterior surface. The remedy for the conditions of adhesion and obstruction is iridec- tomy. Its efficacy will, however, be in the inverse ratio to the severity of the lesion. In the worst cases, especially in those last described, it is sometimes scarcely possible to be performed, and seldom, if done, is of much service. Where the iris is turgid with new vessels, the operation is attended by great bleeding, and no good, but rather harm to the eye, may ensue. In spite, however, of these drawbacks, this operation offers the only chance to rescue the eye from serious and cumulative mischief, and may be the only means of avoiding the necessity of extirpating the organ. For cases of moderate posterior synechia it may be needless to do any thing, or the simple puUing away of the attachments by a fine pair of forceps wiU suffice. This proceeding is attended by only slight reac- tion, and requires a small wound at the border of the cornea — the iris when seized is puUed upon until the adhesion breaks, and is then let go, without being dragged into the wound. The forceps employed should not have teeth. This operation, suggested by Passavant, is preferable to other methods of detaching the pupil, such as that devised by Streat- field. VITEEOUS HUMOR. A common effect of inflammation of the iris and ciliary body and choroid is the production of opacities in the corpus vitreum. They are either effusions from the surrounding vascular tissues or proliferations and degenerations of the cells of the vitreous. The anterior part of the mass is most frequently thus affected. The opacities present every variety of form, as molecules, fibres, tangled nets, flakes, and membranes. They sometimes develop rapidly, more frequently occur slowly. A noteworthy instance of rapid development is the following : Lieutenant D had hard chancre in March, 1873, In the following September, double iritis took place, and disappeared in four weeks, leaving a few adhesions of the pupil of one eye. Vision in the right eye was |-g- ; in the other, f^. In June, 1873 — about eight months afterward — a sudden development of opacities occurred in the vitreous of the left eye, totally abolishing vision, but leaving perception of light. No external hyper- ssmia of the globe existed — the fundus could not be discerned. The ap- pearance of the vitreous was like that of a tumbler filled with muddy water, in which a quantity of torn and broken leaves are floating. He had been under mercurial treatment, both at the time when the chancre 612 SYPHILIS OF THE EYE. appeared and during the attack of iritis ; in the last instance it was maintained for three months. When the acute hyalitis appeared he was directed to take a wine-glass full of Zittman's decoction three times daily, and by a life of regulated exercise in the country to keep his general health in the best condition. After six weeks the vitreous became so clear that the fundus could be perfectly examined. No le- sions of the choroid could anywhere be found, and vision was restored to |-§. The other eye was not affected. A case precisely like the above is not often observed, but a process slower in development and less in degree is a not rare effect of syphihtic poison. It usually requires a long time for vitreous opacities to clear up — generally some of them remain permanently. The cetstaixine leis's is, so far as I know, never the seat of syphi- litic changes, excepting as they ensue in the course of inflammations of the choroid, the ciliary body, or the iris. More especially from chronic cyclitis and choroiditis does the nutrition of the lens become impaired and its transparency become damaged. In other words, it is changed into a cataract. The transformation of the lens-fibres begins in the deeper or posterior layers very often, and the lens when wholly opaque is either of a dead white or yellow tint, or becomes, in old cases, com- pletely calcified. As a result of iritis, the anterior capsule sometimes presents opacities in the pupillary space, by proliferation of the epithe- lium of its posterior siwface. No good is gained in the attempt to cure opacities of the lens or its capsule by anti-syphilitic medication. The case wiU admit of nothing but surgical treatment, and in all cases the encouragement for success is dependent on the degree to which the integrity of the deep tissues has been preserved. It is always imperative to make a rigid investigation of the degree of perception of light, and the limits of the field of vision. Only by so doing can a patient be secured against the pain and disap- pointment of a needless operation. The operation for cataract under these circumst9,nces is always com- plicated, and may be quite difficult. For a discussion of this subject it is proper to refer to treatises devoted to diseases of the eye, while it is right to add that the probabilities of success in this class of cases are not encouraging. THE CILIAJEY BODY. I should not make special mention of inflammation of this part of the uveal tract, were it not that certain acute lesions of this tissue some- times present themselves which have very striking features. It is the most highly vascular structure of the eye, and of necessity participates in the inflammatory changes of the iris and choroid. But it is entirely hidden from direct inspection, either by the naked eye or by the CTCLITIS. 613 ophthalmoscope. I have before alluded to a state of retraction of the periphery of the iris -which indicates adhesion between it and the ciliary processes. So far as superficial vessels may indicate the existence of cyclitis, the same kind of hyperemia appears as when the iris is in- flamed ; that is, the anterior ciliary vessels become engorged. Cyclitis, as an independent affection with unmistakable features, has appeared to me under two forms. In one there are no other symptoms than circum-corneal injection, and a little discoloration of the iris, with- out impairment of the action of the pupil ; the vision may be dim. In the other and more important form, the inflammation presents gummy exudation more or less conspicuous. I shall speak only of the latter condition, and by relating the following case : Case LIT. — A man about thirty-two years of age, had had syphilitic symptoms about four years ; had had iritis. A few weeks before I saw him, sudden blindness fell upon his left eye, without pain, irritation, or visible redness. He was able to perceive only an intense light. The globe was not hard or tender to touch. The pupil dilated fairly by atropine, and no illumination of the bottom of the eye could be obtained by the ophthal- moscope. The vitreous simply gave back an inky hue. As the eye turned in various directions, a white object suddenly flashed across the field, in most instances starting from the inferior part of the globe. It was evidently close behind the lens, and never retired to the depths of the eye. When he looked strongly downward, a white patch was discovered close to the border of the crystalline lens, situated in the ciliary body, or its near neighborhood. This had the look of plastic exudation. The nature of the disease was then assumed to be, a plastic cychtis, with a localized exudation not very abundant, from which a mass had been broken off, and floated about in the anterior part of the vitreous. The general opacity would be the necessary accompaniment of this condition. The patient had been treated by specific remedies, and they were again pre- scribed, but, after a period of two months, no improvement was obtained in vision, and the exudation had scarcely altered its appearance. There was never any visible hypersemia nor pain. In other cases plastic cyclitis appears in a much more formidable way. In addition to the pain, swelling of the lids, and vascularity, characteristic of a severe attack of inflammation of the globe, a swelling soon begins to arise at some portion of the eye near the cornea. The spot on which it springs may be more intensely red than other situ- ations, and the locality where I have most often seen it is at the upper part of the eyeball. The tumor grows rapidly, and within a week I have seen it become larger than a buck-shot, its base occupying nearly one-fourth the circumference of. this part of the globe. There is always severe iritis, the pupil is totally obscure to the ophthalmoscope, and the anterior chamber filled with turbid aqueous humor. The disease occupies several weeks in its course, and the tumor will entirely disappear. Sometimes its site is marked by a dark-bluish discoloration. Sometimes the eye becomes soft and slightly reduced in size, but this is not a uniform result. In no instance have I seen any vision restored. It is not needful to dwell upon the subject of treat- ment, because the measures suitable to a similar process in the iris 614 SYPHILIS OF THE EYE. would be indicated. In two cases I have been obliged to extirpate the eye, because of the severitj of the pain. TBIE CHOKOrDBA. The frequent participation of this membrane, in the inflammations of the iris, has been repeatedly alluded to, and need not be further mentioned. The similarity in structure of the two tissues causes a great resem- blance in their morbid processes, but in many instances it becomes im- possible to see the changes which occur in the choroid, because the pupil and refractive media become so soon and so deeply clouded. A form of choroiditis which may take place without affection of the iris, and without visible hyperaemia of the globe, is known by the name of acute choroiditis disseminata. Illuininated by the ophthalmoscope, the vitreous will be faintly hazy, but through it wiU be discerned a munber of small isolated specks of a light-yellow color upon the posterior wall of the eye. These specks are more apt to exist near the equator, but may appear upon the central part, of the fundus. They are seldom bigger than one-fourth the area of the optic nerve, often are much smaller. They show an unmistakable elevation, and in some instances a retinal vessel may be seen to pass over them. The optic nerve is always hyperasmic, but doos not show infiltration. None of the choroidal stroma appears clear, so far as the degree of pigmentation natural to the individual wUl permit a judgment. These spots of exudation are sufficiently characteristic to secure an easy recognition of the disease, and they suggest the features of iritis gummosa. The picture thus sketched, after two or three weeks, begins to imdergo alterations. The yellow specks grow fainter, but an aggre- gation of pigment takes place at the border of the deposit. After a time, with its more complete disappearance, the place it occupied in the choroid is found to have become thin by the destruction of the epithe- lium ; and finally the stroma of the membrane is absorbed, leaving only a dead-white patch, whose border is deeply marked by black pigment In old and severe cases the aspect of the interior of the eye is most striking. Circular, oval, and rounded white spots with black edges, are clustered thickly over the surface, presenting a brilliant contrast to the red color of the choroid, while upon the apparently normal surface pig- ment-dots are strewed about to give evidence of the extension of the disease over all the tissue. There may also be light-colored red patches, which indicate thinning of the membrane. As above said, these lesions are greatest around the periphery of the choroid, and leave the central and more highly-organized part of the fundus less impaired. But vision is always very badly reduced, and may be entirely lost. I have seen cases in which the above-described atrophy had spread over large spaces, leaving only a few of the greater choroidal vessels as vestiges of the CHOROIDITIS. gl5 vascular tissue. The progress of the above lesions may be completed in a few months, and the efficacy of treatment is only moderately satis- factory. Another form of choroiditis which is seen in syphilitic patients con- sists in the formation of patches of atrophy at the peripheral part of the fundus without previous deposit of lymph. The wasting of the mem- brane is a gradual process, and the patches will present a mixture of white, bordering upon a light-red surface, and the whole bounded by a dark pigment-line. The light-red part of the patch indicates that here a portion of the membrane yet survives. These patches take on most ir- regular forms and may attain large size. They exhibit the most varied mixture of black and red and white, because of the diverse degree to which the choroid is destroyed, and the irregular deposit of pigment, both around and upon the patches. They are very chronic in their development, and may sometimes be discovered in an eye which the patient supposes to be perfectly sound. Indeed, direct vision may be normal, but the visual field must be encroached upon. It is just to state that this kind of lesion is also found in persons who give no evidences of syphilis. The only attainable success of treatment in these cases is to delay or arrest the advance of the disease. I have never, however, convinced myself that a complete arrest has been se- cured. The difficulty of following up patients suffering from such a chronic disease will be readily appreciated. Several years must pass before a certain conclusion could be reached. In the first-described cases a somewhat active treatment would be proper in the exudative stage ; that is, the artificial leech should be ap- plied to the temple to remove from two to three ounces of blood, and the patient be kept for twenty-four hours afterward in a dark room. This may be repeated, according to the strength of the patient, in five or ten days. Dark-blue glasses {coquilles) should be worn. The bowels should be mildly acted upon. The constitutional treatment for syphilis should be pushed with as much energy as the tone of the system wrill bear. Most authors urge a speedy mercurialization, but the same dis- cretion is imperative as in aU other cases of syphilitic lesion. The health of the retina is not more likely to survive the evil effects of overdosing with mercury than of the taint of syphilis. In the choroiditis last described only the slow and milder methods of cbnstitutional treatment are appropriate. Local treatment, beyond pro- tection against excessive light, and moderation in the use of the eyes, is of little value. EETINITIS. When produced by syphilis, retinitis exhibits only a slight haziness and oedema of the retina, with lack of sharpness in the outline of the vessels and of the optic disk, and hypersemia both of the retinal vessels ei6 SYPHILIS OF THE EYE. and of the optic nerve. The deeper part of the vitreous is hazy. The optic nerve is not swollen, there is very little radiate striation of the retina near the nerve ; there are no ecchymoses and no thick plaques of yellowish-white exudation. The peripheral part of the retina may re- main free from perceptible change, and not only is the disease usually oonlined to the central region of the retina, including the nerve, but it sometimes is more narrowly localized to the vicinity of the yellow spot itself. Because it is thus inconspicuous, this inflammation is, on the one hand, liable to be overlooked, and, on the other hand, to be confounded with such troubles as faint haziness of the vitreous, or of the cornea, or perhaps of the lens. Indeed, I have had a case of slight astigmatism of the mixed variety, which, because there had been a syphilitic history, I for a time mistook for retinitis. The way to escape such errors is by careful refractive adjustment with the upright image to the several parts and depths of the dioptric media. Examination with the inverted oph- thalmoscopic image will fail to assure a diagnosis. This kind of inflammation may attack one or both eyes, and may pass from one to the other. It may last a very short time, say for three or four weeks, or it may persist for several months. It does not always, but may sometimes, cause lasting harm to sight. In both the tran- sient and the obstinate cases it shows a disposition to recur. The sub- jective symptoms consist of occasional flashes of light at the beginning of the disease, and subsequent dimness of sight ; there is no pain nor lachrymation, and but little photophobia. There is no external hyper- aemia. Treatment never needs to be energetic : protection against bright light by colored glasses, abstinence from use of the eyes, the artificial leech, according to the usual rules, two to four times, at intervals of a week, constitute the local treatment which can be of much avail. The chief reliance is in the constitutional treatment, according to the prin- ciples before enunciated. NEtTRITIS OPTICA. This is of two varieties : 1. That which is primarily in the outer and orbital extremity of the nerve ; and, 3. That which is set up by intracra- nial causes. In both cases the retina may be more or less implicated. The distinction between the two classes of cases cannot be made with any certainty by the ophthalmoscope alone, but the question of intra- or extra-cranial origin of the lesion always presses for solution. The symptoms which appear vary according to the quality of the inflamma- tion and according to its stage : 1. In simple cases nothing is seen but redness of the nerve surface, and a little fullness of the central vessels, with scarcely any blur of the edge or of the tissue. 2. In other cases the iierve is swollen to an extreme degree, its structure infiltrated and opaque, NEURITIS OPTICA. 617 often striated, its color red or gray or leaden, its border partially oi wholly obliterated, its vessels tortuous and tm-gid. The aspect is then that of the so-called " choked disk," and its cause is usually intra-cranial. A typical case of this kind has just come to my notice in a man lying in Bellevue Hospital with manifest brain-disease, as denoted by the partial coma and delirium, the headache, the tenderness of the skull on pressure, and the evident periosteal swellings of the forehead and vertex. Both optic nerves are in the condition described, and he has the history of syphilis — a gummy tumor in the substance of the brain, or basilar men- ingitis, may cause the same result. 3. In other cases of brain-syphihs the optic nerves become impaired, and exhibit to inspection only a white color and woolly texture with a little blur of the edge — the vessels being small. There may perhaps be a doubt whether a faint degree of hy- peremia has not preceded this condition — but, if it has, its duration has been extremely brief. The look which the nerve in these cases pos- sesses is difficult to describe, because the change is in texture. In these cases, as well as in the nerve-lesions before mentioned, it is extremely important to determine the extent of the field of vision. It wiU be found in almost all instances to be curtailed at some part. Very common is it, to find irregular hemiopia or the loss of a quadrant of the field — concentric limitation is not so common. Prognosis in these affections is never good, but a valuable degree of sight is often preserved or recovered. Treatment is mainly constitutional. APEECTIONS OF THE OKBITAL MOTOR NERVES. An extremely common effect of syphilis is to disturb the function of some of the motor nerves of the eye ; one muscle, or any number of the muscles, may be paralyzed. Inasmuch as the third (motor communis oculi) supplies four muscles, the eye, when it is impaired, is most help- less; but separate twigs may be singled out while others are undis- turbed. If the whole nerve is at fault, the eye stands at the outer angle, is incapable of motion up or down, and cannot turn inward farther than the median line ; the upper lid droops and cannot be lifted. It can be carried more outward by the external rectus, and under influence of the superior oblique will make some rotatory movements. The pupil will be in medium dilatation and the function of accommodation para- lyzed. Diplopia will not commonly be noticed, even if the lids be opened, because the two images are so far asunder as not to attract attention. As the nerve begins to recover and the eye to regain mobility, diplopia will become annoying and the images will be crossed. If the sixth nerve is paralyzed, the eye stands in abnormal conver- gence, because the abductive power of the external rectus is destroyed, Double images then are correspondent (homonymous), and are most an 618 SYPHILIS OP THE EYE. noying for distant objects, while an object brought very near the eye may be seen correctly. If the fourth nerve is paralyzed a superficial inspec- tion may fail to recognize the defect in mobility. It will be detected with certainty by careful study of the double images. To do this it is better to take a lighted candle for an object, and to put a slip of red glass before one eye. There may be no diplopia in the field above the horizontal line, but, as the eyes descend, double vision occurs, one image (the false one) being below the other, and, as the object is carried to the temporal side of the affected eye, the images, besides being above one another, separate laterally, the false one being farther to the nasal Bide. Another fact about the false image is, that it is not vertical, but leans so that its top inclines inward. Without study of the double images, a strong suspicion of paralysis of the fourth nerve may be awak- ened by noticing that the eyeball when caused to move in a straight line below and parallel to the horizon, in reaching the middle of the orbit in its excursion outward, makes a twitch and an imperfect rotation of the cornea, and also fails to go as easily and completely to the outer angle as the healthy eye. Patients who, from any kind of paralysis, have diplopia, are thereby much disturbed, sometimes having nausea and headache, while, to use their eyes, they must either shut one, or correct the double sight by some twist of the head, or by means of properly-adjusted prisms. The use and choice of prisms is a subject not suited to the present treatise, and for which the reader is referred to the works on ophthalmology, e. g., vide Wells on " Diseases of the Eye." During the early stages of the trouble, the proper treatment is coun- ter-irritation to the temples, the faradic electric current, and constitu- tional remedies. After a number of months have passed, if some imper- fection of motion remain, the use of prisms, or the performance of te- notomy, or of some operation on the muscles, may be resorted to. Periosteal iNELAMMATioif of the orbit does not often occur, but some symptoms which it causes are worth attention. If it affect the deep parts of the cavity, it may cause disturbance in the function of some of the muscles, and hence diplopia ; or, if attended by serous or other effu- sion in sufEoient quantity, may produce exophthalmus, and visible signs of inflammation in the globe and eyelids. This I have seen, in the most emphatic character, in a case where the anterior part of the orbit was the seat of periostitis. So great was the congestion, cedema, and secretion from the conjunctiva, and the swelling of the lids, that the disease resembled acute purulent conjunc- tivitis. The pain which the patient suffered was intense, and greater than is common in conjunctival inflammations. This fact, and the pres- ence of an eruption on the face, led to digital exploration of the margin of the orbit. The exquisite tenderness at once revealed the true nature of the diseased action, and indicated the need of constitutional as well PERIOSTITIS ORBITAL. 619 as of local treatment. After one eye had suffered in this way between two and three weeks, the other was similarly though less severely at- tacked, and in this instance the onset of the trouble was distinctly seen to be in the lining membrane of the orbit, and from it acute inflamma- tion was propagated to the external structures of the globe. There was no evidence of gummy exudation. The treatment of the case consisted in leeches to the temples, iced-water compresses changed so often as to be constantly cold, application of a solution of nitrate of silver — ten grains to the ounce — to the everted palpebral conjunctiva, at first twice and afterward once daily, and hypodermic injections of sul- phate of morphia: besides this, very high doses of iodide of potassium, at one time reaching three drachms a day, were employed, but the benefit derived from the heroic doses did not appear to be great. The patient recovered without damage to her eyes. As to gummy tumors growing in the orbit, nothing special need be said : that their bulk must displace the eyeball, and that they must otherwise interfere with its functions, is self-evident. CHAPTER IX. SYPHILIS OF THE EAR. Syphilis as affecting the External, Middle, and Internal Ear. The affections of the ear, caused or modified by sj'philis, are con- veniently considered by arranging them, in accordance with the anatomy of the organ, into those of the external, middle, and internal ear. The integument of the external ear is liable to be involved in the cutaneous affections of syphilis, its substance to be destroyed, or its cartilage eaten away by syphilitic ulcers and gummy tumors. The auditory canal may be invaded by mucous patches, sometimes showing exuberant granulations, by erythematous spots, or by pustules. A dry exfohation of portions of its skin is not uncommon, together with a change in the quality of the sebaceous matter, so that the latter accumu- lates in a scabby way over the drum-head, perhaps causing partial deaf- ness. The cerumen may also become impacted. Bony growths — exos- toses and hyperostoses — in the external auditory canal may also be en- countered in the course of syphilis, but Roosa' believes that these growths occur quite as commonly as the result of local irritation in per- sons who have never had syphilis. The middle ear may be involved, in the course of secondary disease, by an inflammation of its lining membrane. This inflammation is not ' "Diseases of the Ear," p. 402. 620 SYPHILIS OF THE EAK. attended by increase of secretion (catarrh of the middle ear), but by a proliferation of tissue, which does not tend to suppuration but to thick- ening of the drum-head, and to adhesions between the ossicula and the walls of the tympanum. Wilde' described this affection under the name of " syphilitic myrmgitis," and he believed that it was charactei^ ized by the relative insignificance of the pain, in comparison with that felt in the same disease when not due to syphilis. Bumstead,' however, thinks that the absence of local pain is not a characteristic of the malady. Eoosa ' believes that there are no peculiar aural symptoms in this form of disease. He remarks, however, that " a syphilitic diathesis seems to cause the proliferation of tissue to be more rapid." He agrees with Schwartze, of Halle, who thinks that periostitis of the middle ear is at the basis of these cases. Local bloodletting, the warm douche, and opiimi for pain, will, with the ordinary anti-syphilitic treatment, usually master the affection, if employed during the early stages. It will probably also be necessary to inflate the ear by Politzer's method, in order to prevent the formation of adhesions in the tympanic cavities. Young children affected with congenital syphilis may be attacked by a catarrh of the middle ear, which resists local and constitutional treat- ment, very obstinately — that is to say, intra-auricular adhesions occur, the drum-head becomes sunken, the nerve is secondarily involved, and the impairment of hearing often remains permanent.* The mouth of the Eustachian tube is sometimes, but rarely, the seat of ulceration, and thus impairment of the hearing may be caused. Permanent loss of hearing is sometimes due to cicatrization of the pharyngeal orifice of the tube. The portio mollis of the seventh pair may be the seat of special dis- ease, and periostitis of the labyrinth, as well as gummy tumors, may occur. The resiilts of treatment of syphilitic disease of the labyrinth or nerve are often unsatisfactory. The use of the tuning-fork will be an efficient aid in the differential diagnosis of cases in which there is doubt as to whether the loss of hearing depends upon disease of the middle or internal ear. If the middle ear be affected, the sound of a tuning-fork, the handle of which, while the instrument is in vibration. has been placed upon the forehead or teeth of the patient, will be in- tensified in the diseased ear; while, if the internal ear be the seat of dis- ease, the intensity of sound will be much diminished, or the vibrations wiQ not be at all perceived on the affected side. • " Aural Surgery," English edition, p. 260. ' " Venereal Diseases," p. 590. • Loc. cU., p. 286. * Boosa, he. cU. SYPHILITIC ONYCHIA. 621 CHAPTEK X. SYPHILIS OF SPECIAL TISSUES AND ORGANS Byphilis of the Nails.— Dactylitis.— Syphilis of Tendons, Sheaths of Tendons and Aponeuroses.— Syphilis of llasole.- Syphilis of Joints.— Syphilis of Bone.— SyphiUs of Cartilage.— Syphilis of Lymphatic Glands. — Syphilis of the Mammaiy Gland. Syphilis of the Nails. — Mucous patches are sometimes seen under the free border of the nail. A whitish or brownish, badly-smelling, characteristic secretion, is furnished by such patches. With the earlier eruptions on the skin, the nails are liable to lose something of their lustre. They are apt to become seamed by slight longitudinal furrows, brittle, friable, cracked, and shaling off at their extremities, sprinkled with an abundance of white points showing an imperfect epithelial formation. This dry form of onychia may cease at any period of its progress, healthy nail growing out from the matrix, or it may go on, very rarely, to a complete shedding of the nail. Instead of these changes, occasionally the nail becomes thickened, rough, discolored (Fournier).' OmrcHiA. — During the secondary period of syphilis, specific onychia is sometimes encountered upon the fingers, more often upon the toes. It is not uncommonly symmetrical, the same toe on each foot being in- volved. Spontaneously, or after slight injury, pain is felt somewhere about the border of the nail. The painful point becomes swollen and of a reddish-brown color. This goes on to ulceration at the edge of the nail, and spreads around it. The surface of the ulcer is moist, brownish, fungous ; the secretion ichorous, fetid. The nail loosens, superficial ul- ceration progresses beneath it. The nail, with the progress of the affec- tion, sometimes softens and falls away, its place being supplied by the ulcer, only a small portion of nail remaining at the point occupied by the luuula. The whole end of the toe or finger becomes engorged, vio- let-colored, very painful ; deep inflammation, -with necrosis of the ungual phalanx, may follow. Instead of reaching this extreme, the affection sometimes remains confined to a portion of the circumference of the nail. Here the skin is swollen, livid, ulcerated ; the nail seeming to act like a foreign body, preventing repair. All the forms of syphUitic onychia pro- gress very slowly, but terminate habitually in recovery. Diagnosis. — The dry form of secondary syphilitic onychia must be distinguished from the somewhat similar condition found in eczema, ^ American Journal of Dermatology and Syphilography, 1873, translation. 622 SYPHILIS OF SPECIAL TISSUES AND ORGANS. psoriasis, and parasitic affections, by the history and concomitant sj'mp- toms. The ulcerated form of secondary onychia is distinguished from ordinary in-growing naU, run-round, etc., by this, that in it, ulceration and inflammation take place primarily in the matrix of the nail, while in the latter affection it commences first in the outlying tissues. Tertiary onychia is a gummy, destructive inflammation of the matrix in a more severe form. It has the same general characters as the secondary afieo- tion, only more severely. It usually commences in the matrix, at some point along the lunula, the naU thickens and softens, finally falls, while destructive ulceration is slowly advancing, involving the deeper tissues in an irregular manner, perhaps attacking the bone. Treatment. — The constitutional treatment is regulated accordingly as the disease partakes more of the secondary or tertiary type. Locally cleanliness, removal of nail and loosened portions of naU which act as foreign bodies, nitrate of silver for exuberant granulations, iodoform pure or diluted for ulcerated surfaces, or black or mild yeUow-wash, SYPHILIS OP THE PINOEBS AND TOES. Dacttutis {dcLKTvXog, a digit — finger or toe). — This rare affection requires a special description. But few cases of it are on record.' Dactylitis is gummy in character, and bence belongs to the later stages of syphilis. Taylor makes two varieties : 1. Subcutaneous and articular, the bone not being much affected. 3. Nearly confined to the bone and joint. 1. The first form comes on rapidly or slowly, difiiise gummy infiltra- tion takes place subcutaneously, involving the periosteum upon the first phalanx (most often), but perhaps including the whole fingers. The swelling usually terminates abruptly, as a more or less perfect ridge at the articulation of the finger or toe with the hand or foot, and is most marked on the dorsum. The swelling is sometimes very great, so as mechanically to impede motion, but there is no complaint of pain. The skin is natural or slightly bluish, from venous obstruction. The swelling is firm, resistant to the touch. The fibrous structures around the joint next become also involved. The synovial membrane seems to escape, there being no effusion into the joint unless the bone is also implicated. After a variable time crepitation (rather rough) may be observed in the joint. Disintegration of the joint is possible, the skin ulcerating over it. The bones, especially near the affected joint, also enlarge slightly, participating in the disease. The malady runs a slow course, perhaps relapsing several times after apparent efforts at repair, but vields in the long-run to specific remedies, leaving behind more or less disturb- _ ' ^*?,^1"'1« 4'x?''^' ^i™,""^ *' r." *= "'^'■'"'y' '^ (comprised in a recent able paper by R. ^■^^y'^ov, of New York, published m the American Jmirrud of J)ermM Ibid., 1870. ' " Archiv fur Ophthalmologie," Bd. i,, 2. Heft, §§ 313-318. SYPHILIS OF THE SPINAL NERVES. 659 sometimes precedes hemiplegia by several days, announcing it as it were. When facial paralysis due to syphilis occurs aloiie, not connected with other manifestations of profound nervous disease, it is liable to come early. Bassereau and Vidal de Cassis have each recorded two cases within the first few weeks after infection. Van Buren and Keyes have reported a case ' during the second month. Alrik Ljunggr6n " gives several others, occurring alone and quite early in the general malady. Many other oases, coming on during the first few months, might be cited. These early paralyses are mild, there is rarely any pain, and they tend to get well quickly, under the continuance of ordinary anti-syphilitic treatment, appropriate to secondary disease. The variety that occurs late is more apt to be occasioned by some severe lesion of the bone, brain, or nerve, and its removal is generally difficult and slow. When occurring late in syphilis, facial paralysis is but one of a group of phenomena, paralytic, intellectual, and emotional, with a general train of forerunning and accompanying symptoms, such as has been already traced, antecedent pain, amnesia, emotional excitability, etc., etc. The attack may be sudden, or slowly progressive, painful or not, perhaps followed by hemiplegia. It is rare for both facial nerves to suffer at the same time. Evidence is accumulating concerning the effects of syphilis upon the other pairs of nerves, but as yet there are no positively fixed facts to be guided by, although it is evident that no nerve in the body is cer- tainly free from possible implication, by syphilitic disease. SprsTAL Neevbs. — Local neuralgias, anesthesia, analgesia, paralyses, contractions and wasting of groups of muscles, are the symptoms characterizing lesions of special spinal nerves, such lesions being within or without the vertebral canal. Sciatica, pleurodynia, etc., occurring during syphilis, and getting well under anti-syphilitic treatment, are not very uncommon. Atrophy of single muscles or groups of muscles affected with syphilitic paralysis is more rare.' Crss V loc at 2 " Klinis'che Beobachtungen iiber Visceral-Sypliilis."— ^niAtw fiir Derm, und Syphil., No. 2,, 1870, p. 141. » Case XIX., Van Buren and Keyes, is an example in point. 660 INHERITED SYPHILIS. OHAPTEE Xni. INHEBITED SYPHILIS. Inheritance from either Parent, the other remaimng sound.— Abortion due to SyphiJia.— Date of Appear. ance of Symptoms.— Symptoms.— Visceral SyphUis.— The Syphilitio Countenance.— Treatment of In herited Syphiiis. Stphius may be acquired by a healthy baby from nursing a woman with chancre, or mucous patches of the nipple, or through vaccination. When so acquired, the disease is essentially the same as in the adult. It is called infantile syphilis. When inherited, however, its course and symptoms are modified. Syphilis may be inherited from a mother who has had the disease, but does not at the time appear to be suffering from its symptoms ; or again, if she become infected at the moment of impregnation, or during gestation up to the end of the seventh month, after which time, according to Diday,' the child escapes.' Syphilis may probably be inherited from the father, the ovum be- coming poisoned by impregnation with an imhealthy germ, the mother being healthy. As the foetus develops, the mother becomes syphilitio. This point is not yet absolutely decided, certain excellent authorities claiming that, if the mother escapes, so does the chUd necessarily {see note, p. 531). Finally, either a father or a mother may be syphilitic, pass along well into the tertiary stage, and then produce healthy children ; ' or a healthy child may be born while the parents are under treatment, which being discontinued prematurely, a subsequent child may be syphilitic,' or, in one of the natural lulls of the disease,' the wife not yet having been contaminated, a healthy child may be born ; then the father having a relapse, and the mother becoming infected, the next child is syphilitic. A syphilitic mother is far more liable to produce a syphilitic child than a father, who, at the moment of impregnation, may have been under treatment, and for procreative purposes sound ; not so the mother, whose intimate anatomical connection with her child during nine months is certain to communicate to it some of whatever poison she may possess, unless she is under continuous treatment.' The ability of a father to infect his child, without at the same time poisoning his wife, has been questioned by high authority. This un- doubtedly is of less common occurrence than is supposed, but it may happen. The power of poisoning offspnng wanes with the age of the ' Ue la Syphilis cles Nouveaux-nSs." » See note, page 621. 1 111 DATE OF APPEARANCE. 661 disease, but not so rapidly, seemingly, as does the power of communi- cating it to one of the other sex. Thus, with the woman, syphilis may have been acquired from a former husband ; with him, as is usual, she miscarries several times. Finally, a child is born with eruptions on its skin, and visceral syphilis, from which it dies in a few days. The next child is born, perhaps, fat and apparently healthy ; it continues so for two or three weeks, and then gets the snuffles and cutaneous symptoms. Neglected, it dies, or under careful management gets well. The next child seems healthy, does not develop any marked disease during its infancy, but, growing up, may have the syphilitic teeth, interstitial keratitis, etc. After the birth of this child the husband dies, and the wife marries a healthy man. She has lost her power of communicating syphilis to him. They have a child, who appears and continues healthy, but who, at some time during boyhood, has evidences about the mouth, the bones, or the glands, of mild tertiary disease, the father remaining healthy. Changing the sex of the foregoing examples, it becomes evident how, late in the disease, after the power of direct communication has been lost, a father, through a healthy, uninfected woman, may beget a child, who, continuing healthy for several years, may finally evince signs of undoubted syphilitic disease, which will yield to appropriate treat- ment, the mother remaining healthy. Most of these problems of in- herited syphilis are still undecided. They are not for the theorist, but for the clinical physician to solve. It is impossible yet to speak with absolute conviction upon some of them. Aboetion due to Syphilis. — A syphilitic woman usually aborts. If no treatment be employed, abortions continue, perhaps at later and later months, until finally a living child, with inherited syphilis, is pro- duced. When a woman who is distinctly syphilitic becomes pregnant, a continuous mild mercurial course offers her the best chance of bringing a living child into the world. The causes of abortion do not seem to lie in syphilitic disease of the womb, but in a blasting of the vitality of the foetus, through visceral syphilitic disease, and through fatty de- generation of the placenta (Barnes). Date of Appeaeanoe of Symptoms. — The date at which the syphi- litic poison may manifest itself in an infant who has inherited it is variable. The germ may be blighted, and early or late abortion ensue ; the child may come into the world covered by an eruption and with advanced syphilis of the liver, thymus, etc. Most often, however, the child is born seemingly healthy, but fails to gain weight, and develops an eruption, with snuffles, etc., somewhere during the third or fourth week. It may be two or three months before positive signs appear, but this is rare, and much more uncommon, though stiU possible,is the lapse of several years before symptoms come on. Cases are not very in- frequently encountered where a growing or full-grown child first presents 362 INHEEITED SYPHILIS. evidences of syphilis, tlie disease being unmistakably inherited, perhaps the father known to be syphilitic, yet neither the child nor the mother can be brought to confess directly or indirectly any antecedent syphi- litic disease. That there may have been some undiscovered symptom in babyhood must be allowed, but still it is as near a certainty as possi- ble, without absolute proof, that a child of a parent whose syphilis has nearly run out, may show no signs of disease until many years after birth, and then the lesion wiU be of a bone, a joint, a gland, the eye, or perhaps there will be a patch on the mucous membrane of the buccal cavity, an ulcer of the nose resembling lupus (Case LL), or some other single localized lesion, usually passing undiagnosticated as far as its etiology is concerned. These symptoms were often designated by the older surgeons by the somewhat vague term of " strumous," as evincing characteristics which were not absolutely identical with those of scrofula. The popularity of Astley Cooper's well-known tonic for struma, in early childhood (corrosive sublimate in Huxham's tincture of bark), is probably explained in this manner. Symptoms of Inheeeced Syphilis. — ^A child born with inherited syphilis often manifests no evidences of the disease at the time, unless it be that he has more of the weazened, old-man look, and dried-up ap- pearance, than is common with babies at birth. This condition may hold for several weeks, or months, before eruptions appear. The infants in the mean time do not take on flesh, they continue thin, the skin be- comes more sallow, dry, and wrinkled, they look bloodless and mummi- fied, the eyes seem large, and the expression is one of aged, unearthly, half-idiotic intelligence. Before affairs have reached this pass, the junction of the skin with the mucous membrane at the different mucous orifices usually begins to show some signs of disease. Fissures, chaps, excoriations, mucous patches, ulcers, appear about the lips, in the mouth and throat, at the edges of the nose, around the anus, genitals, and buttocks, groins, axiUfe, umbUicus, etc. The child gets the snuffles ; its nose first runs, and then becomes stopped up by the swelling of the membrane and the collection of mucus, pus, and blood. If the nose is entirely stopped, nursing is interfered with. The disease may go on in bad cases to ulcerative destruction of the cartilages and bones of the nose. This nasal inflammation sometimes extends downward through the pharynx into the larynx, occasioning a hoarseness of the cry often observed in syphilitic children. Great or small (mucous) patches of livid excori- ation appear on the buttocks, legs, and trunk, oozing a little thiddsh fluid, which partly scabs into a dark crust ; perhaps these patches be- come the seat of true ulceration, especially around the anus and in the groin. Among the scabbed excoriations and scattered patches may appear a roseolar eruption, the tint of which is particularly livid, and soon assimies the coppery-brown. Usually there are papules scattered SYMPTOMS. g(33 througli the eruption, either small and acuminated, or broad and flat ; the latter in convenient situations, kept moist and warm by being over- lapped by skin, become mucous patches. Papules appear by preference about the palms, soles, and buttocks. Subcutaneous tubercles are seen in some cases. Pustules are not wanting in feeble children, but the excoriation and mucous patch of the skin are most common and most characteristic. Infantile pemphigus is encountered in syphilitic children. That it may occur from simple cachexia, without any virulent cause, has been hotly contended, and is exceptionally correct, but it is vastly more com- mon to find it upon syphilitic subjects. It indicates a bad type of disease. The child may be, and not infrequently is, born with it, or it may come out with other manifestations of the disease some days after birth. It consists in bull®, varying in size from a pin's-head to a penny — usually about as large as a split pea — filled with sero-pus, which rapidly becomes purulent, situated upon a reddened, excoriated base, surrounded by a red areola, which latter is sometimes slightly thickened and raised. When the bullae burst, thickish scabs with a green tinge form, and underneath them ulceration goes on. The palms and soles are the favorite seats of syphOitic pemphigus, but in bad cases the eruption spreads from these points until it may cover the entire body. Almost all cases die, though occasional recoveries have been noted. The nails in children do not suffer from syphilis so often as they do in adult life, yet they are not exempt. The best description of the changes in the nails in children is given by Hutchinson ; ' one or more naUs on each hand split and become dry, cracked, jagged. The matrix may suppurate, and the nails be shed several times. The affection is very rare. It runs a chronic, obstinate course. The eyes of young infants do not suffer very often, except from con- junctivitis in connection vnth the coryza. The testicles usually escape, but may become the seat of gummy deposit. The bones, except of the nose, are not often involved in the first series of troubles of the infant. If it survive these, later on bony le- sions develop just as in the adult, nodes of the skull, clavicle, tibia, etc., and other periosteal and interstitial bony lesions. Induration in the shafts of the long bones of children, and a softening of the cartilages at the epiphyses, tending to terminate in suppuration under the peri- osteum, are met with upon syphilitic children, and were first pointed out by Bouchut ° as due to syphilis. ViscEEAi. Syphilis est Oheldeek. — Of more importance than the lesions already alluded to, is the visceral syphilis of young children. ' "Pathological Transactions," vol. xii., p. 269. » " Maladies des Enfans nouTeaux-n6s," 1861. 664 INHERITED SYPHILIS. Their tender organs, blighted in the bud, in the early stages of the disease, whUe cutaneous symptoms are still superficial, readily take on interstitial proliferation of connective tissue, and gummy change, which properly (in the adult at least) belong to the later manifestations of the disease. Even the brain and cord do not escape. Schott ' gives a positive example where a gummy tumor of the liver, and another under the anterior cerebral lobes, were found in a syphilitic child born before term with pemphigus of the palms and soles. Case XXVII. of Van Buren and Keyes ' is that of a boy with inherited syphilis, who had an eruption at three weeks. During the fifth year, nodes on the tibia and ulna, and two slight attacks of syphilitic paraplegia. Some cases of hydrocephalus are believed to have been due to inherited syphilis. Gros et Lancereaux, De M6ric, Roger, Hutchinson, Lancereaux, and HiU,^ give cases of idiocy with inherited syphilis. Several cases of severe nervous syphilis with inherited disease are re- ported by J. HughUngs Jackson.* i The internal organs most frequently found affected in children dying with inherited syphilis are, the thymus, liver (where Thiry, Wedl, Zeissl, Shott, Lancereaux, TesteKn, and others, have observed gummy tumor in inherited disease), lungs less often; peritonaeum, kidneys, spleen, brain, cord, etc. The lymphatic ganglia are liable to enlargement in inherited syphilis (Hutchinson, Lancereaux, Rivington), and the supra- renal capsule does not escape (Huber, Hennig). The changes occurring in these organs have already been detailed in connection with similar lesions in the adult. The testicles suffer in inherited as well as in ac- quired disease. The lesions have been detailed (p. 433). The authors have seen a case, as have Worth,' Bryant,° and others. Lancereaux,' referring to cases by FOrster, Eberth, Roth, and Oser, describe an enteritis as an essential evidence of hereditary syphilis in new-born children. The lesions are rounded indurations of variable size, situated upon the surface of Peyer's patches, and on the solitary glands, some covered with smooth mucous membrane, others ulcerated deeply. The mass shows, on section, numerous small round cells and connective- tissue hyperplasia. The thymus in syphilitic babies is nearly always diseased {see page 643). The prognosis in inherited syphilis is bad, just in proportion to the date of appearance of the symptoms, and the general physical condition of the child. Nasal catarrh, if severe enough to hinder nursing, vomit- ing and diarrhoea, as interfering with nutrition and indicating implica>- tion of the liver, make the prognosis worse. If a child is born with a general eruption, death is almost inevitable. ' " Jahrbiicher der Kinderheilkunde," 1861. ' IjOc. at. 3 Page 224. ■i " The Transactions of St. Andrew's Medical Graduates' Association,'' vol. i., 1868. ' Medical Times and Gazette, 1862. « Ibid., 1863. ' Op. dt. SYPHILITIC COUNTENANCE. 6g5 The Syphilitic Cottntenan-cb.— To Mr. Hutchinson ' the profession is indebted for the development of many important and interesting facts in connection with the subject of congenital syphilis, especially as in- delibly stamped upon the individual after his earlier childhood. These appearances, until Hutchinson called attention to them, had either been ignored, unobserved, or attributed to scrofula. They are briefly these. A child who has inherited syphilis, who perhaps has never shown marked evidences of the disease in babyhood, becomes somewhat blighted in his development. His skin is coarse, earthy, pallid, perhaps showing cicatrices. He has a squared face, prominent cheek-bones, overhanging forehead, and a sunken bridge to his nose. He looks prematurely old and grave, and may have chronic catarrh, interstitial keratitis, ulceration of the throat, or cicatrices of the mouth or soft palate. The permanent teeth are irregularly set and defective, especially the two middle upper incisors, which Hutchinson calls the " test-teeth." These are small, often converging, sometimes diverging. The cutting-edge of the teeth is some- times narrowed, rounded off, whence the name " pegged teeth." They are stunted and badly developed, often marked with seams (lines, ridges) in front, and of a dirty-brownish color, but their chief peculiarity is found in their edges, which, being thin when cut, break off centrally, leaving a " broad, shallow, vertical " notch on the lower border of the tooth. This becomes smoothed down with advancing years, but the size and shape re- main to indicate a blighted tooth. Not all children with inherited syphilis have these teeth, but many do, and the sign is well worthy to be care- fully watched for. It not infrequently happens that one child of a family has the notched, pegged teeth, while brothers and sisters born after- ward escape, yet still any of these latter may late along in childhood develop some periosteal thickening, some indurated scaly patch on the skin, or mild, raised, excoriated, insensitive patch of thickening on the mucous membrane of the mouth, which the practised eye and touch rec- ognize as syphilitic, and which melts away, under the magic treatment boldly administered, like snow before a summer's sun. Treatment of Inherited Syphilis. — Before a chUd is born, if there is reason to believe that it is syphilitic, its treatment should be commenced by bringing the mother mildly under the influence of mercury. In this way abortion may be averted, and the child's life saved." A positive effect of mercury should be aimed at, without, if possible, producing any diarrhoea or intestinal irritation, which are recognized by most observ- ers to be in themselves efficient causes of abortion. Consequently the proper treatment for a syphUitio pregnant woman is inunction. By common consent also, the treatment of the child is by inunction. The oleate of mercury, five to ten per cent., may be used, in place of the ' " Means of recognizing the Subjects of Inherited Syphilis in Adult Life," Medical Times and Gazette, September, 1858, p. 26B, and art. " Eeynolda's System of Medicine." 2 See Thurmann's case, note, page 52. QQQ INHERITED SYPHILIS. more irritating mercurial ointment, bj Brodie's well-known method, being spread upon a flannel belly-band, or it may be alternated between the soft skin in the flexures of the axilla, elbow, and knee. The quantity should be decreased as soon as the symptoms begin to yield, and the inunctions continued for many months after the disappearance of all symptoms. Gray powder is largely used in infantUe syphilis, in doses of the fraction of a grain, but there is every objection to internal treat- ment, as being uncertain in dose (even a healthy infant constantly re- gurgitates and vomits), and liable to irritate. There is no conceivable objection to inunction, even if the body were one vast ulcerated mucous patch. The extra care required for the inunction would have to be given to the child in any case. If the infant survives a few months, iodide of potassium may be administered through its nurse. Locally the sores require only cleanliness, with (in special cases) some ointment or dusting with calomel and iodoform. GEE"EEAL liffDEX. Abortion due to syphilia 661 Abscess complicating stricture 162 perineal 79 Acne, syphilitic , 576 Adenitis, simple 79, 600 syphilitic 528, 651, 633 virulent 602 Alopecia, syphilitic 550 Aphasia, syphUitio 655 Apoplexy, syphilitic 647 Aquo-capsulitis, gonorrhoea! 86 Arteries, syphilis of the 635 Arthropathy, syphilitic 627 Aspermatism 465 Aspirator 132 B. Balanitis 19 Bladder, anomalies and deformities of. 220 atony of the 180, 184, 249 bar at the neck of the 176 catarrh of the 245 cancer of the 255 chorea of the 231 cysts of the 255 extrophy of the 220 foreign bodies in the 226 hernia of the 223 hypertrophy of the 224 inflammation, acute 240 inflammation, chronic 245 injection of the 197 irritability of the 234 puncture (supra-pubic) 130 puncture through rectum 130 rupture of the 146, 226 sacculation of the 180 tubercle of the 254 tumors of the 265 villous growth 257 wounds of the 224 Bougies 103 bulbous use of 134 Brain, syphilis of the 664 Bubo, chancroidal 601 Bubou d'embl6e 503 Bubo, simple 500 syphilitic 628 Bubo, treatment of 504 virulent 503 Buck's fascia 3 Cachexia, syphilitic tertiary 691 Calcification of the penis 23 Calculus, renal 357 vesical 258 vesical, choice of method of cure. 273 vesical, encysted method of forma- tion 180 Calculus, prostatic 215 Capsules 64 Caries, dry, syphilitic 632 Castration 442 Catarrh of the bladder 245 Catheterism 32 Catheters 108 Catheter, tying in of 190 Chancre, syphilitic, course of. 526 cicatrix of 515 complications of 526 diagnosis of. 631 discharge from 614 duration of 523 Hunterian 625 incubation of. 612 induration of 512 inoculation of. 615 methods of contagion 622 mixed 627 multiple inoculation of 617 number of 623 pain in 614 situation of. 623 size of. 623 transformation into mucous patch. 627 transmissibility to animals 512 treatment of 528 ulceration of 614 urethral 525 varieties of. 624 Chancroid, auto-inoculability of 479 cause of 477 complications of. 488 diagnosis of 494, 631 frequency of. 480 668 GENERAL INDEX. PAGE Chancroid, methods of contagion 481 phagedenic 490 phagedenic, treatment of 494 prognosis 494 symptoms 483 transmissibUity to animals 411 variations from natural type 485 treatment of (general) 500 treatment of (local) 495 treatment of (prophylactic) 494 Chill, urethral 45 Chordee 57 treatment of 66 Chorea of the bladder 245 syphilitic 655 Choroiditis, syphilitic 614 Circumcision 10 Colic, renal 359 Conjunctiva, syphilis of the 601 Conjunctivitis, gonorrhoeal SI Continuous dilatation of stricture 165 Copaiba 64, 69 Cord spermatic, diseases of the 46Y spermatic, hematocele 396 spermatic,hydrocele 409 spermatic, hydrocele, encysted 410 spinal, syphilis of the 656 Cornea, syphilis of the 602 Corpora cavernosa 1, 23 chronic inflammation of 24 Corpus spongiosum 2 rupture of 1 Countenance, syphilitic, in inherited dis- ease 665 Cowper's glands 29 Cowperitis 11 Cremaster, spasm of the 467 Cryptorchidism 390 Crystalline lens, syphilis of the 612 Cubebs 68 Curve of the urethra 29 of urethral instruments 31 Cut-off muscle .' 28 Cystitis 240 Cystitis (gonorrhoeal) 243 Cystocele 223 Cychtis, syphilitic 612 D. Dactylitis, syphilitic 622 Dilatation of stricture 149 Dilating urethrotomes.'. 123 Divulsion, instruments for 114 Dry gonorrhoea (note) 76 Ear, syphilis of the 619 Ecthyma, syphilitic (superficial) 577 syphilitic 592 Eczema marginatum 383 syphilitic 579 Elephantiasis scroti 386 Encephalitis, syphilitic 646 PASl Endoscope 74 Epicystitis • 240 Epididymitis 415 diagnosis 423 pseudo-tubercular 428 sterility due to 421 syphilitic 432 treatment 424 tubercular 429 Epilepsy, syphilitic 655 Epispadias 39 Epithelioma penis 22 scroti 386 Erotomania 464 Extravasation of urine 141 Exstrophy of the bladder 220 Eye, syphilis of the 619 P. False passage in urethra 157 passage in urethra, how to avoid. . 158 Filiform bougies 104 Fistula of urethra, complicating strict- ure of 163 ■with loss of substance 166 Folliculitis 77 Fungus of testicle 436 G. Glands of Tyson 2 Glans penis 2, 18 Gleet 59 treatment of 70 Glossitis, syphilitic 639 Gonorrhoea 52 aural 53 bastard 56 buccal 53 complications of 77 course of. 68 duration of. 68 nasal 53 sicca 76 sequeliE of. 75 symptoms of. 66 treatment of (abortive) 61 treatment of (methodic) 62 umbilical 53 Gravel 357 Guide, filiform, soft 103 whalebone 104 H. Haematocele of the spermatic cord 396 of the testicle 393 Hsematuria 139, 232 Heart, syphilis of the 634 Hemiplegia, syphilitic 654 Hermaphrodism 38 Hernia of the bladder 223 Hepatitis, syphilitic , 641 Herpes progenitalis 18 GENERAL INDEX. 669 Herpes, syphilitic 579 Hydrocele 397 congenital 405 of hernial sac 406 of hernial sac (spurious) 407 of spermatic cord 409 of spermatic cord (encysted) 410 of testicle (encysted) 407 Hydro-nephrosis 370 Hygiene of the urethra 40 sexual 40 Hypodermic injection of mercury 560 Hypospadias 38 I. Impotence 446 false 451 nervous 453 symptomatic 449 true 447 Incontinence of urine 140, 229 Infiltration of urine 143 of urine, complicating stricture . . 161 Inherited syphilis 660 Injection of the bladder 197 of deep urethra 72 in urethral inflammation. . . 66, 69, 73 Inooulability of chancroid 479 Insanity, syphilitic 655 Intestine, syphilis of the 640 Inunction cure of syphilis 662 Iodic eruptions 568 Iodides, bad effects of 566 effect of, on mucous membranes.. 667 Iodine, methods of administering 669 lodism 567 Iritis, gonorrhceal 86 syphilitic 605 Irritability of the bladder 136, 234 Irritable stricture 102 Irritable testis 444 Jaundice, syphilitic 550 Keratitis, syphilitic, interstitial 603 Kidney, ablation of. 379 cancer of 376 colic 359 contusions and wounds of. 351 cysts of. 373 diseases of 350 hydatids of the 373 stone 367 stone, treatment of 367 syphilis of 380 tubercle of 374 Lacuna magna 29 Lafayette mixture 64 Larynx, syphilis of the , 636 Lithotomy. 324 complications in 347 high operation 346 instruments required for 332 lateral operation 332 lateral operation in children 343 median operation 344 statistics of 329 Lithotrite, introduction of 299 Lithotrity 280 after-treatment 315 complications in 310 impaction of fragments in urethra. 293 iu children 322 instruments required for 284 in the female 323 mancEUTres for catching fragments 304 precautions in crushing. 303 preparatory treatment for 281 subsequent crushiugs 307 Liver, syphilis of the 641 Lungs, supplies of the 637 Lymphatic glands, of the 561, 633 Lymphitis, simple 605 syphilitic 530 virulent 506 m. Mastitis, syphilitic 634 Masturbation 454 Mercury, bad effects of. 557 methods of administering 669 by fumigation 560 by hypodermic injection 660 by inunction 562 by the stomach 563 Mixed chancre 627 Mixed treatment of syphilis 665 Monorchidism 390 Mucous patches 686 Mydriasis, syphilitic 604, 658 Myosis, syphilitic 658 N. Nephralgia 363 Nephritic colic 359 Nerves, special, syphilis of. 667 spinal, syphilis of 660 Nervous system, syphilis of the 644 Neuralgia of the prostatic urethra 217 of the vesical neck 234 Neuritis optica, syphilitic 616 O. (Esophagus 640 Onychia, syphilitic 621 Orchitis 412 syphilitic 433 Ophthalmia, gonorrhceal 85 Osteo-periostitis, syphilitic 630 Oxaluria 366 670 GBNEEAL INDEX P. PAGE Pachymeningitis 645 Pancreas, syphilis of the 642 Paralysis of the bladder 252 reflex urinary. 141, 656 Paraphimosis 15 with strangulation 16 without strangulation 18 Pediculi pubis. . .T 384 Pemphigus, syphilitic 578 syphUitic, mfantile 663 Penis 1 absence of the 6 amputation of the 8 anomalies of the 4 calcification of the 23 cancer of the 8, 22 contusions of the 6 cutaneous affections of the V double 4 fracture of the 6 sheath of the 2 tumors of the 7 wounds of the 6 Pericarditis, syphilitic 634 Peri-cystitis 240 complicating stricture 164 Perineal abscess . . . .' 79 Peri-nephritic abscess 366 treatment of 369 Peri-prostatic abscess -. 209 Peritonitis, syphilitic 643 Periurethritis 78 ■ Phagedena 490 treatment of. 498 Phimosis 13 inflammatory 14 operations for 10 Pollution, diurnal 461 nocturnal 460 Posthitis 19 Prepuce 9 Prepuce, anomalies of 10 Priapism 464 Prostate, abscess of the 209 anatomy of the 171 atrophy of the 173 cancer of the 214 concretions in the 215 congestion of the 205 deformities of the 172 diseases of the 170 hypertrophy of the 173 hypertrophy of the, cause 173 hypertrophy of the, course of. 183 hypertrophy of the, complicating stricture 165 hypertrophy of the, diagnosis. . . . 185 hypertrophy of the, internal reme- dies in 201 hypertrophy of the, symptoms and results of 176 hypertrophy of the, treatment 193 hypertrophy of the, with retention 186 injuries of the 172 PASI Prostatitis, follicular. 211 gonorrhoeal 208 parenchymatous 206 tubercular , 213 Prostatorrhoea. , 211 Pseudo-tubercular epididymitis 428 Psoriasis, syphilitic 580 syphilitic, palmar and plantar. . . . 581 Ptosis, syphilitic 601 Pustular syphilide, general 576 syphilide, in groups 593 Pyelitis 362 treatment of 366 Pyo-nephrosis 362 B. Renal colic 359 Resilient stricture 102, 116, 166 Retention of urine 228 complicating stricture 159 complicating impassable stricture. 160 complicating prostatic hypertrophy 186 Rheumatism, gonorrhoeal 80 Roseola, syphilitic 572 Eupia, syphilitic 592 S. Sacculation of the bladder 180 Salivation 557, 567 Sandal-wood oil 64, 69 Sarcocele 432 Satyriasis 464 Scale plate Ill Scaly patches of mucous membranes, syphilitic 588 Scrotum, cancer of 386 diseases of 381 Self-abuse 454 Seminal vesicles, diseases of 473 inflammation of 474 tubercle of .'. . 476 Sexual hygiene 40 Sore throat, syphilitic 684, 697 Sound, introduction of 32 Sound, steel 110 cupped 463 tunneled 110 Soundmg 271 Spasmodic stricture of urethra 93 Spermatic congestion 407 Spermatocele 407 Spermatorrhoea 461 Spleen, syphilis of the 641 * Sterility 454 Stomach, syphilis of the 640 Stone in the bladder 258 causes of. 268 complicating stricture. 140 diagnosis of. 267 selection of method of cure. 273, 329 symptoms of 264 treatment of (local) 327 GENERAL INDEX. 671 ri, , PAGE htone in the bladder, treatment of, sol- vent 328 preventive 325 in the kidney 357 prostatic 215 Strapping the testicle !!.'.'!!.'.' 426 Stricture of the meatus 120 135, 168 Stricture of the arethra 92 irritable I02 organic ".'.'.'.! ..... 98 spasmodic 93 resihent '162, 166 (organic) cause 98 date of appearance 101 diagnosis I34 number 96 lesion ^ 97 seat 96 symptoms and results '. 135 traumatic 99, 156 treatment of 148 Suppression of urine 352 Syphilide, erythematous 8Y2 bullous e^S papular 674 pigmentary 578 pustular, general 676 in groups 593 squamous 580 tubercular, general 582 in groups 582 varicelloid 579 vesicular 679 Syphilides 538 cicatrices of. 547 general characteristics of. 645 secondary 572 tertiary 690 l^yphilia 506 antagonism with cancer 607 bubo of 628 countenance in inherited 668 duration of 540 fever in 648 general 635 glandular engorgement in 661 incubation of. 512 secondary 648 influence of gout and scrofula on. 544 interval before absorption of virus 608 inherited 660 inherited, date of appearance of symptoms 662 inherited, symptoms of 662 inherited, treatment of. 666 visceral 664 intermediary 637 irregular 537 lymphitisof. 529 malignant 537 methods of contagion 522 methods of transmission 520 primary 536 secondary 636 Syphilis, second attacks of secretions capable of transmitting prognosis of. tertiary transmissibility to animals treatment of treatment of, early treatment of, late treatment of, proper duration of., treatment of, hygienic treatment of, mixed treatment of, tonic , unity and duality of visceral of arteries of aponeuroses of bone of brain of choroid of cord (spinal) of cornea of ear of eye of fingers of glands, lymphatic of gland, mammary of heart of intestine of iris of joints of larynx of liver of lung of muscle of nail of nail, infantile of nervous system of nervous system, lesions of nervous system, symptoms of nervous system, prognosis of nervous system, treatment of nervous system, special nerves . of oesophagus of orbital nerves of orbit (periostitis) of optic nerve of pancreas of retina of spleen of stomach of tendons of testicle of toes of tongue of vascular system. of vitreous humor Syphilization 477, T. Table (diagnostic) of bubo of syphilis and of chancroid of chancre, chancroid, herpes, and ulcerated abrasion PiOH , 510 518 638 636 511 562 666 665 570 663 665 654 608 634 635 625 628 664 614 666 603 619 600 622 561 634 634 640 608 627 636 641 637 626 621 663 644 646 649 660 681 657 640 617 618 616 640 615 641 640 625 432 622 639 634 611 665 634 681 672 GENEEAL INDEX. PAGE Table (diagnostic) of cystitis of the neck, and prostatitis 244 gonorrhoea! and simple rheuma- tism 85 gonorrhoeal ophthalmia and con- junctivitis 89 hydrocele and incarcerated hernia. 400 hydrocele (congenital) and hernia. 406 lymphitis of syphilis and of chan- croid 635 orchitis (inflammatory) and epi- didymitis 423 tubercle, syphilis, cancer, and sar- coma of the testicle 440 Testis, atrophy of 392 cancer of 436 cyst (dermoid) of 443 diseases of 38*7 fungus of. 436 hypertrophy of 392 irritable 444 neuralgia of 445 pseudo-tubercle of 428 sarcoma of. 439 strapping the 426 syphUis of 432 tubercle of 429 Thymus, syphilis of the 643 T