(Enlumfaia lltutrcrattg ttt tty dttg of Nfuj fork (Eolljpgp of pi|g0tnanH and ^ttrgpana fofmnr? Uthrary MANUAL OF VENEREAL DISEASES. BY JAMES R. HAYDEN, M. D, CHIEF OF CLINIC AND INSTRUCTOR IN VENEREAL AND GENITO-URINARY DISEASES AT THE COLLEGE OF PHYSICIANS AND SURGEONS (COLUMBIA UNIVERSITY), NEW YORK ; VISITING GENITO-URINARY SURGEON TO THE NEW YORK CITY HOSPITAL; ASSISTANT VISITING GENITO-URI- NARY SURGEON TO BELLEVUE HOSPITAL. With Fifty-four Illustrations, LEA BROTHERS & CO., NEW YORK AND PHILADELPHIA, 1898. KC2QI Entered according to the Act of Congress, in the year 1898, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. PRESS OF THE NEW ERA PRINTING COMPANY. LANCASTER, PA. PREFACE. In this, the second edition of this little volume, which like its predecessor is designated for the use of students as well as practitioners, the author has endeavored to give, in a clear and compact form, a practical working knowledge of the three Venereal Diseases, Gonorrhoea, Chancroid and Syphilis, together with their complica- tions and sequelae. The history and statistics of these diseases have been purposely omitted, as not belonging to an epitome such as this book is intended to be. A new chapter on the care and use of urethral instruments has been added, as have also many new illustrations. The text has been thoroughly revised, thus bringing the subjects up to date. It is hoped that the value of the book will be enhanced, and that in its new edition it may more fully merit the very kind reception accorded to the original issue. JAMES R. HAYDEN. 107 WEST 55TH STREET, NEW YORK, September, 1898. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofvenerealOOhayd PAKT I. GONORRHOEA AND ITS COMPLICATIONS. PAGE CHAPTER I. GONORRHOEA 17-21 CHAPTER II. Acute Anterior Gonorrhoea or Urethritis . 22-26 CHAPTER III. Acute Posterior Gonorrhoea or Urethritis 27-28 CHAPTER IV. Treatment of Acute Anterior Gonorrhoea or Urethritis 29-39 CHAPTER V. Treatment op Acute Posterior Gonorrhoea or Urethritis 40-41 CHAPTER VI. Complications of Acute Anterior Gonor- rhoea or Urethritis, and their Treat- ment 42-51 CHAPTER VII. Complications of Acute Posterior Gonor- rhoea or Urethritis, and their Treat- ment ....... 52-61 vi CONTENTS. PAGE CHAPTEE VIII. Chronic Gonorrhoea, or Urethritis . . 62-63 CHAPTEE IX. Chronic Anterior Gonorrhoea or Urethritis 64-65 CHAPTEE X. Chronic Posterior Gonorrhoea or Urethritis 66-67 CHAPTEE XL Treatment of Chronic Gonorrhoea or Ure- thritis 66-69 CHAPTEE XII. Treatment of Chronic Anterior Gonorrhoea or Urethritis 70-74 CHAPTEE XIII. Treatment of Chronic Posterior Gonor- rhoea or Urethritis .... 75-84 CHAPTEE XIV. Gonorrheal Ophthalmia .... 85-87 CHAPTEE XV. Gonorrheal Eheumatism .... 88-92 CHAPTEE XVI. Stricture of the Urethra .... 93-105 CHAPTEE XVII. Diaojnosis of Stricture .... 108-120 CONTENTS. vii PAGE CHAPTER XVIII. Treatment of Stricture .... 121-150 CHAPTEE XIX. Urethral Instruments —Their Care, Lubri- cation and Use 151-158 PART II. THE CHANCKOID. CHAPTER XX. The Chancroid . ... . . . 159-165 CHAPTER XXI. Treatment of the Chancroid and its Com- plications 166-172 PART III. SYPHILIS. CHAPTER XXII. Introduction 173-177 CHAPTER XXIII. The Initial Lesion of Syphilis . . . 178-183 CHAPTER XXIV. The Secondary Period ..... 184-185 viii CONTENTS. CHAPTER XXV. The Syphilides 186-206 CHAPTER XXVI. Syphilis of the Appendages of the Skin . 207-209 CHAPTER XXVII. Syphilis of the Mucous Membranes . . 210-212 CHAPTER XXVIH. Syphilis of the Digestive Organs . . 213-220 CHAPTER XXIX. Syphilis of the Respiratory Organs . . 221-224 CHAPTER XXX. Syphilis of the Organs of Circulation . 225-226 CHAPTER XXXI. Syphilis of the Genito urinary Organs . - 227-229 CHAPTER XXXII. Syphilis of the Nervous System . . 230-235 CHAPTER XXXIII. Syphilis of the Muscles .... 236-238 CHAPTER XXXIV. Syphilis of the Fingers and Toes . . 239-240 CHAPTER XXXV. Syphilis of the Bones, Cartilages and Joints 241-245 CONTENTS. ix PAGE CHAPTER XXXVI. Syphilis of the Eye 246-254 CHAPTER XXXVII. Syphilis of the Ear 255-256 CHAPTER XXXVIII. Prognosis of Syphilis 257-258 CHAPTER XXXIX. Treatment of Syphilitic Lesions . . 259-267 CHAPTER XL. Constitutional Treatment of Syphilis . 267-278 CHAPTER XLI. Hereditary Syphilis 279-281 CHAPTER XLII. Lesions of Hereditary Syphilis . . . 282-296 CHAPTER XLIII. Treatment of Hereditary Syphilis , . 297-299 PART I. GONORRHtEA AND ITS COMPLICATIONS. CHAPTER I. INTRODUCTION. Gonorrhoea, also called urethritis, blennorrhea, blennorrhagia and clap, is an infectious, virulent and suppurative process, attacking most frequently the mu- cous membrane of the urethra and the structures in anatomical relation with it. The mucous membrane of the mouth, the eye, the anus and the rectum may also be the seat of the blennorrhagic process, either as a result of accident, or of unnatural practices between persons of the same or the opposite sex. It is the most common and most venereal of all of the venereal diseases, and occurs with the greatest fre- quency between the twentieth and thirtieth years. Throughout the following pages gonorrhoea and ure- thritis will be used as synonymous terms. DIAGNOSIS. The diagnosis of acute gonorrhoea or urethritis is, as a rule, readily made from the purulent urethral dis- charge, the redness and swelling of the meatus, painful urination, and the period of incubation. There are cases, however, in which it must be differ- 2 17 18 GOXOERHCEA AND ITS COMPLICATIONS. entiated from balanitis, balano-posthitis, chancre of the meatus or urethra, and chancroids of the meatus. In balanitis or balano-posthitis, if the prepuce be re- tracted far enough to expose the meatus, the parts can then be carefully wiped off and examined, and a correct diagnosis made, as the pus will be seen to exude, either from the meatus or from between the prepuce and glans. Chancre of the meatus or within the urethra gives rise to a slight mucous or muco-purulent discharge, with induration of the sore and inguinal lymphatic glands. Endoscopic examination will reveal the lesion if it be situated in the urethra. Chancroids of the meatus cause a purulent discharge, which is rusty-brown in color and auto-inoculable. They may cause some inflammatory thickening of the surrounding tissues, but never true induration. PROGNOSIS. The prognosis of gonorrhoea or urethritis is, as a rule good, provided the patient is otherwise healthy and will- ing to carry out minutely all of the details of treat- ment, until he is pronounced cured by his physician. There are cases of course, in which serious and some- times even fatal complications occur, such as gonorrhceal rheumatism, pericarditis, endocarditis, peritonitis, pyae- mia and lesions of the cord : so that w r e must always re- member, and inform our patients, that gonorrhoea is at best a very grave and far-reaching disorder, and that treatment should not be relaxed until the urethra, and the structures in anatomical relation with it, have returned to their normal conditions. GONORRHOEA. 19 Provided everything goes smoothly, we can usually promise a cure in from four to eight weeks. INFECTION. Gonorrhoea], infection may be either direct or medi- ate. Direct infection is the transference of gonorrhoeal pus from the genitals of one person to those of another during coitus. This is the usual and most common mode of infection, although it may also result from un- natural practices (gonorrhoea of the anus, rectum and mouth). Mediate infection may and does sometimes occur, as when instruments, syringes, towels, dressings or the fingers have been contaminated with gonorrhoeal pus and then brought in contact with the meatus or urethral mucous membrane. ETIOLOGY. In spite of the vast amount of scientific and valuable work done in this field since the discovery of the gono- coccus by Neisser, in 1879, the etiology of gonorrhoea is not as yet an absolutely settled and fixed question, and the physician should therefore exercise the greatest care and precaution before giving his positive opinion as to its origin, for on his decision may rest the honor of wife or husband. Although the vast majority of cases of gonorrhoea are due to the gonococcus Neisser, yet there are some in which this pathogenic agent cannot be found, and we must therefore attribute the disease to other micro- organisms (staphylococci and streptococci). Clinically, 20 GONORRHOEA AND ITS COMPLICATIONS. these cases are sometimes just as severe and have as many complications as those in which the gonococcns is found. Men may contract gonorrhoea from women either dur- ing or immediately after the menstrual epoch. These cases are usually severe in character, and may be ac- companied by any of the various complications. It is also possible for a man to contract gonorrhoea from the secretions of the uterus, a lacerated cervix and perineum, and vulvo-vaginal secretions due to uncleanli- ness. All of the foregoing facts have been demonstrated by the most competent observers, both clinically and micro- scopically, and should therefore be given due thought and consideration, before giving an absolute and positive opinion as to the etiology of every case of gonorrhoea. THE GONOCOCCUS. The gonococcus, Neisser, is a diplococcus, measuring from 0.8 to 1.6 micromillimeters in length, and from 0.6 to 0.8 micromillimeter in breadth. The gonococci are arranged in pairs, each half of the diplococcus being kidney-shaped in appearance, with their flat or inner borders in apposition, which gives the entire coccus the appearance of a coffee-bean. They grow and multiply very rapidly, each pair splitting into four by means of a cleavage at right angles to the median fissure. The gonococci are always grouped in twos, fours, eights, etc., and never arranged in chains; they are found within the pus-cells, upon the epithelial cells, and among and between these cells. Staining. The entire glans penis and preputial cavity should be thoroughly cleansed, and the pus at the GONORRHCEA. 21 meatus squeezed out, and wiped off with sterile gauze. A sterilized platinum loop is then passed into the ure- thra to obtain the secretion for examination ; this is spread in a thin film on a clean glass slide, allowed to dry in the air, and then passed through the flame of an alcohol lamp two or three times, being careful to have the pus side turned up. A drop of a dilute watery solution of methyl-blue is then applied with a glass rod, and left on for from two to three minutes, when it is washed off with distilled water. The specimen can now be examined in water, or carefully dried, mounted in Canada balsam, and studied with a high-power oil-im- mersion lens. For other methods of staining, and for culture, and inoculation experiments with the gonococ- cus, the reader is referred to more exhaustive works on the subject. Progress of the gonococcus. The gonococci, having been deposited on the superficial epithelial layer of the urethra, increase rapidly in numbers, and give rise to a scant serous discharge, which appears at the meatus, and which consists of serum and epithelial cells, upon and between which are seen gonococci in varying num- bers. At the end of a few hours, or a day or so, the gonococci penetrate the cement-substance between the epithelial cells and pass downward toward the sub- epithelial connective-tissue layer ; this stage of the invasion being marked by the onset of a purulent dis- charge which destroys and throws off the urethral epithelium, thus giving free access to further gonococcus invasion. The purulent discharge is made up of pus- cells and serum, the gonococci being found principally in the pus-cells, although some free groups may be seen. CHAPTER II. ACUTE GONORRHOEA, OR URETHRITIS. Acute gonorrhoea, or urethritis, is spoken of as being either anterior or posterior, according to the portion of the urethra involved by the inflammatory process. If the disease be situated in the anterior urethra — that is, between the meatus urinarius and the anterior layer of the triangular ligament — it is called anterior gonorrhoea, or urethritis ; but, if in the posterior urethra, which includes that portion of the canal situ- ated between the anterior la} T er of the triangular ligament and the bladder (membranous and prostatic urethra), it is called posterior gonorrhoea, or urethritis. When the entire length of the urethra is involved, which is usually the case, we speak of it as an antero- posterior gonorrhoea, or urethritis, and if the disease has extended into the bladder, as a urethro-cystitis. SYMPTOMS OF ACUTE ANTERIOR GONORRHOEA, OR URETHRITIS. After a period of incubation varying in the majority of cases from two to seven days the symptoms of acute anterior gonorrhoea, or urethritis, make themselves manifest, although in some subjects they may be de- layed for ten, fourteen or twenty days, but such long periods of incubation are, as a ride, rare. For clinical purposes the course of the disease is best divided into 22 ACUTE ANTERIOR GONORRHOEA. 23 three stages, as follows : the prodromal stage, the acute stasre and the stage of decline. Prodromal stage. This stage is marked by prick- ling or tickling sensations in or in the region of the meatus, which becomes reddened, slightly swollen and glued together, or filled with a grayish-white secretion. Sometimes decided pain is felt in the glans, but in other cases pain is only experienced during and after urination. This local irritation of the fossa navicularis causes in some individuals a very marked increase in sexual desire, which, if indulged in at this time, greatly aggravates the already existing inflammation. At the end of the second or third day all of the above symptoms are more marked. The meatus is pouting in appearance and surrounded by an area of redness, the secretion is increased in amount and as- sumes a decidedly purulent character, the pain is sharper and during urination gives rise to a decided burning sensation in the urethra, which is spoken of as ardor urinse ; this may be continuous, or only felt during and after the act. Acute stage. In this stage, which usually begins at about the end of the first week, the discharge is pro- fuse, greenish-yellow in color, creamy in consistence, and sometimes tinged with blood ; the lips of the meatus and entire glans penis are bright red in color, hot and swollen ; the oedema extends from the lower angle of the meatus into the fraenum, and thence into the pre- puce, in this way being liable to produce either a phim- osis or paraphimosis, according to the conformation of the parts. The lymphatics on the dorsum of the penis may become swollen and painful, and as they communi- 24 GONORRHOEA AND ITS COMPLICATIONS. cate with the ganglia in the groins may cause them to become enlarged and tender. As the gonorrhoea! pro- cess extends down the urethra, it sometimes causes an inflammation of one or more of the periurethral follicles, which can be felt beneath the skin as small, shot-like bodies. In severe cases the corpus spongiosum becomes hard and painful, and if this condition extends to the bulbous portion, patients experience great pain in sit- ing down, as pressure is then brought directly on this swollen and inflamed mass of erectile tissue. Every act of urination is now accompanied by intense suffer- ing as the acid urine forces its w r ay through the urethra, whose calibre has been greatly lessened by the oedema of its mucous membrane. The stream assumes various shapes and sizes, and in severe cases comes only in drops, or we may have complete retention, from com- pressor spasm, and swelling of the mucous membrane. Chordee and painful erections now come on, especially at night, wdiich rob the patient of his rest, and in this way cause debility and general malaise from loss of sleep. True chordee is due to infiltration of the meshes of the corpus spongiosum, with inflammatory material, which prevents its full extension when the corpora caver- nosa become erect, thus causing the penis to curve down. It is a rare complication of acute gonorrhoea, as com- pared to painful erections, which occur in almost every case. Declining stage. This stage usually begins at about the end of the second or beginning of the third week, and is marked by a general improvement in the patient's condition. Urination becomes less painful, the erec- tions at night disappear, as do also the swelling and ACUTE ANTE RIO R GONORRHOEA. 25 soreness along the corpus spongiosum. The meatus and glans penis begin to assume their normal appear- ance, and the discharge becomes mucopurulent, thinner and sticky in character, until it is so slight in amount as to cause only a gluing of the lips of the meatus in the morning, from which, when separated, a few drops of secretion may be pressed. Relapses are common at this time, as the patient, thinking himself about cured, is apt to indulge in over- exercise, alcoholics or venery, which indulgence is rap- idly followed by a return of all of the acute inflamma- tory symptoms above described. If in acute anterior gonorrhoea, or urethritis, the patient passes the first half of his urine in one glass cylinder, and the second half in another cylinder, the urine voided in the first cylinder will be cloudy from the pus washed out of the anterior urethra, while that passed in the second cylinder will be perfectly trans- parent, as it consists of clear urine from the bladder passed over a now clean urethra. This test, which is known as Thompson's two-glass test, is of great value in differentiating acute anterior from acute posterior gonorrhoea, or urethritis, and for its proper performance the patient should have a con- siderable amount of urine in the bladder and pass an equal amount in each glass ; it is of little value, how- ever, in differentiating chronic anterior, from chronic posterior gonorrhoea, or urethritis. As the opacity in a given urine is not always due to the presence of pus (pyuria), the following table of the late Professor Ultzmann is inserted, which renders this subject clear in a very concise manner. By gradually 26 GOXOBRHCEA AXD ITS COMPLICATIONS. heating the upper half of the urine (in a test tube) to boiling, the opacity — Vanishes Increases Remains unchanged even after addition of acetic acid. If due to acid urates If due to earthy phosphates, carbonates, or pus-corpuscles. Add one or two drops of acetic acid. The dimming is caused by catarrhal secretion, or by bacteria. Dimness vanishes with evolu- tion of gas. Carbonates. Dimness vanishes without evo- lution of gas. Phosphates. Dimness remains unchanged Pus. CHAPTER III. ACUTE POSTERIOR GONORRHCEA OR URETHRITIS. When the gonorrhoeal process passes beyond the anterior layer of the triangular ligament and involves the posterior urethra we speak of it as posterior gonor- rhoea, or urethritis, either acute, sub-acute or chronic. In from eighty to ninety per cent, of all cases of acute anterior gonorrhoea the disease passes rapidly clown the urethra to the bulb, and thence into the posterior por- tion, so that posterior urethritis, instead of being a complication, as was formerly thought, is in reality the usual course of the disease. SYMPTOMS OF ACUTE POSTERIOR GONORRHCEA, OR URETHRITIS. The typical symptoms of acute posterior gonorrhoea, or urethritis, are as follows : A sudden and very marked decrease in the amount of discharge at the meatus, ac- companied by an increased frequency in urination, with inability to hold the urine when the desire comes on, and which is followed by vesical tenesmus, and in severe cases by blood, which comes from the congested vessels of the prostatic urethra, which are ruptured by the spas- modic contractions of the prostatic muscular fibers at the close of urination. The pus from the posterior urethra passes upward into the bladder, thus rendering all the urine uniformly cloudy ; so that if these patients urinate in two glasses 27 28 GONORRHCEA AND ITS COMPLICATIONS. (Thompson's test) both glasses will be cloudy, the jirst a trifle more so than the second, as it consists of turbid urine from the bladder, plus the urethral secretion which it washes out. In some cases the patient has to urinate every few minutes, each act being followed by a few drops of blood and intense pain in the glans penis, prostate and rectum ; in others there is temporary incontinence of urine, due to the extreme irritability of the prostatic mucous membrane, which, when the patient goes to sleep at night, causes painful pollutions that are sometimes blood-stained. Retention of urine may occur at any time from spasm of the compressor urethrse muscle, brought on by the intense local irritation ; therefore the physician should always be prepared for this complication. Vesical tenesmus, if severe, is accompanied by a temporary albuminuria, which disappears as the tenes- mus subsides. The above symptoms vary greatly in different indi- viduals, being very marked in some and mild in others. The duration of the attack depends largely on the treat- ment, and the habits of the patient, lasting anywhere from a few clays to several weeks. If in these cases of acute posterior gonorrhoea, or urethritis, the prostate gland is examined by the finger, per rectum, it will usually be found enlarged (con- gested), hot, throbbing and exquisitely tender; occa- sionally one or both seminal vesicles are involved, but this is a very rare complication in comparison with prostatitis, as has been clearly demonstrated by a vast number of careful and personally conducted examina- tions made during the acute stage. CHAPTER IV. TREATMENT OF ACUTE ANTERIOR GONORRHOEA, OR URETHRITIS. ABORTIVE TREATMENT. The abortive treatment of acute anterior gonorrhoea or urethritis should only be employed during the first day or so of the disease, while the discharge is still mucoid in character, and shows under the microscope only epithelial cells and gonococci, but no pus-cells, as in this stage the gonococci are situated upon the epithe- lium of the urethra, and are therefore in a position to be destroyed by local applications. Unfortunately, patients do not present themselves, as a rule, until the discharge has become purulent in character, when it is then, as a general rule, too late to try any form of abortive treatment, as by that time the gonococci have penetrated the epithelial layer of the urethral mucous membrane, and are therefore beyond our reach. If the abortive treatment has been decided on, the patient should always be informed that it is painful, apt to fail, and may lead to such complications as peri- urethral abscess, posterior urethritis, epididymitis, prostatitis and cystitis. The steps in the procedure are as follows : the patient first urinates, in order to flush out any secretion that may have accumulated in the urethra; then a thoroughly clean No. 12 French soft' 29 30 GONORRHOEA AND ITS COMPLICATIONS. rubber catheter sparingly lubricated with glycerin is passed into the urethra for about four inches ; through this catheter the anterior portion of the canal is irri- gated with a hot boric-acid solution, thrown in gently and slowly by means of an Ultzmann hand-syringe, the solution running from behind forward and escaping at the meatus. The patient then lies down and a Weir's meatoscope (See Fig. 1) is passed into the urethra, the Fig. 1. Weir's meatoscope. obturator removed, and a cotton applicator dipped in silver-nitrate solution of fifteen grains to the ounce is applied to the urethral walls as the meatoscope is slowly and gently withdrawn. In this manner the whole fossa navicularis, which is the seat of the disease at this period, is thoroughly medicated with the silver solution, and the gonococci are destroyed. This application is usually followed in a few hours by painful urination, a profuse purulent urethral dis- charge, sometimes blood-stained, which, if the treatment be successful, subsides in a few days, leaving the patient with a slight muco-purulent discharge, which is readily controlled by a simple astringent hand-injection. The patient in the meantime is kept in bed, on a milk-diet, with cold lead and opium wash around the penis, and given an alkaline mixture internally. The bowels should be moved freely every day by means of TREATMENT OF ACUTE GONORRHOEA. 31 cathartic pills, and the patient allowed to drink liberally of the alkaline mineral waters. The Janet method of treating acute gonorrhoea is much in vogue at the present time, its advocates claim- ing that it will abort the disease in its incipient stage, and cut short the period of acute suppuration if em- ployed at a later date. Ten or twelve treatments are said to be sufficient to accomplish a cure. Warm solu- tions of permanganate of potash are used for the irri- gations, and vary in strength from 1-1000 to 1-4000, and even up to 1—500 during the declining stage. Janet uses an irrigator, with several feet of rubber tubing, to which is attached a conical glass nozzle ; a stopcock on the tubing controls the flow of the fluid. The patient having urinated, lies on his back, and the glass nozzle is gently inserted into the meatus, and the fluid turned on ; the irrigator being raised two feet above the level of the patient, if the anterior urethra alone is to be treated, but if the posterior urethra and bladder are to be medicated, then the irrigator is raised about four and a-half feet, so as to increase the pressure and force of the flow, which in a few minutes tires out and over- comes the compressor urethrse muscle and vesical sphinctus, which, relaxing, allow the solution to enter the deep urethra and bladder ; when the bladder is dis- tended, the irrigation is stopped, and the patient stand- ing voids the solution by the urethra. The irrigations are given once or twice daily, one pint being used for the anterior urethra and two pints when the posterior urethra and bladder are to be medicated. Although this method does cause a rapid cessation of the puru- lent discharge, as is claimed by its advocates, it leaves 32 GONORRHOEA AND ITS COMPLICATIONS. the urethra in a thickened, congested and irritable con- dition, which gives rise to a thin watery or mucoid dis- charge, which is very difficult, and in some cases im- possible, to cure. I have seen a number of patients suffering from the above conditions as a result of this treatment, all of them informing me that the method was uncleanly and painful, and a few stating that the irrigations caused quite a considerable oozing of blood from the meatus. The above facts are not to be wondered at, when one considers the force and strength of the solution rushing through, and distending such an acutely inflamed and delicate canal as the urethra is at this time ; also the injurious effect of overcoming by hydraulic pressure the delicate musculature which guards the deep urethra and bladder. If so desired, the bladder and urethra may be irrigated with a small, soft-rubber catheter and hand-syringe, and most satisfactory results obtained without causing traumatism and increased congestion of the mucous membrane, with injury to the cut-off and prostatic muscles. The new silver preparations, Argonin and Protargol, are being extensively used at present as hand-injections and irrigations in the acute stage of gonorrhoea and are said to act most satisfactorily, as they destroy the gonococci without causing any urethral pain or irrita- tion. In our efforts to annihilate the gonococcus we must not forget that we have a very severe inflammatory process to deal with, which is attacking one of the most delicate and highly sensitive mucous membranes in the body, and which, if roughly and unskillf ully handled in TREATMENT OF ACUTE OONOBRHCEA. 33 the acute stage of this virulent process, will leave the patient's urethra and contiguous structures in a more or less damaged condition. RATIONAL TREATMENT. Before beginning treatment we should always make a thorough examination of the penis, in order to ascer- tain the condition of the meatus, the glans and the prepuce, as by so doing we are often enabled to prevent certain complications and to hasten recovery. Patients must be kept as quiet as possible, rest in the recumbent position being preferable ; the diet should be light, easily digested, and contain no highly spiced or seasoned dishes, red meats or green vegetables ; alco- hol in all forms, as well as coffee, ginger ale and cocoa, are to be forbidden. Smoking in moderation is allow- able, and does no harm, unless the patient is very nerv- ous, when it should be cut down or prohibited. The testicles must be supported in a snug suspensory bandage, and the penis kept scrupulously clean by the frequent use of hot water. The bowels should be kept freely open, preferably by cathartic pills, as saline purgatives are apt to produce more or less urethral irritation. It is extremely im- portant to warn patients of the danger of infecting the eyes and impress upon them the gravity of such an ac- cident, also the danger of contaminating water closets, baths, towels, etc., and in this way causing the infection of others. The best dressing for the penis is a piece of plain absorbent gauze about four inches square, with a slit cut in the center, through which the glans is passed un- 3 34 GONORRHOEA AND ITS COMPLICATIONS. til the gauze is well behind the corona, when the fore- skin is drawn forward carrying the free end of the gauze before it, thus causing it to protrude beyond the preputial orifice. The gauze may be kept wet with cold lead and opium wash if there is much redness and inflammation of the glans and prepuce. This dressing allows the pus to drain freely from the meatus, at the same time preventing it from coming- in contact with the fingers, prepuce and glans, or soiling the clothing. If the prepuce is too short to hold this dressing in place, the glans can be lightly wrapped in absorbent gauze. As soon as the dressing is removed it should be carefully burned and the hands washed, as by so doing we prevent the infection of others and the transference of the gonorrhoea! pus to the eyes. Soak- ing the penis in very hot water three or four times daily allays, to a great extent, the pain and inflamma- tion in the parts, as does also the hot sitz bath which may be taken once or twice daily. To render the urine bland the patient should drink freely of the alkaline waters and take one of the following alkaline mixtures : R. Potass, bicarbonat., sj. Tinct. hyoscyani., gss. Aq., ad ^viij. M. S. 5ss in water two hours after each meal. R. Potass, acetat., 5J. Syr. aurantcort., ^ss. Aq., ad 5 viij . M. S. 3ss in water two hours after each meal. In the last formula we may substitute the bicai'bon- ate or the citrate of potash for the acetate, if so desired. TREATMENT OF ACUTE GONOEBHCEA. 35 Painful erections and chordee. The patient should be told to empty his bladder just before retiring, and to sleep on his side on a hard mattress with as light covering as possible. When awakened by an erection it is well to lay some cold object gently on the penis, unless, as is sometimes the case, hot applications are more beneficial, when they should be advised. Jump- ing out of bed into a cold bath, standing upon the hearth tiling, or placing the back against the cool wall are devices which may be tried in these cases. Painful erections and chordee can sometimes be prevented by injecting a drachm or two of the following formula into the nrethra just before retiring and retaining it for several minutes : R. Liq. morph. Magend., 3ij. Cocaine muriat. , gr. vj. Aq., ad gij. M. S. Inject a drachm or two at bedtime. Internally we may give the monobromide of camphor, potassium bromide, chloral hydrate, or a few drops of laudanum in water three or four times daily. If these drugs do not act satisfactorily, we may be compelled to resort to suppositories of opium or morphine, but these should never be used unless absolutely necessary. When the very acute inflammatory symptoms begin to subside, as is indicated by a diminution and thinning of the urethral discharge, less pain on urination, and a decrease in the redness and swelling of the meatus, then it is time to begin the careful and judicious use of bland and non-irritating injections, administered by the patient himself, or better still, hot medicated irrigations 36 GONORBJKEA. AND ITS COMPLICATIONS. given daily by the physician. In all cases, when a hand- injection is ordered, the patient should be told what kind of a syringe to purchase, and how to use it. A good syringe is made of smooth, highly polished hard rubber, with a bluntly conical tip, holds from two to four drachms, and works smoothly and easily. (See Fig. 2.) Fig. 2. Urethral syringe. These syringes are sometimes made with soft-rubber tips, but they possess no practical advantage over the all-hard rubber ones, and cannot be kept as clean. For a patient with a small meatus it is well to order a syringe with a more or less pointed extremity, as is shown in Fig. 3. Fig. 3. Urethral syringe for small meatus. A glass syringe, built on the same lines as shown in Fig. 2, is much less expensive than the rubber ones, and at the same time quite good, and can therefore be used in hospital and dispensary work, where the item of ex- pense is an important one. Injecting. The patient urinates, and standing up gently inserts the nozzle of the completely filled syringe TREATMENT OF ACUTE GONORRHCEA. 37 into the meatus, the lips of which are lightly pressed together from side to side against the syringe ; the solu- tion is then thrown in slowly until there is a feeling of distention or discomfort, when it may be allowed to escape, or, if not too uncomfortable, kept in for a few minutes. These injections should be taken two or three times daily. It is well to begin injecting with hot boric acid solu- tion, or a weak solution of hot lead-water ; if these in- jections work satisfactorily, then any of the following formulae may be used in the order given below : R. li R. R. Zinc, sulphat. , gr. vj-viij Liq. Magend., 3ij. Aq. destillat., ad giv. M. Zinc, sulphat., Plumb, acetat., aa gr. vj-xij. Ext. op. aq., m- Aq. destillat. ad 5vj. M. Zinc, sulphat., gr. xv. Plurab. acetat., gr. xxx. Ext. Kramer, fid., Tr. op., aa 3iij. Aq. destillat., ad 5viij. M. Zinc, sulphat., Plumb, acetat. aa gr. xxx. Aq. destillat., ad svj. M. Potass, permanganat. , gr. ss. Aq. destillat., ad 5vj. M. In the last formula the permanganate may be in- creased up to one-fourth or even one-half of a grain to each ounce of water, if indicated. 38 GONORRHCEA AND ITS COMPLICATIONS. If at about this time the patient can come to the surgeon every day, great benefit will be derived from the use of irrigations thrown into the bulb, instead of the hand-injections above alluded to. These irrigations are given daily or twice a day in the following manner : The patient having urinated, stands before the surgeon, who passes a No. 12 French soft-rubber " velvet eye " catheter, lubricated with pure glycerin, into the bulb, and injects from four to ten ounces of hot medicated fluid, slowly and gently by means of an Ultzmann hard- rubber hand-syringe and coupler. (See Figs. 11 and 12.) In this manner the fluid washes out the entire anterior urethra and escapes at the meatus, where it is caught in a basin. We may use for this purpose hot solutions of boric acid, or lead water to which has been added a little laudanum, and later, solutions of ziuc, alum, per- manganate of potash, and nitrate of silver. In the declining part of the acute stage great benefit is derived from the use of the antiblennorrhagics, which now take the place of the alkaline mixtures. In private practice we may prescribe liaquin's cap- sules of copaiba, or the Mathey-Caylus capsules of copaiba and cubebs, ordering three after each meal, or the pure yellow santal oil, put up in five- and ten-drop capsules, one or two of which are to be given an hour and a-half after meals. In ordering these capsides be sure to see that your patient gets the pure yellow santal oil, as there are so many impure and adulterated oils in the market. In hospital and dispensary practice we are obliged to substitute the Lafayette mixture for the capsules, as the latter are too expensive for this class of patients. TREATMENT OF ACUTE GONORBHCEA. 39 Lafayette Mixture. R. Bals. copaib., gj. Liq. potass., 3ij. Ext. glycyrrhiz. , ^ss. Spts. a3ther. nitros., ^j. Syrup, acac, gvj. 01. gaulth., gtt. xvj. M. S. oj-ij in water after each meal. When the discharge becomes sticky and mucoid in character it is well to discontinue the use of these reme- dies, as they are apt, if continued for too long a period, to delay the cure by overstimulation of the urethral mucous membrane. If the foregoing treatment has been successful, the patient now has but a trifling urethral discharge, some- times only seen in the morning, with gonorrhoea! shreds and perhaps a little free pus in the urine. The treatment for this condition is so similar to that for chronic gonorrhoea or urethritis that the reader is referred to page 68, where all of the details will be found fully described. CHAPTEE V. TREATMENT OF ACUTE POSTERIOR GONORRHCEA OR URETHRITIS. Injections and all instrumental treatment of the urethra must be suspended as soon as symptoms of acute posterior urethritis develop ; the patient is put to bed, on a milk diet, the testicles suspended, and the bowels kept freely open. Antiblennorrhagics are stopped, and in their place one of the following for- mulae is given : R. Potass, bicarb., gj. Tinct. hyoscyam., Fid. ext. kav. kav., aa ^ss. Aq., ad sviij. M. S. 3ss in water two bours after eacb meal. R. Fid. ext. trit. repent., Fid. ext. urva>ursi., aa ^jss. Liq. potass., £ss. Tr. op., 3jss. Aq., ad 5iv. M. S. 5j in water two bours after eacb meal. Alkaline mineral waters may be taken in moderation. Hot-water bags over the bladder and on the perineum give relief, as do rectal injections of hot water or the hot sitz bath ; if these means do not control the vesical and rectal tenesmus, we can then resort to morphine suppositories. If retention of urine occurs, it should be 40 TREATMENT OE ACUTE GONOURITCEA. 41 relieved according to the methods described on page 141, to which the reader is referred. When the frequency in urination, vesical tenesmus and other acute symptoms begin to subside, we may then resume local urethral treatment and allow the patient to be up and about. CHAPTEE VI. COMPLICATIONS OF ACUTE ANTERIOR GONORRHOEA, OR URETHRITIS, AND THEIR TREATMENT. BALANITIS. Balanitis is an acute or chronic inflammatory pro- cess, attacking the mucous membrane of the glans penis, and if accompanied by inflammation of the mucous membrane lining of the prepuce is called balano- posthitis. It is caused by uncleanliness and by allowing the gonorrhoeal pus to collect beneath the foreskin, where it sets up more or less inflammation. It usually occurs in persons with a long, tight prepuce, which condition prevents retraction and proper cleansing of the parts. The mucous membrane becomes red, thickened and covered with a thin, purulent and very offensive secre- tion ; this is followed by swelling of the glans, which may be covered with irregular patches of excoriation : these, if untreated, may go on to superficial ulceration. Treatment. The parts must be kept absolutely clean by washing and soaking in hot water, and separated by meaus of absorbent gauze wet in a weak solution of lead-water, or boracic acid : the following formula for red wash is also found very serviceable in this condi- tion : 42 COMPLICATIONS OF ACUTE GONORRHOEA. 43 Red Wash. R. Zinc, sulphat., Tinct. lavand. co., Aq., S. External use. gr. xx. 3ss. ad gviij. M. If the prepuce cannot be retracted, it may be washed out with any of the above solutions, or plain hot water, these being injected with Taylor's subpreputial syringe (See Fig. 4), an ordinary syringe, or irrigator. If Fig. 4. E TIEMANWVCO Taylor's subpreputial syringe. there is considerable swelling of the prepuce and glans, the patient must be kept on his back, and the penis en- veloped in gauze wet in cold lead and opium wash, or bichloride solution. PHIMOSIS. Gonorrhoeal phimosis is that condition of the prepuce which renders its retraction behind the glans penis im- possible. It is usually due to a balanitis, or balano- posthitis, which by its irritation causes oedema, redness and swelling of the foreskin : the oedema may be so great as to cause various deformities of the preputial orifice. Treatment. The patient should be put on his back and the cavity of the prepuce thoroughly irrigated several times daily with hot bichloride solution, 1—5000, 44 GONORRHOEA AND ITS COMPLICATIONS. It is well to keep the penis enveloped in absorbent gauze, which is constantly wet with cold lead and opium wash. Congenital phimosis is caused by such a degree of narrowing of the preputial orifice that the foreskin can- not be retracted beyond the glans ; it is frequently complicated by bands, or adhesions running between the glans and the inner surface of the prepuce, and may, or may not, give rise to mild or very severe attacks of balano-posthitis, with painful and annoying manifesta- tions. Treatment. The palliative treatment consists in keeping the parts as clean and dry as possible, but cir- cumcision should be strongly advised as the only real cure for this condition. Circumcision. The parts are shaved and rendered surgically clean in the usual manner ; the patient uri- nating just before the operation, which is done under ether, or cocaine anaesthesia in the following manner : The prepuce is drawn well forward, and Taylor's clamp (See Fig. 5) applied in such a manner that its blades Fig. 5. Taylor's circumcision forceps. are exactly parallel with the corona (See Fig. 6) ; this gives them an oblique position as shown in the figure ; the foreskin is now ablated with a pair of heavy curved scissors, cutting close to the distal side of the clamp, COMPLICATIONS OF ACUTE GONORRHOEA. 45 which is now removed, when the integument retracts to the coronal sulcus and leaves the mucous layer of the prepuce exposed. The clamp is now applied to this layer and the cutting done in exactly the same manner Fig. 6. Clamp applied to foreskin. as above described, which leaves the frsenum intact and also plenty of mucous membrane. Bleeding points are caught and ligated with fine gut, and the wound closed with black silk, interrupted sutures placed about one- quarter of an inch apart. A moist bichloride dressing is then applied, and the patient kept on his back, or very quiet for a day or so. If the operation is done under cocaine anaesthesia, the solution (4 to 8 per cent.) should be injected hypodermically between the two lay- ers of the foreskin after the clamp has been applied, and allowed five or ten minutes to act before cutting is com- menced ; when the tegumentary layer has been removed, a little cocaine solution may be dropped on the raw sur- face of the mucous layer. Local cocainization produced in this manner, renders the operation comparatively painless. Patients must be told not to soil the dressing while urinating. 40 GONORRHOEA AND ITS COMPLICATIONS. PARAPHIMOSIS. Gonorrhoeal paraphimosis is that condition in which the prepuce has been retracted behind the corona giandis, and cannot be brought forward. The small preputial orifice, which is now pushed back behind the corona, forms the band of constriction on the dorsal surface of the penis, which, preventing return circula- tion, causes more or less deformity of the organ from oedenia. This condition comes on gradually, the patient neglecting, either from ignorance, fear or shame, to take proper care of it when first discovered. Fig. 7. v»pe%gf Reduction of paraphimosis. Treatment. The deformity should be reduced imme- diately, in the following manner : The organ is thor- oughly washed and dried, then with the two thumbs COMPLICATIONS OF ACUTE GONORRIICEA. 47 pressing on the end of the glans, and the index and ring fingers behind the constriction and corona (See Fig. 7) the blood is entirely massaged out of the glans, which, being reduced in size and softened, is pushed back through the constricting ring, and the prepuce drawn forward. If the foregoing procedure is impos- sible, then a small incision must be made completely through the dorsal surface of the constricting band, after which the glans can be readily reduced and the prepuce brought forward, the little wound being dressed antiseptically and the preputial cavity kept clean. As both of these procedures are liable to be more or less painful it is well to give the patient an anaesthetic, a few whiffs of ether or gas answering the purpose. PERI-URETHKAL ABSCESS. Peri-urethral abscess, or phlegmon, is situated on the under surface or sides of the penis, anywhere between the frsenum and the peno-scrotal angle, the region of the frsenum being the favorite location. It may occur as a complication of both acute and chronic gonorrhoea, and is probably caused by infection of a peri-urethral follicle, which as a rule goes on rapidly to abscess-for- mation. The abscess may be either unilateral or bilateral, especially when situated near the frsenum. It feels at first like a hard, shot-like body, but when fully developed has all the characteristics of an ordinary acute abscess ; and, if very large, may impinge on the calibre of the urethra and cause more or less obstruc- tion to urination. Treatment. Injections and all instrumental treat- ment of the urethra must be stopped for a time and the 48 GONORRHOEA AND ITS COMPLICATIONS. inflamed parts kept at rest and covered with cold lead and opium wash or bichloride solution, which, in some cases, may lead to a disappearance of the swelling. If, however, suppuration occurs, the abscess should be laid freely open, irrigated with peroxide of hydrogen and bichloride of mercury solution, 1-3000, and packed with iodoform or sterile gauze. It is important to remember that these abscesses should not be opened until suppuration is well advanced, as by that time the urethral orifice of the follicle is closed by a plug of inflammatory material, which prevents the urine from leaking into the abscess-cavity, thus causing a urinary fistula, which is very difficult to cure in this region. PREPUTIAL FOLLICULITIS. Preputial folliculitis may occur at any time during the course of a urethral gonorrhoea, and is due to infec- tion of one or more of the little follicles which are situated between the two layers of the prepuce, either on its sides, or dorsum, and which open on its free border, or on its mucous surface. In the acute stage of the infection the tissues about the follicle are acutely inflamed, and a small drop of pus exudes, or can be pressed from the tiny orifice of the abscess cavity ; the folliculitis, like the urethritis, passes into the subacute, and then the chronic stage. The follicles on the under surface, and near the median line of the penis, even as far back as the scrotum, may also be infected during the course of a urethral gonorrhoea, and give rise to the same conditions as above described. If unrecognized, or untreated, these follicular abscesses and sinuses are COMPLICATIONS OF ACUTE GONORRHOEA. 49 very liable to lead to the infection of women, and to cause auto-infection of their bearers. Treatment. The parts should be rendered surgically clean in the usual manner, and the follicle thoroughly resected under cocaine anaesthesia, after which the little wound is brought together with two or three sutures, and a light dressing applied. PARA-URETHRAL FOLLICULITIS. During the course of a urethral gonorrhoea the fol- licle in either one or both lips of the meatus may be- come infected from the urethral discharge, thus giving rise to a small abscess, from the minute orifice of which a little drop of pus escapes or can be pressed. In some cases the follicle forms a sinus opening on the mucous membrane of the fossa navicularis, thus consti- tuting a true urinary fistula. This form of folliculitis, if uncured, may cause the infection of women and auto- infection of the individual himself. Treatment. The pus having been pressed out, the follicle is injected with pure carbolic acid, or strong ni- trate of silver solution, by means of a hypodermic syringe with a blunt needle. These means failing, the little abscess must be laid open, curetted and the raw surface touched with pure carbolic acid. COWPERITIS. Cowper's glands, like the urethral follicles, may be the seat of abscess-formation, the infection travelling down their ducts, which open on the floor of the bulb, the glands themselves being situated between the an- terior and posterior layers of the triangular ligament, 4 50 GONORRHOEA AND ITS COMPLICATIONS. in the substance of the compressor urethrse muscle. As a rule, but one gland is affected at a time. The abscess is situated in the perineum on either side of the median line, and, if large, burrows forward and back- ward and may interfere with urination. Treatment. The patient is kept in bed, and all urethral instrumentation suspended for a time. Cold lead and opium wash or bichloride solution is applied locally, which in some cases may cause resolution ; if, on the other hand, fluctuation can be plainly felt, the pus must be immediately evacuated. The patient, having been etherized, is properly prepared for operation, and placed in the lithotomy position. A full-sized sound is then passed to the bladder, and held there directly in the median line, by an assistant, thus rendering the urethra prominent and preventing it from being cut or injured during the operation, as in many of these cases, when the abscess is large, the bulb of the urethra can be distinctly seen hanging in the wound, thus rendering it liable to injury if not made prominent by a sound, The abscess is then freely incised, and if burrowing has occurred in any direction it must be followed up by free incisions which thoroughly efface all blind pockets or cul-de-sacs. The abscess cavity is then irrigated with bichloride of mercury solution, packed with iodo- form gauze and covered with a large pad of sterilized gauze, held in place by a T-bandage. LYMPHANGITIS. Inflammation of the lymphatics of the penis may oc- cur during the acute stage of gonorrhoea, or urethritis. The vessels can be felt as hard and painful cords run- COMPLICATIONS OF ACUTE GONORRHOEA. 51 ning along the dorsum of the organ up into the groins, where they empty into the inguinal glands. The penis becomes (Edematous and enlarged, and the course of the lymphatics is marked by red lines beneath the skin, which are hot and tender to the touch. Suppuration occurs very rarely. Treatment. The patient should be put to bed, and the penis kept in the horizontal position and surrounded by cold lead and opium wash, or bichloride solution. ADENITIS. The inguinal glands frequently become enlarged and tender during an acute gonorrhoea, or urethritis ; but, fortunately for the patient, they very rarely suppurate. Treatment. The patient should be kept as quiet as possible, and the groins painted with tincture of iodine, or, better still, covered with compound iodine ointment laid on a piece of gauze, and held in place by a spica bandage. CHAPTER VII. COMPLICATIONS OF ACUTE POSTERIOR GONORRHOEA, OR URETHRITIS, AND THEIR TREATMENT. PROSTATITIS. Acute congestion of the prostate to a greater or less degree usually occurs in all cases of acute posterior gonorrhoea, or urethritis. The gland becomes hyper- remic and swollen, which gives rise to a sense of fulness in the perineum and rectum, accompanied by severe vesical and rectal tenesmus, with local pain in the pros- tate as the fecal masses pass over it. In some cases there is great difficulty in urination, which may go on to complete retention. Frequently there are painful nocturnal pollutions which are sometimes bloody. Rectal examination shows the gland to be congested, hot and painful : firm and tense in some cases, but soft and boggy in others. As a rule, the congestion subsides as the urethritis improves, although there are rare cases in which it goes on to the formation of abscess, which, if not properly and promptly treated, may rupture into either the bladder, rectum, peritoneal cavity or peri- neum. Suppuration is ushered in by a throbbing pain in the prostate, rigors, rise of temperature and dribbling of the urine, which may even go on to complete reten- tion caused by occlusion of the prostatic urethra, and compressor spasm. Treatment. The patient should be put to bed and 52 COMPLICATIONS OF ACUTE GONORRHOEA. 53 ordered a milk diet. Antiblennorrhagics, injections and all instrumental treatment must be stopped, and the urine rendered bland by the following formula, to which a little tincture of opium may be added if neces- sary : R. Potass, bicarb., gj. Tr. hyoscyam., Fid. ext. kav. kav., aa gss. Aq., ad gviij. M. S. 5ss in water two hours after meals and at night. The bowels should be moved freely every day. Hot- water bags over the bladder and on the perineum, and hot rectal injections given with Kemp's irrigator (See Fig. 8) or a fountain syringe afford great relief, as Fig. 8. Kemp's double-current, hard-rubber rectal irrigator. does also the hot sitz bath. Morphine suppositories must be given for the vesical and rectal tenesmus when indicated. If an abscess forms in the prostate it must be promptly opened through the perineum, by a transverse, semilunar or vertical incision, great care being taken not to wound the rectum or the urethra, which acci- dents can be prevented by a finger in the rectum, and a sound passed into the bladder and held there, exactly 54 GONORBHCEA AND ITS COMPLICATIONS. in the median line by an assistant, who, at the same time, retracts the scrotum, thus exposing the operative field ; the patient having been properly prepared and put in the lithotomy position, the pus is evacuated by a free incision and the abscess cavity irrigated, drained and dressed in the usual manner. Chronic prostatitis as a result of posterior gonorrhoea, or urethritis, is of much more frequent occurrence than was formally supposed, and is often the cause of chronic urethral discharges, which are too frequently attributed to diseased conditions of the seminal vesicles, which in reality are of rare occurrence when compared to affec- tions of the prostate gland itself. Chronic congestion of the prostate may also be the result of posterior urethritis, caused by excessive masturbation in young- boys, and by sexual excesses in men of riper years, also long-continued and ungratified sexual desire. Symptoms. The symptoms of chronic prostatitis are very marked in some cases and practically absent in others : there may be some frequency in urination, in- creased by sexual and alcoholic indulgences ; nocturnal pollutions and premature ejaculation may be present, the ejaculate being blood-stained in some instances. Some subjects say they are losing their sexual desire, while others think they are more vigorous than ever. The urine is more or less cloudy, as a result of the pos- terior urethritis, which is almost always present in these cases, and which gives rise to a varying amount of urethral discharge. In advanced cases there is an oozing of prostatic fluid after urination and defecation, especially when the bowels are constipated ; this greatly alarms nervous and excitable individuals. Some sub- COMPLICATIONS OF ACUTE GONORRHOEA. 55 jects complain of a sensation of fulness and distress in the rectum and perineum, which is greatly increased by defecation and coitus, also by long walks, over exercise, bicycle and horseback riding, and standing for a long time. Catching cold aggravates any or all of the above symptoms. Diagnosis. The diagnosis of chronic prostatitis can only be arrived at by making a careful rectal examina- tion, when the gland will be felt, either enlarged, ten- der, soft and boggy, or very tense and firm. Digital pressure on the gland will usually cause an oozing of prostatic fluid from the meatus, which should always be collected and examined microscopically. As a general rule, the enlargement is most marked on the left side. Treatment. If the gland is soft and boggy it should be gently massaged about once a week, but if firm and tense very little if any benefit will, as a rule, be de- rived from this treatment, although it may be tried. The rectum should be irrigated once or twice a day with hot or cold water, by means of a Kemp's double- current irrigator, or fountain syringe, and the bowels kept open. Normal sexual relations are not harmful. The urethritis, or urethro-cystitis, should be handled in the manner already described for these conditions, and strychnine, quinine and ergot given to tone up the gen- eral and local condition. EPIDIDYMITIS AND EPIDIDYMO-OECHITIS. Epididymitis is one of the most frequent complica- tions of acute gonorrhoea, or urethritis, and consists of an acute inflammation of the epididymis, which, if it ex- tends to the testicle, is called epidiclymo-orchitis. In 56 GONORRHCEA AND ITS COMPLICATIONS. severe cases the vas deferens is also involved in the inflammatory process, and the tunica vaginalis may be the seat of an acute hydrocele. Swelled testicle (epididymitis or epididymo-orchitis) usually occurs during the first three weeks of gonor- rhoea, and is caused by an extension of the inflamma- tory process from the floor of the posterior urethra into the ejaculatory duct, and thence to the epididymis and testicle. It is unilateral in the majority of cases, al- though both glands may be attacked at the same time, or successively. Symjrtoms. The symptoms of epididymitis and epididymo-orchitis will be described together, as they are practically the same. The patient usually has all the symptoms of an acute posterior gonorrhoea, or urethritis, when suddenly or gradually he complains of pain in the testicle, and a dragging, aching sensation extending up the cord, groin and even to the kidney. There is a rise in temperature, accompanied by chilly sensations or a well-marked chill, which is followed by a feeling of general malaise. As the inflammation in the epididymis and testicle increases all of the above symptoms become more marked, the temperature some- times going to 105° F.; the pain in the testicle, groin and lumbar region becoming so great that the patient has to lie down, supporting the scrotum with his hand. The intensity of these symptoms varies greatly in dif- ferent individuals, some being compelled to go to bed, while others are up and about attending to their ordi- nary duties. Examination. The scrotum is hot, red and cedema- tous. The epididymis, either in part or in whole, is COMPLICA TIONS OF A CUTE GONOBRHCEA . 5 7 enlarged, hard and exquisitely tender ; if the testicle be involved, it also is very painful, firm and enlarged, becoming in severe cases as large as an ordinary orange. There may be an accumulation of hydrocele fluid in the cavity of the tunica vaginalis. The entire cord is sometimes painful and thickened and can be felt as far up as the ring. The duration of the attack depends greatly on the treatment, and whether the epididymis or epididymis and testicle be involved. Treatment. The patient should be put to bed and given the general treatment for acute posterior gonor- rhoea. (See page 40.) The scrotum is supported by a band of rubber plaster three to four inches wide, which passes beneath the scrotum to each thigh, care being taken to have the thighs close together before applying the plaster. If there is much hair on the thighs it should be shaved to prevent pain when the plaster is removed. The scrotum over the affected testicle should be lightly touched with the curved tip of the Paquelin cautery, or the cautery held so close to the scrotum that sharp counter irritation is produced; for the same pur- pose a solution of nitrate of silver, 60 grains to the ounce of distilled water, may be painted over the scro- tum, care being taken that it does not stain the fingers or bed clothes ; after either of these procedures the en- tire scrotum, properly supported, is surrounded with absorbent gauze, which is kept covered, day and night, with cold lead and opium wash. When the acute in- flammatory symptoms have subsided, as a result of the above treatment, an ointment of lead and opium is spread over the scrotum, which is then surrounded by a 58 GONORRHOEA AND ITS COMPLICATIONS. layer of cotton-wool over which is placed a piece of oiled silk, the whole dressing being kept in position by a snug suspensory bandage. The patient is allowed to get up when local pain and tenderness have disappeared. If there is very marked hydrocele, great relief can often be afforded by careful aspiration of the fluid, thus re- lieving the local pain and tension. Chronic or relapsing epididymitis is only cured by treating the lesions in the posterior urethra ; in other words, by treating the chronic posterior gonorrhoea, or urethritis, which is the cause of the testicular trouble. For this treatment the reader is referred to page 75. The little hard mass hi the epididymis, which is the result of the inflammatory process, should be gently rubbed with mercurial or icthyol ointment, covered with cotton and oiled silk, and properly supported in a bandage. Iodide of potash combined with this local treatment will, as a rule, cause softening and absorption of the chronically enlarged epididymis which, if left un- treated, ma}^ result in partial, and even complete steril- ity, if both epididymes have been involved. SEMINAL VESICULITIS. By seminal vesiculitis or spermato-cystitis is meant an inflammation of the seminal vesicles, which may be either acute or chronic. When gonorrhoea! in origin it occurs about the same time as epididymitis ; that is, during the first three weeks of the disease. The in- flammation passes directly from the floor of the posterior urethra through the common ejaculatory duct to either one or both vesicles. Symptoms. The symptoms of acute seminal vesic- COMPLICATIONS OF ACUTE GONORRHOEA. 59 ulitis are practically the same as those of acute pos- terior urethritis or acute prostatitis, the patient having frequent and painful urination with vesical and even rectal tenesmus. There may be painful nocturnal pollu- tions stained with blood. These patients usually com- plain of a feeling of fulness just within the anus or in the perineum. In severe cases there is more or less fever, accompanied by a feeling of general malaise. Diagnosis. The diagnosis is arrived at by making a rectal examination, when the vesicle or vesicles can be felt as hot, swollen, tender bodies situated just beyond the base of the prostate and running upward and out- ward. For this examination, the patient should be in Fuller's position, that is, standing up, with the trunk bent at right angles to the thighs, the feet apart and the palms of the hands resting on the seat of an ordi- nary chair. The right index finger is used for exami- nation and should be well anointed with vaseline. Treatment. The treatment is the same as that for acute posterior gonorrhoea, or urethritis, except that cold water may be injected into the rectum instead of hot water, if it gives more relief. Should the inflammation go on to abscess-formation, the pus must be immediately let out by a transverse, vertical or similunar incision through the perineum just in front of the anus, great care being taken not to wound the urethra or rectum, which can be prevented by having a sound held in the urethra, and the index finger in the rectum, with its tip in contact with the apex of the prostate gland. The abscess- cavity is irri- gated, packed and dressed in the ordinary manner. Chronic seminal vesiculitis may follow the acute 60 GONORRHOEA AND ITS COMPLICATIONS. form, or be caused by the extension backward of a chronic, and low-grade inflammation in the posterior urethra, or prostate, the result of gonorrhoea, excessive masturbation and sexual excesses. Symptoms. The symptoms of chronic seminal vesic- ulitis are varied, and differ greatly in different indi- viduals, some complaining that they are losing their sexual appetite and powers, others that they have noc- turnal pollutions and premature ejaculations, both of which may be blood-stained ; these conditions may or may not be associated with a mucoid or muco-purulent urethral discharge, which varies greatly at different times, and according to the habits of the individual. Some complain of a sense of weight and fulness in the rectum and perineum, while others are absolutely free from these sensations, the only symptom of the disease being a cloudy urine with flakes, and slight discharge at the meatus. Some patients have constant and greatly increased sexual desire, with perhaps little relief after intercourse. Diagnosis. The symptoms of chronic seminal vesic- ulitis are so similar to those of chronic prostatitis and posterior urethritis that a correct diagnosis can only be arrived at by making a careful rectal examination as described in the acute form. When diseased, the vesi- cle or vesicles can be plainly felt by the skilled finger, running up and out from the base of the prostate gland. Treatment. The vesicle or vesicles can be gently massaged about once a week, and the patient given the regular treatment for chronic posterior urethritis and prostatitis, the details for which will be found on page 75. COMPLICATIONS OF ACUTE GONORRHOEA. 61 URETHROCYSTITIS. Urethro-cystitis is not an uncommon complication of acute posterior gonorrhoea, or urethritis, and is caused by an extension backward of the inflammatory process from the posterior urethra into the bladder. As a rule, the inflammation is limited to the mucous membrane surrounding the urethral orifice, but may extend and involve the entire bladder surface. Symptoms. The symptoms of acute urethro-cystitis are practically the same as those of acute posterior gonorrhoea, or urethritis, except perhaps that they are more severe in character, the patient also complaining of a constant deep-seated pain over the bladder. Treatment. As in acute posterior gonorrhoea, or urethritis, these patients should be kept in bed, with hot applications over the bladder and on the perineum ; hot sitz baths and hot rectal irrigations afford great re- lief. All instrumentation of the urethra must be sus- pended, the patient put on a milk diet, and the urine kept bland by means of the prescription already given for acute posterior gonorrhoea, or urethritis. Tenesmus must be controlled by morphine, either in suppository or by hypodermic. The patient may drink Poland, Vichy or Bethesda water, but not in too great quantity. It is very important to keep the bowels moving freely and for this purpose we may employ any good cathartic pill. As soon as the acute symptoms subside, the pos- terior urethra and bladder should receive proper local treatment by means of irrigations or instillations, the technique for which is fully described in Chapter XIII. CHAPTEK VIII. CHRONIC GONORRHOEA, OR URETHRITIS. Chronic gonorrhoea, or urethritis, also known as gleet, is spoken of as chronic anterior gonorrhoea, or urethritis, when the lesion is situated somewhere in the anterior urethra ; as chronic posterior gonorrhoea, or urethritis, when in the posterior urethra ; as chronic anteroposterior gonorrhoea, or urethritis, when the en- tire urethra is involved, and as chronic urethrocystitis when the disease has invaded the bladder. A gonorrhoea, or urethritis, becomes chronic when it has existed for more than eight or ten weeks. Causes. The causes of chronic gonorrhoea, or ure- thritis, are many, prominent among them being sexual and alcoholic indulgences during the declining stage, patients thinking themselves cured at that time as they see no discharge at the meatus, and therefore stopping- treatment at this the most important period in their disease. Gonorrhoea is apt to run a chronic course in debilitated, run-down and anaemic subjects, also in those who will not, or cannot, take sufficient rest or proper treatment in the acute inflammatory stage of the disease. The numerous so-called abortive methods, with strong- injections, retrojections, irrigations and endoscopic ap- plications during the acute inflammatory stage, are very liable to leave the patient with a thickened urethra, congested prostate and a chronic watery discharge that is most rebellious to any and every form of treatment. 62 CHRONIC GONORRHOEA. 63 Chronic congestion and inflammation of the prostate gland, as a result of gonorrhoea, is a frequent cause of chronic urethral suppuration, and should therefore not be overlooked in the treatment of these cases. Seminal vesiculitis is undoubtedly the etiological factor in some cases of chronic gonorrhoea, but is very rare indeed, as compared to chronic affections of the prostate gland. An abnormally small meatus, or a condition of phimosis, associated with balano-posthitis, may, from the irritation they produce, be important factors in the continuation of a chronic urethritis. Uncured preputial folliculitis, para-urethral follicu- litis, or infection of any of the glands or follicles open- ing into the anterior urethra, may cause the lighting up, or prolongation of a gonorrhoea; therefore these little structures should receive due consideration and treatment. Warty growths in the anterior urethra may, from the irritation they occasion, keep up a urethral discharge for a long time, unless diagnosticated by endoscopic exami- nation, which is permissible in very chronic and rebel- lious cases. CHAPTER IX. CHRONIC ANTERIOR GONORRHOEA, OR URETHRITIS. Symptoms. The symptoms of chronic anterior gon- orrhoea, or urethritis, are as follows ; in some cases the lips of the meatus are glued together in the morning by the discharge which has accumulated in the urethra dur- ing the night ; in others there is a variable amount of muco-purulent, mucoid or serous discharge at the meatus, which is commonly known as the " morning drop ;" and which is usually increased after sexual or alcoholic indulgence. In still other cases there is neither gluing of the meatus nor " morning drop," the only symptom of the chronic inflammation being gonorrhoeal flakes and shreds in the urine. In the majority of cases there is no visible discharge at the meatus during the day, as the urethra is so frequently flushed out by the stream of urine. Patients usually complain of a dribbling of urine (a few drops up to a drachm) after each act of urination ; this is due to a loss of elasticity of the urethral walls as a result of the chronic inflammation, which leaves them in a more or less rigid condition, and unable to empty themselves completely. The Thompson two-glass test, for the differentiation between chronic anterior and chronic posterior gonor- rhoea should not be relied on, as it is only applicable to acute cases, associated with much suppuration. Gonorrhoea! shreds, threads or flocculi consist of moist scales made up of pus and epithelial cells, and held 64 CHRONIC ANTERIOR GONORRHOEA. 65 together by fibrin or mucus ; they are situated upon spots of congestion, erosion and superficial ulceration along the urethral walls which mark the localities where the gonorrhceal process has been most severe. These congested, eroded or ulcerated patches form the lesions of chronic gonorrhoea, or urethritis, and are most com- monly found in the bulbous urethra, as this portion of the canal is dilated (33 to 36 F.), has no capsule, is surrounded by erectile tissue, and being dependent, drains poorly ; all of the above conditions greatly favor- ing a long-continued inflammatory process. When the stream of urine strikes the edofes of these moist scales it rolls them up, and they therefore appear as threads or shreds floating in the glass of urine. As the healing process advances the pus-cells disap- pear, the flocculi being made up entirely of epithelial cells, which, when the case is cured, also vanish, leaving a clear, transparent urine. In a general way it may be stated that the threads or shreds from the anterior urethra are usually long, thread-like in character, and float about for some time in the urine, while those from the posterior urethra are lumpy and ragged in appearance, and sink rapidly to the bottom of the glass, but too much reliance must not be placed on these conditions. Microscopically they are both found to be composed of the same elements. CHAPTER X. CHRONIC POSTERIOR GONORRHOEA, OR URETHRITIS. Although chronic posterior gonorrhoea, or urethritis, may occur alone, it is accompanied in the vast majority of cases by a chronic bulbous urethritis, as well as by some chronic urethro-cystitis, which in turn may be as- sociated with prostatitis, or, in some rare cases, seminal vesiculitis, which conditions must not be forgotten in its treatment. Symptoms. The typical symptoms of chronic poste- rior gonorrhoea, or urethritis, are increased frequency of urination with a feeling of discomfort either at the be- srinniner or termination of the act, and absence of, or a very slight discharge at the meatus. The urine may or may not be turbid and contains thick, clumpy shreds from the posterior urethra, which sink rapidly to the bottom of the glass. In some cases there are frequent nocturnal pollutions, which may be bloody ; in others premature ejaculation at intercourse, associated with dull, painful sensations in the region of the prostate. These sexual manifestations are due to the congested and inflamed condition of the posterior urethra and prostate gland. The above symptoms vary widely in different indi- viduals, in some well-marked and constant, in others very slight and only brought into activity by alcoholic and sexual indulgences, which cause a congestion of the 66 CHRONIC POSTERIOR GONORRHOEA. 67 posterior urethra and prostate, with a lighting up of the dormant inflammation. If, as is usually the case, the patient also has an an- terior gonorrhoea, a more marked discharge will then be noticed at the meatus. CHAPTER XI. TREATMENT OF CHRONIC GONORRHOEA, OR URETHRITIS. In all cases of chronic gonorrhoea, or urethritis, either anterior, posterior or antero-posterior, the morn- ing urine should be carefully examined in order to ascer- tain to what extent and degree the urethra is involved. If urination is painful the patient should take an alkaline mixture and drink freely of the alkaline waters. Coffee and alcohol are to be stopped until the case is well under control, when they may be resumed in moderation. The diet should be nutritious, but simple, the patient avoiding all highly spiced and seasoned dishes. As soon as the pain or smarting on urination ceases, great benefit will be derived from the use of the antiblennorrhagics. All sexual excitement must be strictly guarded against, as it causes urethral and prostatic congestion and thus retards a cure. If the urine contains free pus as well as gonorrhoea! threads it is best to begin with the retrojection treat- ment, which consists of throwing into either the an- terior or posterior urethra several ounces of warm medicated fluid. When from this method the pus dis- appears, and nothing but threads remain in the clear urine, then it is time to stop retrojections and substitute for them instillations, which will be described in de- tail farther on. 08 CHRONIC ANTERIOR GONORRHOEA. 69 If chronic gonorrhoea, or urethritis, is complicated by stricture of the urethra, prostatitis, seminal vesiculitis, an abnormally small meatus, or phimosis associated with balano-posthitis, these conditions should receive appropriate treatment which will be found fully de- scribed under these separate headings, and to which the reader is referred. CHAPTER XII. TREATMENT OF CHRONIC ANTERIOR GONORRHOEA, OR URETHRITIS. The general rules, described in the previous chapter having been minutely carried out, the anterior urethra is irrigated in the following manner : The patient passes his urine in order to flush out the canal ; then a thoroughly clean No. 12 French soft- rubber velvet-eye catheter (See Fig. 9) or a Mitchell's Fig. 9. Soft-Rubber Velvet-Eye Catheter. soft-rubber reflux catheter (See Fig. 10) is lubricated sparingly with glycerin and passed very gently into the bulb of the urethra, the patient standing up before the Fig. 10. G.TIEMANN & L"0 Mitchell's Keflux Catheter. surgeon. An Ultzmann four-ounce hard-rubber hand- syringe (See Fig. 11) is then attached to the end of the 70 CHRONIC ANTERIOR GONORRHOEA. 71 Fig. 11. Ultzmann syringe. catheter by means of a conical hard-rubber coupler (See Fig-. 12), and the warm medicated fluid injected 72 GONORRHOEA AND ITS COMPLICATIONS. slowly and gently into the bulb of the urethra, beyond which it does not pass on account of the compressor urethras muscle, but flows forward and escapes at the meatus, where it is caught in a suitable vessel. Fig. 12. Hard-rubber coupler. In this manner all of the diseased areas in the an- terior urethra are brought into direct contact with the medicated solution. The irrigations or retrojections may be given every day or every second or third day, according to the re- sults obtained and the kind and strength of the solu- tion employed. On the alternate days the patient can use an ordi- nary hand-injection if so desired, and provided it does not cause irritation, which is frequently the case. The amount of solution used at each sitting varies from two to eight ounces, and should always be warm, and thrown in with the utmost care and gentleness. For retrojection solutions we use the following for- mulas in the order given and manner described. Solution I. R. Alum, crud., Zinc, sulphat., aa 2.00. Aq. destillat., 500.00. M. Sig. — Add half an ounce of this solution to seven and a- half (7i) ounces of warm hoiled water, and inject. Increase strength from day to day until equal parts of solution and water are used, CHRONIC ANTERIOR GONORRHOEA. 73 Solution II. R. Potass, permanganat., 1.00. Aq. destillat., 500.00. M. Sig. — Add one-quarter (\) of an ounce of this solution, to seven and three-quarters (7|) ounces of warm boiled water, and give a retrojection every day, or every other day, in- creasing the strength slowly up to 1-1000. Solution III. R. Argent, nitrat. , 1.00. Aq. destillat., 500.00. M. Sig. — Use in precisely the same manner as the second so- lution, increasing the strength very slowly, as the silver is liable to cause severe pain, irritation and tenesmus if used too strong. In the same manner may be used very weak solutions of the bichloride of mercury, and the chloride of zinc, beginning with about 1—40,000, and increasing the strength very slowly and guardedly. If at about the end of the twelfth or fourteenth week of the disease the patient still complains of a dribbling of urine from the meatus after urination, good results will be obtained by the judicious use of medium-sized steel sounds passed to the triangular ligament every fifth to seventh day, and left in the urethra for about a minute ; the pressure which the sound exerts helps to restore the lost elasticity of the urethral walls, and in that way cures this troublesome and disagreeable symp- tom. In the majority of cases of chronic anterior gonorrhoea, or urethritis, sounds should not be employed until at least three months after the acute stage, after which 74 GONORRHOEA AND ITS COMPLICATIONS. time they are of great service in certain selected cases, but must not be used as a routine treatment. If, after using the above irrigations in the manner described, the urine still contains gonorrlioeal shreds, it is advisable to give the patient instillations in the ante- rior urethra. This method is fully described on page 77. CHAPTER XIII. TREATMENT OF CHRONIC POSTERIOR GONORRH(EA, OR URETHRITIS. The general lines of treatment described in Chapter XI. having been instituted, the posterior urethra and bladder are irrigated in the following manner : The patient, having urinated, to cleanse the canal, lies down with head and shoulders elevated and muscles relaxed, and a thoroughly clean, No. 12 to 14 Trench soft-rubber catheter dipped in glycerin is gently passed into the prostatic urethra, so that its eye is just beyond the compressor urethrae muscle. In some rare and ex- ceptional cases it will be found impossible to pass a soft- rubber catheter beyond the compressor urethras muscle. For these cases we can substitute a small woven-silk catheter, which, although more rigid than the rubber one, is flexible and less liable to cause irritation than the metal instruments, which are sometimes recom- mended for this purpose. This spasm of the compressor muscle is, as a rule, caused by rough, rapid and unskill- ful instrumentation of the anterior urethra with large or rigid instruments, and will rarely if ever be en- countered provided the surgeon is gentle and skillful and uses soft and flexible catheters in preference to metal, or rigid ones. The Ultzmann syringe is attached to the free end of the catheter by means of a hard-rubber coupler with stopcock (See Fig. 13), and the warm fluid thrown slowly and gently into the prostatic urethra, from which 75 76 GONORRHOEA AND ITS COMPLICATIONS. it passes to the bladder. When the syringe is empty the stopcock is turned off, the syringe uncoupled, re- filled, and more fluid injected until the bladder feels Fig. 13. Author's hard-rubber coupler with stopcock. full, or the patient complains of a desire to urinate, when the catheter is withdrawn. The patient now stands up and passes the medicated fluid, which, having already acted on the posterior urethra and bladder, washes out the posterior urethra a second time, and flowing through the anterior urethra distends it as it rushes out, and in this manner medicates all of the con- gested, eroded or ulcerated spots and patches along the canal. The solutions to be used for these irrigations are the same as those given for chronic anterior gonorrhoea, or urethritis, on page 72. They must always be warm, and increased very slowly in strength, especially the nitrate of silver and bichloride of mercury solutions, which, if too strong, will set up intense vesical and rectal tenesmus, which may last for several hours. The fluid should always be injected with a four- or five- ounce hand-syringe, as with it we know the exact amount of solution thrown in, the resistance offered by the bladder, and the force used ; whereas if an irriga- CHRONIC POSTERIOR GONORRHOEA. 77 tor were employed, none of the above information could be obtained, and more or less damage might be done. The amount of fluid used at each sitting varies, a good average being about eight ounces, although many bladders will not hold more than from four to six ounces at first ; this is probably due to the irritability of the posterior urethra and more or less contraction of the bladder, which has been produced by the frequent calls to expel the urine during the acute attack ; this irritability subsides rapidly under the treatment, and patients frequently speak of the comfort they experi- ence after the first few washings. If, in spite of the above treatment, carefully carried out, the urine does not clear up promptly, then the pros- tate, seminal vesicles and ampullated ends of the vasa deferentia must be examined per rectum, and if found affected, treated as already described in the chapters devoted to these subjects. If a patient have a chronic antero-posterior gonor- rhcea, or urethritis, and this is usually the case, the treatment is exactly the same in every detail as that just given. If, after having used the retrojections the urine clears up but still contains gonorrhoeal threads, then it is ad- visable to change our plan of treatment by using small amounts of concentrated solutions ; these are called in- stillations, and are given in the following manner : After the patient urinates we pass a properly cleansed No. 12 French soft-rubber catheter, lubricated with glycerin into the posterior urethra if posterior urethritis exists, or into the bulb of the urethra if we have only an anterior urethritis to deal with, and by means of a 78 GONORRHOEA AND ITS COMPLICATIONS. Taylor's instillation syringe (See Eig. 14) we throw in several drops of a 1-2000 solution of nitrate of silver, the catheter is then drawn slowly out of the urethra, while at the same time we may inject a few drops of the silver solution into the bulb and pendulous portion. Fig. 14. Taylor"s Instillation Syringe and Catheter. These instillations should be repeated every third, fourth or fifth day, according to the results obtained. In some rebellious cases we may be compelled to in- crease the strength of the silver solution up to 1-1000, 1-500, or even 1—250 ; this should be done very slowly and carefully, and the instillations given at longer in- tervals, our guide in these cases being the urine, which should be examined at each visit. Instillations of strong solutions of the bichloride of mercury will be found useful in some cases, also 1 to 3 per cent, sul- phate of copper solution, or 3 to 6 per cent, sulphate of thallin solution. If, as is sometimes, although very rarely, the case, a soft-rubber catheter cannot be passed beyond the com- pressor urethra?, muscle, we can then use a small, straight woven-silk one, or the drop-catheter of Ultzmann (See Fig. 15), which consists of a silver catheter 16 cm. long, with capillary bore and thick walls, holding ex- CHRONIC POSTERIOR GONORRHOEA. 79 Fig. 15. actly two drops ; to the extra-vesical end of the catheter is attached a hard-rubber hypodermic syringe, by means of which the operator can deposit with accuracy a given number of drops into the prostatic or bul- bous urethra. CHRONIC CYSTITIS. For chronic cystitis, following a gonorrhoea, or urethritis, we em- ploy these same irrigations, filling the bladder completely and dis- tending all of its folds, so that every part of the inflamed blad- der mucous membrane comes in direct contact with the solution and is thereby acted on. As the patient voids the solution it med- icates the mucous membrane of his prostatic urethra, which was the starting point and cause of the cystitis, so that in this man- ner we treat not only the bladder, but the entire length of the ure- thral canal. There are some cases, however, of chronic gonorrhoeal cystitis and urethro-cystitis which resist all forms of local and medicinal treatment, applied in the most skillful manner and for a sufficient length of time. These cases must be subjected to bladder-drainage through the perineum, the tube being left in for a vari- Ultzrnann's drop-catheter. 80 GONORBHCEA AND ITS COMPLICATIONS. able length of time, depending on the results obtained. In this manner the urethra and bladder have absolute rest, and at the same time can be treated and irrigated as the surgeon deems advisable. This operation will be found fully described on page 133. ENDOSCOPY. The use of the endoscope, in the treatment of chronic gonorrhoea, or urethritis, is sometimes of service in those rare cases which have resisted the different forms of Fig. 16. Taylor's meatus-speculum. treatment already given for these conditions. It should only be employed in certain selected cases, in the chronic stage of the disease, and by one who is skilled in the use of urethral instruments and accustomed to the ap- pearance of the urethral walls, both in their normal and diseased states. By its aid we can examine with CHRONIC POSTERIOR GONORRHOEA. 81 the eye the entire length of the urethra, recognize poly- poid growths, and in some cases locate the areas of dis- ease and treat them locally by topical applications of various drugs. It must be remembered, however, that the endoscope is at best an instrument of reserve, and should never be employed in a routine manner, as its frequent pas- sage through the urethra causes more or less irritation and congestion of this sensitive and highly vascular mucous membrane. For examination of the fossa navicularis, Taylor's meatus-speculum (See Fig. 16) will be found very use- ful, the fossa being illuminated by direct sunlight, or, if that is not sufficient, the rays can be reflected in by means of a head-mirror. For general endoscopic work the W. K. Otis " per- fected " urethroscope is, in my hands, by far the best instrument we have. (See Fig. 17.) It is very light, weighing less than an ounce, easily cleaned, adapted to the Klotz tube, and illuminates the urethral field most brilliantly by means of a small electric lamp and lens. A portable electric-light bat- tery of six cells gives all the required illumination, which may also be obtained from the Edison street cur- rent, properly modified by resistance lamps. The patient, having urinated, lies on his back with the buttocks resting on the extreme end of the opera- ting table, and his thighs supported by proper foot rests or two ordinary stools. A Klotz tube that will enter the meatus with ease is then selected, cleansed, lubri- cated with glycerin and passed slowly and gently into the bulb of the urethra (in rare cases into the prostatic 6 82 GONORRHOEA AND ITS COMPLICATIONS. urethra), the obturator withdrawn, and the light turned on; the urethral walls are then seen bulging into the lumen of the tube, which being slowly withdrawn, gives Fig. 17. The W. K. Otis " perfected" urethroscope. a clear and distinct picture of the entire canal from be- hind forward. As diseased areas are discovered they may be touched with strong solutions of silver nitrate or copper sulphate by means of wooden applicators wrapped with absorbent cotton, which has been dipped in the medicated solution. WHEN IS GONORRHOEA CURED? Having considered the treatment of gonorrhoea and its complications, the important question now arises, When is it cured, or at what time does the discharge lose its infectiousness? In order to answer these ques- tions properly we must examine the patient's morning urine* passed in our presence* for several successive mornings, and if it is clear and contain neither pus nor CHRONIC POSTERIOR GONORRHOEA. 83 gonorrhoea! shreds ; that is, if it be perfectly normal on repeated examinations, we know that the urethral lesions at least have been cured. If, on the other hand, there are shreds, which under the microscope are found to consist of pus and epithelial cells, whether they con- tain gonococci or not, we know that the urethral lesions are still un cured, and that the secretion may be infec- tious. If the shreds consist of epithelial cells alone, they, of course, in themselves, may not be dangerous ; but even these patients must be warned not to have sexual relations, and advised to take a proper course of treatment. In order to ascertain that there is no lurk- ing trouble in the prostate, seminal vesicles or ampul- lated ends of the vasa deferentia, as a result of pos- terior gonorrhoea, or urethritis, the patient should pass the first half of his urine, and then standing in the proper position (see section on seminal vesiculitis) have his prostate, vesicles and vasa deferentia examined and massaged by a finger in the rectum ; the material ap- pearing at the meatus is received on a glass slide and kept for examination ; the patient now passes the second half of his urine, which washes out any remaining se- cretion that has been expressed into the urethra ; the sediment of the second urine and the material caught at the meatus are examined microscopically, and if the findings show disease these conditions must be treated as already described under chronic prostatitis and semi- nal vesiculitis. The examiner must be familiar with the normal secretions of the prostate, vesicles and am- pullar, so as not to err in his microscopic findings. The physician cannot be too guarded in giving his opinion on this subject, and should, therefore, make the 84 GONORRHOEA AND ITS COMPLICATIONS. above examinations in a most thorough and careful manner, and warn patients against matrimony or sexual relations until they are absolutely cured. The follicles in the integument of the penis, between the two layers of the prepuce, in the lips of the meatus, and also the glands that open into the anterior urethra should be carefully examined, in order to ascertain that they are free from the gonorrhoea! process. CHAPTER XIV. GONORRHEAL OPHTHALMIA. Gonorrheal ophthalmia in the adult is caused by the transference of gonorrhoea! pus from the genitals to the eyes by means of the fingers, dressings or towels. In the newly born the infection occurs during par- turition, from the gonorrlioeal pus in the mother's vag- inal tract. Symptoms. The symptoms usually begin within a few hours after infection, and consist of redness and swelling of the conjunctiva, increased lachrymation, with a collection of mucus at the inner angle, which is accompanied by intense itching and a feeling as if for- eign bodies were beneath the lids. The conjunctivitis soon involves both of the lids, as well as the ocular mucous membrane, and is associated with a profuse purulent secretion, which flows out from between the intensely red and greatly swollen lids. The patient is at this time unable to open the eye, or eyes, voluntarily. The foregoing manifestations are accompanied by in- tense pain in the eyeball, forehead and temple, with rapid pulse, rise of temperature, and general malaise. Prognosis. The prognosis is always grave, and de- pends greatly upon the time the patient applies for treatment, whether one or both eyes are attacked, and the extent and situation of the ulceration. It is at best one of the most serious complications of gonor- 85 86 GONORUHCEA- AND ITS COMPLICATIONS. rlioea, and as it may result in either partial or complete blindness the prognosis must always be made in a most guarded and careful manner. Treatment. The patient is put to bed in a well- ventilated room and two competent nurses are employed, one for day and the other for night. If only one eye is affected, the sound one is covered with a shield to prevent its infection ; the shield is made of two pieces of rubber plaster, one four and the other four and one- half inches square, with their adhesive surfaces in con- tact, between which, in a hole made in the center, a deeply concave watch-glass is fastened ; through this glass the patient can see and the eye be inspected by the physi- cian ; the rubber plaster is fastened to the skin about the eye, and its edges sealed with collodion. The nurses must be warned of the danger of infection, and told how to avoid it by keeping their hands and nails clean, and by wearing large, plain-glass spectacles to protect their eyes during the dressings and irrigations. The eye must be washed out day and night with a 3 per cent, solution of cold boric acid (made with distilled water) as often as any secretion accumulates, and in the intervals between the washings the eye should be kept covered with cold cloths (absorbent gauze or sheet lint) taken from a block of ice, and changed every two or three minutes ; these cloths must be burned as soon as removed, and never used again. The eye is flushed out by means of an irrigator, held high enough to allow the cold boric-acid solution to flow out in a gentle stream. From the onset of the infection well up to the declin- ing stage two drops of a 2 per cent, solution of nitrate of silver should be dropped into the eye once or twice GONORRHEAL OPHTHALMIA. 87 in twenty-four hours, according to the severity of the inflammation ; the silver-nitrate solution being applied directly after a boric-acid washing. If the cornea be- comes involved, instillations of a sulphate of atropine solution (gr. ij-3J) should be employed three times daily, and the nitrate of silver stopped. Unless the attending physician is very familiar with diseases of the eye, he should send immediately for a competent ophthalmic surgeon, as a faulty treatment may result in the loss of either one or both eyes. CHAPTER XV. GONORRHOEA!, RHEUMATISM. Gonorrhceal, or blennorrhoeal, rheumatism is an in- flammatory process which may occur during the course of urethral gonorrhoea, gonorrhoeal vulvitis, vaginitis and conjunctivitis. It attacks the joints, bursa?, muscles, nerves, fibrous tissues, sheaths of tendons and the eye. It complicates about 10 per cent, of all cases of gonorrhoea, and is observed more frequently in men than in women ; in some cases it accompanies every attack of urethral gonorrhoea, in other cases only one. From what has been learned in regard to the origin and nature of gonorrhoeal rheumatism, it may be said that the chief etiological factor is the gonococcus and its toxins, which may be associated with pyogenic microbes. It has been clearly demonstrated by compe- tent observers that the gonococcus is carried by the blood current and deposited in the various tissues of the body. If the exudation in the joint be serous or sero-fibrinous in character we find the gonococcus, but if sero-purulent or purulent we discover pyogenic mi- crobes. Gonorrhoeal rheumatism may appear at any time from the end of the first week to the fourth month of the disease, the majority of cases occurring in the chronic stage, which has led to the theory that the septic ma- terial (gonococci or their toxins) is only absorbed from the posterior urethra, which, as a rule, is corroborated GONORRHCEAL RHEUMATISM. 89 by clinical observation, as in the vast majority of cases rheumatic manifestations do not develop until the pos- terior urethra has been invaded by the gonorrhceal process. In most cases several joints are attacked at the same time, although it is not uncommon to see patients with only one joint involved. The following table (Finger) gives the situation of the rheumatism in 375 collected cases : Times. Knee-joint, . . . 136 Tibio-tarsal joint, 59 Wrist-joint, 43 Finger-joint, 35 Elbow-joint, 25 Shoulder -joint, . 24 Hip-joint, . 18 Maxillary -j oint, 14 Metatarsus, 7 Sacro-iliac joint, 4 Sterno- clavicular joint, 4 Chonclro-costal joint, . 2 Intervertebral joint, . 2 Peroneotibial joint, . 1 Crico- arytenoid joint, 1 375 The joint-lesions consist ordinarily of a serous, sero- fibrinous or sero-purulent synovitis ; rarely of a purulent synovitis. Gonorrhceal synovitis usually begins with sudden pain and heat in the joint or joints, rise of temperature, chilly sensations and a feeling of general malaise. The urethral discharge at this time is usually very slight or absent. 90 GONORBHCEA AND ITS COMPLICATIONS. Examination of the joint shows it to be distended with fluid, fluctuating and painful, the integument over it being reddened and hot. The severity of these symp- toms varies according to the character of the exudation. If serous or sero-fibrinous, resolution usually occurs, leaving a good joint ; if sero-purulent or purulent in character, there is more or less destruction of the articu- lar surfaces, followed by ankylosis. Accompanying gonorrhoeal inflammation of the joints we sometimes see involvement of the eye, heart, bursas, spinal cord, sheaths of tendons, fascia? and muscles. Gonorrhoeal bursitis may attack any of the bursas, but is usually observed in the bursa beneath the os calcis, or in the one in front of the tendo-Achillis, the lesion being the same as in synovitis. The sheaths of the extensor tendons of the hand and fingers, the dorsal flexors of the toes, and the flexor pollicis, are the ones usually attacked, although it is not uncommon to see the sheaths of the biceps brachii and tendo-Achillis involved. The palmar and plantar fascise are sometimes, although rarely, attacked. The muscles generally, especially those of the neck, may be the seat of this gonorrhoeal inflammation, which gives rise to pain and stiffness. Diagnosis. The diagnosis may be readily made from the urethral discharge of threads in the urine, the time the rheumatism appeared, which is generally in the chronic stage of the disease, and the successive involve- ment of the large joints, such as the knee, ankle, wrist and shoulder. Prognosis. The prognosis depends upon the degree GONORRHEAL RHEUMATISM. 91 of inflammation, the number of joints involved, and the time the patient applies for treatment, the attack usually lasting from six to twelve weeks. Treatment. If the lower extremities are attacked, the patient should be put to bed ; otherwise he can be up and about with the part properly supported. The joint or joints are immobilized, and during the very acute stage covered with compresses wet in cold lead and opium wash ; when the acute symptoms begin to subside the cold is stopped and the joint is blistered, or touched lightly with the Paquelin cautery, tincture of iodine being painted between the blisters or points that have been cauterized, after which firm and uniform pressure is exerted by means of a cotton dressing and proper splints. In the chronic stage the splints are re- moved, and the joints massaged or steamed and exer- cised daily, after which they are wrapped in icthyol or compound iodine ointment, the patient taking full doses of iodide of potassium, which is often of benefit at this time. If the fluid does not disappear under this treat- ment it must be withdrawn and the joint irrigated with 1—5000 bichloride of mercury solution in the usual manner. If the inflammation goes on to suppuration with ero- sion of the articular surfaces and great deformity the joint will have to be resected to secure better posi- tion ; this, of course, is not necessary until the disease has passed into the chronic suppurative stage. The most important point in the treatment of gonor- rhoeal rheumatism is to cure all of the lesions situated in the urethra, as they are the points of entry of the infectious material. 92 GONORRHOEA 4ND ITS COMPLICATIONS. If the gonorrhoea is acute, subacute or chronic the patient should receive treatment appropriate to these conditions. For the local pain, which in some cases is very severe, we are compelled to resort to the use of opium or morphine in a very guarded and careful man- ner, as it may have to be employed for some time. Full doses of the oil of wintergreen or salicylate of sodium are apparently useful in some cases, although internal medication is as a rule of little value. CHAPTER XVI. STRICTURE OF THE URETHRA. In order that the reader may clearly understand what stricture is, and how to detect and treat it properly, it is necessary to devote a few lines to the anatomy, calibre, length and shape of the urethra. The male urethra is a collapsed canal or a continuous closed valve, whose surfaces, or walls, are always in con- tact, except during urination, ejaculation and the pas- sage of instruments. It extends from the meatus uri- narius externus to the bladder, which it joins at right angles. It is made up of three layers, an internal or mucous layer, a middle or submucous connective tissue layer, and an external or muscular layer, which consists of circular and longitudinal fibers running from the blad- der to the meatus, the circular or ring-shaped fibers be- ing situated outside of the longitudinal ones. Mucous membrane. The mucous membrane of the urethra is shining in appearance, yellowish pink in color, arranged in longitudinal and small transverse folds, and covered with flat pavement-epithelium for about the first quarter of an inch to one inch of its length, beyond which it is of the columnar variety as far as the bladder. Penile or Pendulous Portion. On the roof or upper surface of the penile urethra about one-half to three-quarters of an inch from the meatus is the lacuna 93 94 GONORRHOEA AND ITS COMPLICATIONS. magna, consisting of a valve-like reduplication of the mucous membrane, into which small instruments are apt to pass during urethral examinations. Situated principally in the roof or upper surface, but also in the floor or lower surface of the canal for about the first three or four inches of its length are the mucous follicles or glands of the urethra, with their orifices opening directly toward the meatus ; these, if dilated, may also engage the tips of small examining instruments. Bulbous portion. Opening directly on the floor of the bulbous portion of the urethra are the two orifices of Cowper's ducts, the glands themselves being situated between the anterior and posterior layers of the triangu- lar ligament, and in the substance of the compressor muscle. Membranous Portion. We next come to the mem- branous portion, which is surrounded by the compressor urethral muscle and limited in extent by the anterior and posterior layers of the triangular ligament. Prostatic Portion. The prostatic portion, situated, as it is, in the prostate gland, and extending from its apex to its base, presents the following structures upon its floor : running longitudinally in the median line is the verumontanum or caput gallinagiuis, containing on its summit the uterus masculiuus, in the walls of which are the openings of the common ejaeulatory ducts. The prostatic ducts open into the prostatic sinuses, which are situated on each side of the verumontanum. It will, therefore, be seen that the seminal vesicles, testicles and prostate gland are in direct communication with this portion of the urethra by means of their ducts. Length. The length of the urethra varies in differ- STRUCTURE OF THE URETHRA. 95 ent individuals and under different conditions, the average being from seven to eight and one-half (7 to 8|) inches ; this is increased in hypertrophy of the prostate gland and during erection of the penis. The following- table from Sir Henry Thompson gives the approximate length of the different portions of the canal : Inches. Penile or pendulous portion, 6J Mernbranous portion, | Prostatic portion, 1\ Total length, 8} Calibre. The calibre of the urethra is not uniform, but varies greatly in different individuals and in differ- ent portions of the same urethra, there being certain points of physiological contraction and dilatation, which points are well shown in Fig. 18, which was drawn from a plaster cast of the normal urethra. Fig. 18. 7 9 5 4 3 I Showing points of contraction and dilatation in a normal urethra. 1. Meatus uriuarius, 21 to 28 French. 2. Fossa navicularis, 30 to 33 " 3. Middle of pendulous portion, 27 to 30 " 4. Bulbous portion, 33 to 36 " 5. Membranous portion, 27 " 6. Apex of prostatic portion, 30 " 96 GONORRHOEA AND ITS COMPLICATIONS. 7. Middle of prostatic portion, 45 French. 8. Base " " " 33 " 9. Indentation caused by verumontanura. Therefore, in examining a patient for stricture of the urethra the surgeon must bear in mind the fact, that the meatus urinarius, the middle of the pendulous por- tion, and the membranous portion, are normally nar- rower than the rest of the urethra, and also that the fossa navicularis, the bulb, and the middle of the pro- static portion, are larger and more dilatable. Shape. The shape of the urethra varies greatly in the different regions of the canal, being vertical at the meatus and throughout the fossa navicularis, transverse in the penile, or pendulous urethra, and like an inverted Y in the middle of the prostatic portion, thus a ; this formation is due to the jutting up of the verumonta- num from the floor of the prostatic urethra. DEFINITION OF STRICTURE. Various definitions of stricture have been given from time to time by different authors, the most prominent among them being that by Sir Henry Thompson, who says, " stricture may be defined as an abnormal organic contraction of some part of the urethral canal." Sir Charles Bell speaks of stricture as " any loss of dilatability of the urethra." Prof. R. W. Taylor defines stricture as " a condition of the canal attended by decidedly well-marked contrac- tion or stenosis and an utter loss of normal dilatability, caused by an inflammatory process which produces a sclerosis of greater or less density and contractile power." STRICTURE OF THE URETHRA. 97 SEAT OF STRICTURE. For conciseness and clearness of description we will follow the plan of Sir Henry Thompson, who divides the urethra into three regions, as follows : (See Fig. 19.) Fig. 19. Region II. Region III. |l%ins.j 2 l / 2 to 3 ins. \ 2]/ 2 ins. Showing division of urethra into regions. Region I. includes all of the membranous, and one inch of the bulbous urethra, and is therefore about one and three-quarter (If) inches in length. Region II. extends from the anterior limit of Region I. to within two and a-half (2i) inches of the meatus, its length varying from two and a-half to three inches (2| to 3). Region III. includes the first two and a-half (2J) inches of the canal from the meatus down. In two hundred and seventy specimens examined by Thompson, three hundred and twenty strictures were found, their situations being as follows : Strictures. Per cent Kegion I. 215 67 Region II. 51 16 Region III. 54 17 It will, therefore, be seen that the majority of gonor- rhoea! strictures occur at the bulbo-membranous junc- 7 98 GONORRHOEA. AND ITS COMPLICATIONS. tion, or Region I.; next in the region of the fossa navicularis, or Region III. ; and least frequently in the middle of the pendulous urethra, or Region II. Primary gonorrhoeal stricture of the prostatic urethra has never been found, the changes in this portion of the canal being due to submucous cell-infiltration, which does not go on to true stricture-formation. The reason for the so frequent occurrence of stricture in the bulb of the urethra and fossa navicularis is the fact, that in these regions the mucous membrane is lax and surrounded by a large amount of erectile and vas- cular tissue, which arrangement tends to prolong a gon- orrhoeal inflammation which has settled there, and which naturally results in more or less cicatricial contraction. NUMBER OF STRICTURES. In the majority of cases stricture is single, although there may be two, three or even four in the same case ; this however, is not at all common. Out of the two hundred and seventy museum specimens of stricture, Thompson found the stricture to be single in two hun- dred and twenty-six cases. TIME OF OCCURRENCE. Urethral stricture, as a rule, comes on slowly, and in the majority of cases does not give rise to symptoms until several years after the initial attack of gonorrhoea ; this fact is borne out by statistics, which show that the great majority of men apply for treatment between their twenty-fifth and fortieth years. There are cases, however, in which symptoms are observed as early as the sixth mouth after the urethral inflammation, which STRICTURE OF THE URETHRA. 99 goes to show that stricture-formation is in some cases very rapid. The lesion in stricture of the urethra consists at first of a small, round-cell, exudative infiltration into the submucous connective-tissue layer ; this is soft and yielding, and if sufficient in amount to cause any loss of urethral calibre it is called " soft " stricture. As the process advances, however, the small round-cells are re- placed by connective-tissue cells, and we then have a fully formed dense " semifibrous " stricture, which causes more or less impairment of the urethral lumen, with loss of dilatability. These cell-changes may be sharply limited to the sub- mucous connective-tissue layer or involve the corpus spongiosum to a greater or less degree, giving rise to a peri-urethritis. The mucous membrane over the stric- ture becomes more or less thickened, and loses its smooth and shining appearance. VARIETIES AND FORMS OF STRICTURE. Linear Stricture. A linear stricture consists of one or more thread-like bands situated just beneath the mucous membrane and encircling the urethra to a greater or less degree. Annular Stricture. An annular stricture consists of a broader ring of stenosis than the linear variety. If the narrowing involves an inch or more of the canal, we then speak of it as an irregular or tortuous stric- ture. Diaphragmatic stricture consists of a fold of mucous membrane, with the opening, either large or small, situ- ated in its center or side. 100 GONORRHOEA AND ITS COMPLICATIONS. Crescentic or Bridle Stricture. In this form of stricture the mucous fold arises from either the roof, floor, or one of the urethral walls, and juts out into the canal. Inodular Stricture. In this variety the lumen of the urethra is greatly contracted, and the canal is con- verted into an irregular mass of fibrous tissue. Inflammatory stricture. The so-called inflammatory stricture is due to a temporary swelling of the mucous membrane covering any of the above forms of stricture, and is caused by alcoholic or sexual excesses, irritating urine, cold, bodily fatigue and unskillful instrumenta- tion. It should, therefore, be looked upon as a compli- cation, and not as a form or variety of true stricture. Resilient Stricture. Resilient strictures are elastic, and therefore cannot be cured by dilatation, as after instruments are passed they rapidly contract several sizes, leaving the patient with a greatly reduced urethral lumen. Spasmodic or Muscular Stricture. Spasmodic stric- ture is due to the sudden contraction of the compressor urethra? muscle, which surrounds the membranous urethra, or to the circular muscular fibers of the urethra itself. It occurs most frecmently in nervous, irritable and excitable subjects. The spasm may be caused by the rapid or unskillful passage of urethral instruments, operations on or diseases of the rectum and anus, highly acid urine, the long retention of urine, sudden exposure to cold, or, in some cases, from a feel- ing of shame or fear, as when patients are unable to pass their urine before a class or even in the presence of the examining surgeon. STRICTURE OF THE URETHRA. 101 CAUSES OF STRICTURE. The great majority of cases of urethral stricture are clue to gonorrhoea, or urethritis. In two hundred and twenty cases of stricture reported by Sir Henry Thomp- son, seventy-five per cent, were due to gonorrhoea. Traumatic stricture is usually single, and may occur in any portion of the urethra, depending on the seat of injury, but in the vast majority of cases is found in the bulbous or membranous portions or at the bulbo-mem- branous junction; in these regions it follows falls or blows upon the perineum, causing more or less lacera- tion of the urethra, either with or without fracture of the pelvis. Congenital stricture is sometimes observed, especially at the meatus, or just beyond it in the anterior portion of the canal. Stricture may also result from the healing of sores situated within the urethra or at the meatus. SYMPTOMS OF STRICTURE. The symptoms of stricture vary greatly in different cases, their severity depending upon the degree of con- traction of the strictured area. As a rule, there is more or less gleety discharge from the meatus, which may amount to a drop or so in the morning, or only to a gluing together of the meatus ; in other cases, how- ever, there is no gleet, but if the urine be examined, it will be found to contain threads and flakes which are made up of pus and epithelial cells. The meatus is often quite blue in color from the congestion caused by the cicatricial tissue around the urethral walls, which interferes with the return circulation. In old cases of 102 GONORRHOEA AND ITS COMPLICATIONS. tight stricture the urine may be quite cloudy from the presence of pus which arises from the urethra and bladder. As the stricture contracts there is more or less dilatation of the urethra behind it, caused by the damming back of the stream at each act of urination ; this mechanical irritation in time causes congestion and inflammation of the urethral mucous membrane from the posterior surface of the stricture up to and, in some cases, into the bladder, so that these patients really have posterior urethritis with more or less urethro- cystitis, which gives rise to an increased frequency in urination, which may be preceded, accompanied or fol- lowed by a varying amount of pain and uneasiness in the urethra, perineum, prostate and testes. As the stricture contracts the muscular walls of the bladder hypertrophy from the extra amount of pressure they are compelled to exert in order to empty the viscus through the stenosed canal. The urine now comes with less force, and cannot be thrown any distance from the meatus ; in severe cases it comes in scalding, blood- stained drops, which can only be expelled by severe and long-continued straining ; this may cause either hernia, hemorrhoids or prolapse of the rectum, and be associated with evacuation of the bowel at each attempt at urina- tion. From the inflammation in the prostatic urethra and around the verumontanum these patients may have either painful erections or nocturnal pollutions, or, if the inflammatory process involves the ejaculatory ducts, epididymitis or epididymo-orchitis. Some cases at this time have a constant dribbling of urine from the meatus, this incontinence being due to a loss of contractile power of the vesical sphincters. STRICTURE OF THE URETHRA. 103 Retention of urine may occur at any time during the course of stricture-formation ; in some cases it is the first symptom that calls the patient's attention to his real condition ; it is due to a sudden swelling of the mucous membrane covering the stricture, caused by irritating urine, over-zealous instrumentation, catching cold, sexual or alcoholic excesses, etc., some patients being more prone to this complication than others. If the cystitis is well marked, patients complain of con- stant and deep-seated pain over the bladder. The urine in some of these advanced cases becomes ammoniacal (from decomposition of the urea), bloody, and loaded with crystals and pus, which, being coagulated in the bladder by the ammonia, causes a ropy and gelatinous condition of the urine, which is liable to obstruct the eye of the instrument during catheterization. If the above condition of the urine is not modified by proper treatment it may result in stone-formation. COMPLICATIONS OF STRICTUKE. That portion of the urethra situated behind the stricture, as already stated, becomes dilated to a greater or less extent and its mucous membrane and connective- tissue layer become much thickened : the orifices of the prostatic sinuses and the ejaculatory ducts which are situated in the floor of the prostatic urethra are also dilated ; these changes are all produced by the back pressure of the urine, whose free outward passage is prevented by the stenosed and thickened canal. Ab- scesses and fistulae may form behind the stricture, originating in inflamed urethral follicles or ulcerated spots into which the urine escapes, and finally burrows 104 GONORRHOEA AND ITS COMPLICATIONS. in fistulous tracts, which may open in the perineum, on the buttocks, scrotum or the abdomen. In some severe cases abscess of the prostate occurs, which, if untreated, may rupture either into the urethra, perineum or rectum. The bladder walls become greatly thickened from hypertrophy of the muscular layer, which causes trabecule of muscular tissue to project into the viscus ; between these ridges the bladder-wall becomes very thin and dilated, going on to the forma- tion of sacculi, which may in time rupture and allow the contents of the bladder to escape into the peritoneal cavity. Following these changes in the bladder the ureters become dilated, as do the pelves of the kidneys, the secreting portions being pushed out and compressed by the accumulated urine. The inflammation ascending from the bladder through the ureters finally enters the pelves of the kidneys, causing pyelitis, with all of its concomitant symptoms. EXTRAVASATION OF URINE. The urethra behind the stricture having become thin and weakened may, as the result of violent straining, or without apparent cause, give way and allow the uriue to escape into the surrounding tissues in greater or less amount. Rupture of the urethra may occur in any of the following regions, depending, of course, upon the site of the stricture : 1. Between the meatus and the peno-scrotal junction. 2. Between the peno-scrotal junction and the anterior layer of the triangular ligament. 3. In the membranous urethra ; that is, between the anterior and posterior layers of the triangular ligament. STRICTURE OF THE URETHRA. 105 4. Behind the posterior layer of the triangular liga- ment. It is, of course, possible for two of these regions to be included by the rupture of the urethral wall at the same time. Symptoms. The local symptoms depend on the point of rupture, and will be described later. The constitu- tional symptoms are as follows : The patient sometimes experiences a sudden sensation as if something had given away in some part of the urethra ; this is followed by a feeling of momentary relief, accompanied by swell- ing of the penis, hypogastrium, scrotum or perineum, ac- cording to the locality of the rupture. The skin, which at first is very tense, bright red in color, and shining in appearance, soon becomes gangrenous, sloughing and emphysematous from the presence of the gases situ- ated beneath it, which are produced by the decompos- ing urine extra vasated through the tissues. It is a well established fact that normal urine does not cause gangrene or destruction of the tissues even when injected beneath the integument in considerable quantities. The patient at this time has fever, with chilly sensa- tions or well-marked chills and a feeling of general malaise. The local symptoms, as already stated, vary according to the point of rupture, and are as follows : When the opening in the urethra occurs between the meatus and the peno-scrotal junction the extravasation takes place into the tissues of the corpus spongiosum, pushing forward into the glans penis and causing great swelling of the organ. 106 GONORRHOEA AND ITS COMPLICATIONS. When the rupture occurs between the peno-scrotal junction and the anterior layer of the triangular liga- ment the urine is extravasatecl into the scrotal tissues and upward on the hypogastrium, sometimes as far as the umbilicus. When the rupture takes place between the anterior and posterior layers of the triangular ligament (in the membranous urethra) the urine is at first confined be- tween these layers, but soon makes its way backward into the pelvic cavity, or, in exceptional cases, burrows forward into the perineum. When rupture takes place behind the posterior layer of the triangular ligament the urine passes either into the recto-vesical space, and thus works down to the perineum, or passes upward into the pelvic tissues. Treatment. No matter how great or small the amount of extravasated urine is, we must always bear in mind the clinical fact that it is due to a constant leakage of urine through a more or less damaged urethra, and that in order to check it the bladder must be promptly drained through the perineum. This must be done without delay, as the longer it is put off the greater the extravasation becomes, which, if left un- controlled, means abscess-formation, or sloughing and gangrene of the soft parts, with more or less absorption of septic material. The patient, having been etherized, is put in the lith- otomy position, and the parts shaved and rendered sur- gically clean in the usual manner. External urethrotomy or perinea] section is then performed, according to the manner described under perineal operations for blad- der drainage and stricture of the urethra. All of STRICTURE OF THE URETHRA. 107 the stricture-tissue having been thoroughly divided a lai-ge perineal tube is passed into the bladder and se- cured in the usual manner. By free and deep incisions all of the extravasated urine must be liberated, the sloughy and gangrenous tissues removed, and bleeding points controlled. The incisions are thoroughly irri- gated with hot-salt solution, and lightly packed with iodoform or sterilized gauze. The incisions are kept scrupulously clean by frequent irrigation and dressing, and treated on general surgical principles. If urinary abscesses or flstulae exist, they must be freely opened, scraped, resected and drained at the time of the perineal operation. CHAPTEE XVII. DIAGNOSIS OF STRICTURE. In order to ascertain the presence of stricture, its situation, consistency and calibre, the following instru- ments are necessary : Filiform and olivary bougies, bougies a boule, steel sounds, a scale plate and measure combined, and for certain selected cases an Otis urethrameter. The scale plate, as well as all of the urethral instru- ments, should be made and marked according to the French scale, which runs as follows : No. 1 French = J of a millimeter in diameter. No. 2 French = f of a millimeter in diameter. No. 3 French = 1 millimeter in diameter. Thus it will be seen that each instrument increases in size by one-third of a millimeter hi its diameter. Scale Plate. The scale plate or gauge is made of nickel-plated steel, with numbers or sizes running from No. 1 to No. 35, or even 40 French, inclusive. (See Fig. 20.) One edge is marked in inches like a rule, so that it can be used for measuring the distance from the meatus at which instruments are stopped by stricture. Sounds. Sounds are made of smooth, highly pol- ished nickel-plated steel, and should rim from No. 18 to No. 35 French, inclusive. They should have the Thompson curve and conical point, which is three sizes smaller than the shaft. (See Fig. 21.) Olivary bougies. The French olivary bougies are the most durable, although quite good ones are made in 108 DIAGNOSIS OF STRICTURE. 109 this country ; they are black or yellow in color, with a very smooth and highly polished finish. (See Fig. 22.) Fig. 20. Scale plate. Fig. 21. Fig. 22. French olivary bougie. 110 GONORRHOEA AND ITS COMPLICA TIONS. The shaft tapers gradually into the neck, which terminates in the olivary end, this being about seven sizes smaller than the shaft. These bousies must be Fig. 23. Gouley's whalebone filiform bougies. flexible, so as to adapt themselves to the curves of the urethra, and should run from No. 3 to No. 20 French, inclusive. Filiform Bougies. Gonley's whalebone filiform bougies are the best. (See Fig. 23.) They are twelve Fig. 24. Bougie u boule. inches long and about Nos. 1 to 3 of the French scale in size ; the shaft must be smooth and polished, and DIAGNOSIS OF STRICTURE. Ill Fig. 25. terminate in a tiny bulb. The points of some of the instruments may be turned and twisted in various ways, in order to facilitate their entrance into irregular contractions. The remainder however should be made straight, and in my hands are really the most useful for cases of tight stricture. The sur- geon should have a dozen at least. Bougies a Boule. These instru- ments should be soft and flexible, as is well shown in Fig. 24. Those made of metal cause more pain, and do not give the examiner as good an idea of the con- dition of the urethral walls. The shoulder of the bulb should be well marked and smooth. It is best to have a set of these bougies from No. 8 to No. 32 French, inclusive. The Urethrameter. The Otis ure- thrameter, if skilfully used, is a very valuable instrument for detecting and locating strictures in cases with abnor- mally small meati. If, however, the little bulb is screwed up too high and then withdrawn, there is great danger of mistaking physiological contractions of the urethra for true strictures. The instrument (See Fig. 25) con- sists of a No. 8 French straight canula, terminating in a bulb made up of short arms, which can be dilated (.4) and contracted (Z?) by means of a rod run- Otis urethrameter. 112 GONORRHOEA AND ITS COMPLICATIONS. ning through the canula and terminating in a screw at the handle of the instrument. A thin rubber shield (C) is drawn over the metallic bulb to protect the urethra from injury. The index on the handle shows the size in millimeters to which the bulb has been di- lated or contracted. The bulb when closed is about No. 18 French, but can (although it never should) be expanded up to No. 40 or 45 of that scale by turning the screw at the handle, which indicates at the same time the increase in size on the index. METHOD OF EXAMINATION. Before exploring the urethra with instruments the surgeon should ascertain the date of the gonorrhoeal infection as well as its duration, severity and compli- cations, as these points will throw much light on the patient's present condition. If there is a muco-purulent or purulent urethral discharge, with swelling and red- ness of the meatus, the patient must be put on appro- priate treatment, and instrumentation deferred unless imperative until the acute symptoms have subsided. As a rule, examining instruments ought not to be passed into the urethra until at least three months after the last gonorrhoeal attack. Inquire into the frequency of urination during the day or night ; if it is painful or causes uneasiness in the region of the prostate ; also, if there is any morning discharge or sticking of the lips of the meatus. Ask if there is a dribbling of urine after urination, or any change in the character, force or size of the stream. Have the patient pass his urine at the time of his visit in a glass cylinder ; this is care- fully examined for gonorrhoeal shreds, pus or mucus, as DIAGNOSIS OF STRICTURE. 113 these elements, by their presence in the urine, together with a history of the case, will give a clear idea as to the extent and severity of the urethral or even bladder inflammation. URETHRAL EXPLORATION. The following rules should be carefully carried out in making all urethral examinations or explorations, no matter what kind of instruments are being employed. Large instruments should always be used first, as small ones are more apt to irritate the urethra, and thus cause spasm, which interferes greatly with further examina- tion. If instrumentation causes bleeding, it should be stopped immediately, and not be repeated for a day or so, appropriate treatment being employed in the mean- time. The patient having urinated in order to wash out any secretion that may have collected in the urethra, lies down on an operating table, with head and shoulders slightly elevated on a pillow or cushion ; in this way re- laxing the belly muscles, and the suspensory ligament, which runs from the symphysis pubis to the dorsum of the penis. The clothing should be drawn down as far as the knees and up to the umbilicus, as by so doing the instrument can be readily depressed between the thighs as it enters the bladder, and at the same time we can note the median line by the position of the um- bilicus and the linea alba. The glans penis and meatus should be carefully wiped off with warm water or a little bichloride solution, and the prepuce well retracted, so that the penis can be held in the sulcus, which will pre- vent it slipping from the examiner's fingers. 114 GONORRHOEA AND ITS COMPLICATIONS. For exploring the urethra for stricture, the best instru- ment to use is the flexible bougie a boule, selecting one that will readily enter the meatus. It is washed in soap and warm water, dried on absorbent gauze, and lubri- FiO. 26. Sound entering meatus. cated with plain white vaseline. The penis is held at right angles to the body by means of the thumb and index finger of the left hand, which grasps it in the sulcus behind the corona. As the bougie, held lightly between the right thumb and forefinger, glides slowly and gently down the canal it imparts to the examiner an accurate idea of the condition of the urethral walls : DIAGNOSIS OF STRICTURE. 115 whether they are inelastic and rigid, soft and pliable, or the seat of contraction. If preferable, the exploration may be made with a steel sound, or olivary bougie, selecting one that enters the meatus with ease ; it is washed in soap and hot water, dried on absorbent gauze, lubricated with plain white vaseline, and passed slowly and with the utmost care and gentleness in the following manner : Fig. 27. Tip of sound entering bulb. The operator stands on the left side of the patient, holding the penis in the coronal sulcus, between the thumb and index finger of the left hand ; in this way the penis is put on the stretch at right angles to, and 116 GONORRHOEA AND ITS COMPLICATIONS. in the median line of the body ; thus effacing the first curve of the urethra. The sound is held lightly between the thumb and first two fingers of the right hand, which Fig. 28. Tip of sound at the opening in triangular ligament. rests on the median line of the belly wall, and the tip of the instrument is gently inserted into the meatus. (See Fig. 26.) The hand still resting on the abdominal wall, urges the sound gently downward into the urethra, the penis DIAGNOSIS OF STRICTURE. Ill at the same time being drawn upward, so that the sur- geon's hands approach each other. (See Fig. 27.) At this time the tip of the sound is just entering the bulb. The left hand now drops the penis, which is swept slowly downward and at right angles to the body by the sound, whose tip now rests against the opening in the triangular ligament, and its convexity in the bulb of the urethra. (See Fig. 28.) In order to reach the prostatic portion the handle of the instrument is gently depressed, it being now held in the left hand. (See Fig. 29.) The patient usually Fig. 29. Sound in prostatic urethra. complains at this time of a desire to urinate, owing to the pressure of the instrument on the mucous membrane 118 GONORRHEA. AND ITS COMPLICATIONS. of the prostatic urethra, which is extremely sensitive, even in health. If the bladder is to be explored, the handle of the sound is depressed still further between the thighs and pushed gently upward, when it will be felt to glide easily into the bladder. (See Fig. 30.) Fro. 30. Sound in bladder. Endoscopic tubes, cystoscopes, stone searchers, litho- trites, evacuating tubes, and in fact, all instruments used in the deep urethra and bladder, are introduced in the same manner as above described. In examining old men the tip of the instrument will sometimes catch or hitch in the bulb, as in these cases it is often in a more or less relaxed and sacculated con- dition, and is easily carried on the tip of the sound for a short distance upward and beneath the membranous urethra. This complication can be easily obviated by DIAGNOSIS OF STRICTURE. 119 keeping the end of the instrument in close contact with the roof of the canal. While the sound or bougie is still in the urethra much information can often be obtained by palpating the canal against it, as in this manner thickened patches on the floor of the urethra or strictured areas can be felt. If the olivary bougie or sound detects a stricture we should then employ a flexible bougie a boule in order to ascertain its exact location and calibre. It is washed in soap and warm water, dried, lubricated with vaseline, and passed in the same manner as the olivary bougie down to the obstruction, the distance down being noted by holding the finger on the shaft of the instrument at the meatus ; it is then withdrawn, when the distance be- tween the finger and the bulb is measured, which gives the exact depth of the contraction in inches. Smaller bougies a boule are tried until one finally passes the ob- struction which, of course, gives its calibre or size. If the stricture is so tight that it will not admit our smallest olivary bougie, or bougie a boule, we then employ whalebone filiform bougies. In passing fili- forms it is best to hug the floor of the urethra with the penis on the stretch and at right angles to the body, so as to avoid the lacuna magna on its roof, in which these little instruments often catch. The tip of the in- struments may be left straight, or turned and twisted in various ways and shapes, as already shown. The urethra having been fully injected (distended) with warm olive oil if so desired, a filiform is passed down to the face of the contraction, and rotated slowly and care- fully until it engages in the opening, when we make a diagnosis of filiform stricture ; if this does not occur 120 GONORRHOEA AND ITS COMPLICATIONS. we pass another filiform, and so on, until one finally enters the opening in the contraction, when it is left in situ and the others removed, or, if this is impossible, we speak of it as an impassable stricture ; that is, it may be impassable to instruments, and yet the urine can be voided in drops or even in a fair-sized stream. If the patient has such an abnormally small meatus that it will not admit bougies or sounds of a sufficient size to examine the urethra properly, and if it is not thought wise to enlarge the meatus at the time by meat- otomy, then we may employ for exploratory purposes the Otis urethrameter in the following manner : It is cleansed, lubricated with plain white vaseline, gently passed into the bulb, and screwed up to about No. 28 or 30 of the French scale. As the instrument is slowly withdrawn the stenosed areas or spots of thickening are noted, great care being taken not to diagnose physiolog- ical contractions as strictures of the urethra. CHAPTER XVIII. TREATMENT OF STRICTURE. The treatment of urethral stricture depends greatly upon its situation, duration and extent, and whether it be soft, semifibrous or modular. As a broad, general rule, however, it may be stated that the best routine treatment is gradual dilatation with bougies and sounds combined with local urethral and internal medication. If these methods fail or cannot be employed, we then resort to one of the cutting operations about to be de- scribed. The urine should be carefully examined in order to ascertain the condition of the kidneys, and at the same time the extent and severity of the urethral and bladder inflammation, if these conditions exist. If the patient has urethritis, or cystitis, it must be treated in the manner already given for these affections, to which the reader is referred. Kidney disorders are to be handled on general medical and surgical principles. The reaction of the urine must be modified either by the administration of acids or alkalies, as indicated, and the patient's diet carefully looked into and regulated, so that we may render the urine as bland and non-irri- tating as possible. STRICTURES OF OR WITHIN THE MEATUS. Strictures in this situation do not yield to dilatation and must therefore be cut (meatotomy). The normal meatus varies from No. 21 to 28 French, and should 121 122 GONOBBHCEA AND ITS COMPLICATIONS. never be interfered with unless absolutely necessary, as over-zealous cutting of this part of the canal leads to a flat spluttering stream that cannot be thrown any dis- tance from the body, and a disagreeable dribbling of urine after each act of urination. If the meatus is so small that normal urination is interfered with, or that proper treatment cannot be applied to the parts beyond, then it may be cut up to No. 28 or even 32 of the French scale, according to the case. MEATOTOMY. The patient urinates and lies on his back ; the parts are cleansed, as is also the urethra, by irrigations of warm boric-acid solution. Local anaesthesia may be caused by injecting a little 4 per cent, cocaine solution, which produces its full effect in about ten minutes. The prepuce is retracted and the penis grasped in the sulcus behind the corona ; then, with a straight, blunt bistoury, the meatus is slowly incised downward on its floor and directly in the median line to the desired size. Contractions just beyond are dealt within the same man- ner, except that a little cutting may have to be done in the median line of the roof of the urethra ; this fact hav- ing been ascertained at the time of the first examination. A steel sound is then passed through the meatus to see that all is clear, and repeated daily to prevent contraction of the little wound. If bleeding occurs it can be readily controlled by pressure and a light gauze dressing. STRICTURES OF THE PENILE URETHRA. Strictures of the penile urethra include all of those contractions which are situated between the meatus TREATMENT OF STRICTURE. 123 and the junction of the penis with the scrotum. If these contractions are soft and yielding, gradual dilata- tion should be tried with the olivary bougie or steel sound. If dilatation causes pain or irritation, and it is found impracticable, it should be stopped and the stric- ture cut (internal urethrotomy) either with a straight blunt bistoury if near enough to the meatus or with a urethrotome if further down the canal. For a descrip- tion of internal urethrotomy the reader is referred to page 127. The incision with the bistoury is made directly in the median line and on the roof of the ure- thi-a. A No. 28 to 30 French steel sound is then passed, and the divided contraction kept open by pass- ing sounds every few days until the wound is healed, when the intervals between instrumentation can be made much longer. The urethra should be cleansed, anaes- thetized and irrigated, as already described under meat- otomy. STRICTURES BEYOND THE PENOSCROTAL JUNCTION. For strictures situated in the bulbous portion of the urethra, or at the bulbo-membranous junction, if they are soft or even semifibrous, we should always try gradual dilatation and local urethral medication before resorting to any cutting operation. GRADUAL DILATATION. Gradual dilatation consists in passing olivary bougies, if the stricture is under No. 18 French, or steel sounds, if No. 18 French or over, every fifth or seventh day, depending on the reaction and results obtained ; these can be noted by the patient's sensations and the appear- 124 GONORRHOEA UND ITS COMPLICATIONS. Fig. 31. ance of the urine, which should be examined at each visit. The dilating instrument is passed slowly and gently and left in the urethra for a minute or so, in this manner exerting pressure on the thickened and infil- trated urethral walls, which in many cases resume their normal consistency as the result of the absorption of the inflammatory material. The size of the bougies or sounds must be increased slowly and in the fol- lowing manner : if a stricture takes a No. 15 French at the first visit the surgeon shoidd pass a No. 15 and 16 at the second visit, and so on until he has reached No. 28 or 32 of the French scale. If the contraction is tortuous or ir- regular, and involves a considerable portion of the bulb, very satisfactory results will be obtained from the use of the Beneque steel sound (See Fig. 31), as by its double curve it exerts more pressure on the stenosed and thickened urethral walls. By the careful employment of gradual dilatation many cases of even filiform stricture may be dilated up to No. 30 French and over, as the case requires, Beneque steel sound. an( j kept g0 f or t ] ie rema incler of the patient's life, provided he will have a sound passed a few times during the year. TREATMENT OF STRICTURE. 125 If the surgeon is too hasty, rough, unskilful or uncleanly in his urethral manipulations he may cause such complications as ure- thritis urethro-cystitis, urethral chills and fever, or retention of urine from swelling of the ure- thral mucous membrane. If, after a fair trial, gradual dilatation fails we will then have to resort to urethrotomy, either external, internal or a combina- tion of both, depending on the seat and extent of the strictured area. EAPID DILATATION. If the stricture will only admit a filiform bougie it may be left in place and used as a guide for a small Gouley's tunnelled sound (See Fig. 32), which consists of a grooved, conical steel sound, the groove terminating in a canal or tunnel at its vesical extremity, through which the filiform guide passes. These sounds should run from about No. 6 to 18 French, inclusive, and must be well made so that the tunnel will not cut the filiform bougie as it passes through it. The sound is passed Fig. 32. Gouley's tunnelled sound and guide. 126 GONORRHOEA. AND ITS COMPLICATIONS. over the filiform and through the stricture, which can in this manner be dilated through several sizes at one sitting, the subsequent dilatation being carried out with bougies and sounds. This method of rapid dilatation is in reality a form of divulsion, and is attended with risk, even in the most skilful hands, and is not to be employed except in an emergency, and unless the patient can remain in bed, with proper constitutional and local treatment. DIVULSION. The treatment of stricture of the urethra by rupture or divulsion is purposely omitted, as it is considered dangerous, inexact and rough, as compared with gradual dilatation and the various forms of urethrotomy. ELECTROLYSIS. The treatment of stricture by this method is still so incomplete and wanting in results that nothing definite or authoritative can be stated at present. Professor Fort, of Paris, has done very satisfactory work in this line, his apparatus and instruments being most com- plete ; the operation is of short duration, and so pain- less that no anaesthetic is required. Carefully observed cases for a sufficient length of time will alone give us the real worth (if any exists) in this method. URETHRECTOMY. By urethrectomy is meant either the partial or com- plete excision of all of the stricture tissue at the time of the external urethrotomy, and the building up of a new urethra, sutured about a retained catheter or tube. TREATMENT OF STRICTURE. 127 This method should be reserved for those rare and ex- ceptional eases of traumatic stricture that will not yield to simple external urethrotomy. INTERNAL URETHROTOMY. This operation consists of the division of the strict- ure within the urethra, the incision being made on the roof of the canal and directly in the median line, thus producing a linear wound. When the operation is properly performed there will be no danger of wound- ing either of the corpora cavernosa, as the little cut is situated below and between them, in the base of the septum pectiniforme. As a broad, general rule, internal urethrotomy should be limited to undilatable strictures situated in the pen- dulous urethra and not further down the canal than four or five inches from the meatus, unless it is com- bined with external urethrotomy for the purpose of properly draining the bulb. Instruments for Internal Urethrotomy. Instru- ments for this purpose are called urethrotomes, of which there are many forms and varieties. The sur- geon should have two or three of these instruments, as no single one is adapted to all forms of stricture. Maisonneuve's urethrotome (See Fig. 33) consists of a small grooved shaft with a short curve. The groove carries the knife, and is situated on the upper surface of the staff, stopping at the point where the curve begins. The distal end of the staff has a screw tip, to which may be attached a filiform guide, tun- nelled, or solid tip. The knife, fastened to a long sty- let, is triangular in shape, sharp in front and behind, 128 GONORRHOEA AND ITS COMPLICA TIONS. Fig. 33. Fig. 34. Maisonneuve's urethrotome. Maisonneuve-Fluh rer urethrotome. TREATMENT OF STRICTURE. 129 but blunt at its apex, so as not to cut the healthy urethra. The instrument is used as follows : the staff, with its solid tip, is passed into the bladder and held firmly in the median line of the penis, which is pulled forward on the stretch ; the knife is then slipped into the groove and pushed down, cutting the contractions before it, when it is withdrawn, the penis and staff be- ing held in exactly the same position. If the staff cannot be introduced alone, it can be screwed to the filiform, which it will follow, or passed over a long whalebone filiform bougie threaded through the eye in the tunnelled tip. The Maisonneuve-Fluhrer urethrotome (See Fig. 34) consists of a straight No. 12 French grooved staff, the groove for the knife being situated on the upper surface of the instrument and terminating in a tunnelled tip, which is slightly curved upward. The knife is like the Maisonneuve and cuts to about No. 24 French. A whalebone filiform bougie is passed into the bladder and its end slipped through the tunnelled urethrotome, which is introduced over it through the stricture. The penis is held on the stretch in the median line, the knife pushed down the groove, and the stricture cut from be- fore backward. This instrument is especially useful for tight strictures in the penile urethra. The Otis urethrotome (See Fig. 35) is a dilating and cutting instrument combined. It consists of two steel shafts, which, when closed, are about No. 16 French ; these shafts are connected by short bars like a parallel ruler, which can be opened or closed by means of a screw at the handle of the instrument, which at the same time indicates the calibre to which they are opened 130 GONOEEH03A AND ITS COMPLICATIONS. Fig. on a little index. The blade running in a groove in the upper bar becomes concealed in a slot when it reaches its extremity. The instrument, with blade con- cealed, is passed just beyond the stric- ture and gently and slowly dilated until the stricture feels tense, when the blade is drawn out, cutting through the stricture on the roof of the canal in the median line, and from behind forward. The blade is then pushed back and concealed, the shafts approxi- mated, and the instrument withdrawn. This . urethrotome is serviceable for strictures of the pendulous urethra with a calibre of No. 16 French or over, provided that the urethra is not over- dilated and unnecessarily cut. Preparation of the Patient. In- ternal urethrotomy having been decided on, the urine must be examined in order to ascertain the condition of the kidneys and whether the bladder or urethra is the seat of inflammation. If diseased conditions exist they must be treated n|§P on the lines already laid down. The patient is put to bed for twenty-four hours before the operation and his gen- eral condition carefully attended to in every detail. Coffee and alcohol in all forms must be stopped and the urine rendered bland by a light nutritious diet and boric acid or alkalies, as Otis urethrotome. TREATMENT OF STRICTURE. 131 indicated. There is no better tonic than strychnine and quinine given in quite full doses before and after these operations. The bowels should be freely opened. If the kidneys will not allow of ether, the urethra may be anaesthetized with a little four per cent, cocaine solution. Operation. The patient having urinated, is ether- ized, the pubes and genitals are shaved and rendered surgically clean in the usual way. If possible, the urethra and bladder are thoroughly irrigated with warm boric-acid solution by means of a hard-rubber hand- syringe and catheter, and the cutting performed with one of the instruments already described, which has been scrubbed, sterilized and placed in warm boiled water. After the urethrotome has been taken out a bougie a boule, or steel sound, properly cleaned and lubricated, should be passed, to see that no bands or constrictions are left, after which the urethra and bladder are again irrigated with warm boric-acid solu- tion, several ounces of which are left in the bladder with the idea of diluting the urine and rendering it less irritating as it is voided over the wound in the urethral wall. The operation being completed an opium sup- pository is placed in the rectum, and the patient put to bed, with a light sterile gauze dressing around the penis. The stricture having been cut up to No. 25 or 30 French is kept open by dilatation, which is begun on about the second day after the operation, and con- tinued as already described. If internal urethrotomy is performed in this conservative manner we will not have such unnecessary complications as severe hemorrhage, urethral chills and fever, and permanent curvature of the penis. In this operation, no matter what instru- 132 GONORRSCEA AND ITS COMPLICATIONS. ment is used, it should always be held firmly in the median line, and the penis pulled out over it and well on the stretch, so that the incision will be as nearly as possible in the medium line, thus avoiding injury of the corpora cavernosa, with subsequent hemorrhage. EXTERNAL URETHROTOMY. For strictures situated deeper than four to five inches from the meatus, that is, in the bulbous, the bulbo-mem- branous or membranous portion, we should perform either a combination of internal and external urethrot- omy, or external urethrotomy alone ; the object of the external cut being to drain the bulb properly through the perineum, and in this manner prevent the accumu- lation and absorption of any irritating or infectious secretion that might occur. The following perineal operations are for bladder drainage and for the relief of strictures of the bulbous, the bulbo-membranous and membranous portions. The preparation of the patient and the instruments for all of these operations is the same, and to prevent repetition will be described here, and not with each special opera- tion. Preparation of the patient. The condition of the kidneys is carefully looked into, and if disease exists it must be treated on the usual medical or surgical lines. The patient goes to bed for a day or so before the operation, aud his general health is put in as good con- dition as possible by a light, nourishing diet and tonics, such as strychnine and quinine. Alcohol and coffee must be stopped, as they cause more or less urethral and bladder irritation. TREATMENT OF STRICTURE. 133 If possible, the bladder and urethra should be irri- gated daily with warm boric-acid solution for several days before the operation. The bowels are kept open. The patient, being etherized, is placed in the lith- otomy position on the extreme end of the table, and in a good light, and held there flat on his back and exactly in the median line by assistants or appropriate appa- ratus. The symphysis, scrotum and perineum are shaved and rendered surgically clean in the usual man- ner, as are also the penis and preputial cavity. The urethra and, if possible, the bladder are flushed out with warm boric-acid solution by means of a cathe- ter and an Ultzmann hard-rubber hand-syringe or irri- gator ; if the bladder can be entered, it should be left partially filled with the solution. All metal instruments must be sterilized and placed in trays of hot boiled water ; the soft ones are carefully washed in soap and hot water, and laid in sterilized gauze. The surgeon prepares himself as he would for any major operation, and sits on a stool facing the perineum and with his back to the light. EXTERNAL URETHROTOMY FOR BLADDER DRAINAGE. This operation is performed for draining the bladder in cases of chronic cystitis and urethritis that have re- sisted all forms of local treatment and that are not com- plicated by stricture. A full-sized Gouley's tunnelled sound (See Fig. 32, Page 125) is passed to the bladder as a guide to cut upon, and held exactly in the median line by an assist- ant, who also retracts the scrotum and bulges out the 134 GONORRHOEA AND ITS COMPLICATIONS. perineum by pressing the convexity of the instrument downward and forward. An incision about two inches in length is then made in the median line down to the groove on the convex side of the guide, and the urethra opened by a single cut, through which the index finger may be passed to explore the bladder, and if so desired, to dilate the prostatic urethra. An Otis perineal tube of about No. 30 to 35 French (See Fig. 36) is passed into the bladder and held there by means of a sills: su- ture, which, being passed through both edges of the wound and the tube, is securely tied. The bladder is irrigated with warm boric-acid solution, which is thrown in by means of an Ultzman hard-rubber hand-syringe Fig. 36. Otis perineal tube. or irrigator through the perineal drain, which, when the bladder is partially filled with warm solution, should be clamped, to retain a few ounces of fluid in the bladder until drainage is established. Bleeding points are caught and ligated, the wound packed with iodoform gauze, an opium suppository administered, and the dressing held in place by a firm T bandage. When the patient is put to bed the clamp is taken off and the perineal tube is attached to a piece of rubber tubing by means of a glass coupler through which we can see whether the bladder is draining properly or not. The tubing terminates in a bottle under the bed, which is one-quarter filled with 1-1000 bichloride solution ; TREATMENT OF STRICTURE. 135 this keeps the urine sweet which runs into it and pre- vents the entrance of air into the bladder. The per- ineal tube is left in place for from one to two weeks, according to the results obtained, but must be taken out every few days and cleansed to prevent the deposit and accumulation of urinary salts upon and within its in- terior. During' this time the urethrocystitis is being- treated by irrigations and internal medication. When the tube is removed permanently the perineal wound should receive special attention to promote its rapid healing. EXTERNAL URETHROTOMY. GOULEY's OPERATION. The patient being prepared for operation as already described, a whalebone filiform bougie is passed through the stricture into the bladder. A good-sized Gouley tunnelled sound is then passed over the filiform to the anterior face of the stricture and held there exactly in the median line by an assistant, who pressing the in- strument downward, renders the perineum tense. The operator then cuts down on the groove on the convex surface of the sound, being careful not to cut the fili- form guide. The urethra is opened by a single clean incision, which thus exposes the sound and the filiform bougie lying in its groove. The sound is now with Fig. 37.