i?' THE > 5 LIBRARIES 1 O HEALTH Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofurologOOpede A TEXT-BOOK OP UROLOGY MEN, WOMEN AND CHILDREN, f INCLUDING UEINARY AND SEXUAL INFECTIONS UEETHROSCOPY AND CYSTOSCOPY BY VICTOR COX PEDERSEN, A.M., M.D., F.A.C.S. MAJOR, MEDICAL CORPS, UNITED STATES ARMY; CONSULTING PHYSICIAN TO THE SELECTIVE SERVICE HEADQUARTERS IN THE CITY OF NEW YORK; MEMBER OF THE COUNCIL OF NATIONAL DEFENCE, NEW YORK STATE COMMITTEE, MEDICAL SECTION; VISITING UROLOGIST TO ST. MARK's HOSPITAL; MAJOR, MEDICAL RESERVE CORPS, UNITED STATES OF AMERICA. MEMBER OF THE AMERICAN UROLOGICAL ASSOCIATION, AMERICAN MEDICAL ASSOCIATION, NEW YORK STATE AND COUNTY MEDICAL SOCIETIES, NEW YORK ACADEMY OF MEDICINE, AMERICAN ELECTROTHERAPEUTIC ASSOCIATION, THE ASSOCIATION OF MILITARY SURGEONS OF THE UNITED STATES, AND OF THE COMMITTEE ON VENEREAL DISEASES OF THE ADVISORY COUNCIL OF THE DEPARTMENT OF HEALTH OF NEW YORK CITY ILLUSTRATED WITH 362 ENGRAVINGS, OF WHICH 152 ARE ORIGINAL AND 13 COLORED PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 1919 Copyright LEA & FEBIGER 1919 61 IN MEMORY OF WILLIAM WALTER GENGE, M.D., CM. WHO AMID THE DIFFICULTIES AND TRIALS OF PRACTICE IN THE GREEN MOUNTAINS OF VERMONT FIRST TAUGHT THE INSPIRATION AND BLESSING IN A LIFE SPENT IN THE SERVICE OF MANKIND AND IN GRATITUDE TO WALTER BROOKS BROUNER, A.B., M.D. WHO THROUGH A HUMAN GENERATION HAS SHOWN A PERSONAL AND PROFESSIONAL FRIENDSHIP WHICH HAS NEVER FALTERED NOR FAILED, THIS BOOK IS SINCERELY DEDICATED PKEFACE. In preparing a text-book on any branch of medicine originality, except perhaps in arrangement, is ahnost impossible. The present work is planned on a rather uniform discussion of the clinical side of the diseases included, for the benefit of students and general practitioners, who, in not being widely familiar with the sub- jects, will be served by a fixed view-point. The reader will perceive this outline in such subjects as etiology, pathology, symptoms, diag- nosis and treatment. A further advantage of this method is that these five subjects are correlated unmistakably by it — a fact which also assists the student. The disadvantage of fixed structure is a varying amount of similarity of style in passing from one disease to another or from one chapter to the next, but the effort has been made to correct this disadvantage by variations in diction. The usual paragraphs on course and prognosis have been omitted as separate subjects but have been carefully embodied in symptomatology as parts of "termination" of each disease. The stages of incubation, invasion, establishment and termination are described so that the student receives a word-picture of the important affections and learns the course and prognosis not as afterthoughts, but as integral elements of the various cases. For the same reason, complications are mentioned during " termination" of the primary disease. The complications have, however, individual portions of the text because in turn their stages of development, progress and cessation are detailed. Under diagnosis in the subject of functional test of the kidneys, hematology has been included as one of the latest additions to oiu* knowledge and as one of the most accurate methods. Authorities are quoted as to the normal range of urea, uric acid, creatinin, sugar, cholesterin and urinary salts, and also as to pathological proportions and their causes. Doubts as to values are clearly verified and explamed. Physical treatment is certainly in the ascendant. The next genera- tion will see it more and more amplified, not to supplant but to augment VI PREFACE other metliods. A familiar example is the use of Roentgen rays and radiimv, and less usual at present are hydrotherapy, heliotherapy and electrotherapy. In human nature the average eriticism is adverse and destructive, while relati\ely few are favorable and constructive. Nearly e\-ery urologist who discourages physical treatment is not possessed of the necessary apparatus, and therefore cannot say from his owi\ experience more than that he obtains good results from other methods. The ^^'riter is not content and believes that the profession should not be satisfied with nonconunittal inexi)erience. He therefore deter- mined to ha\e jjhysical treatment well discussed in his work, and is indebted to Dr. Edward C. Titus, one of the well-known American authorities, for suggestions and additions. Those who have not tried physical methods are thus aided to do so in good faith and with encour- agement, because when compared with drugs and chemical methods, their action is far more definite and more under control of the physi- cian at all times. The data on physical treatment comprise hydrotherapy, heliotherapy and electrotherapy. It has been the design to outline proper cases for one or all these methods, the suitable machine and instruments, the type of application, the strength of application and the duration and frequency of the treatment. To these facts have been added aftercare and adjuvants. In this way a reliable foundation has been given to the student and the practitioner for the judicious and comprehensive treat- ment by these methods of cases properly selected. Under the heading of treatment, aftertreatment is carefully con- sidered, because the average student learns little of it and general practitioners neglect aftertreatment in whole or in part. This subject is subdivided into hnmediate aftertreatment, comprised chiefly in bed care; and remote aftertreatment, which is provided mainly by atten- tion in the office. It is felt that these principles of following cases for long periods after immediate discharge will result in a far higher percentage of complete cures and a larger average of cures without relapses and without sequels. In separate paragraphs in all diseases, the standard of cure is briefly stated, so that the student and the general practitioner will understand exactly what degree of relief should be reached before the patient is discharged from treatment. So far as the author knows, such brief discussions of the standard of cure do not occur in any other work. In order to do justice to other authorities, every quotation and PREFACE Vll illustration is accompanied by a verified reference in literature. For the detail of these verifications, the author is indebted to Dr. Edward Preble. Nearly all the a>ray work of this volume has been executed by Dr. Byron C. Darling, to whom great appreciation is hereby offered. The writer is personally indebted for advice and encouragement to his life-long friend. Dr. Walter B. Brouner, and to his associates in St. Mark's Hospital, Dr. Benjamin T. Tilton and Dr. Charles R. L. Putnam, and particularly among the members of his own staff, to Dr. Alexander Alexion and to the late Dr. Joseph Kaufman. Numerous friends have loaned illustrations and notes of cases, for which credit has been given in the text and for which gratitude is now extended. This book represents the experience of many years in urological departments in New York City, in private practice and in the author's clinic at St. Mark's Hospital. The actual production of the manuscript and illustrations required four years of consistent and concentrated effort. If the outcome has become a serviceable and accurate book, the time and energy thus expended will be more than amply repaid. V. C. P. 45 West Ninth Street, New York City. CONTENTS. CHAPTER I. Acute Urethritis 17 CHAPTER II. Complications and Sequels op Acute Urethritis 82 CHAPTER III. Complications and Sequels of Acute Urethritis (Continued) . . . 201 CHAPTER IV. Chronic Urethritis 263 CHAPTER V. COMPIJCATIONS AND SeQUELS OF ChRONIC URETHRITIS 307 CHAPTER VI. Complications and Sequels of Chronic Urethritis (Continued) . . 334 CHAPTER VII. Treatment of Stricture of the Urethra. Complications of Stricture. Urethral Infections in Childhood and Old Age 358 CHAPTER VIII. General Principles of Diagnosis 428 CHAPTER IX. General Principles of Treatment 483 CHAPTER X. Gonococcal Infection in the Female 524 CHAPTER XI. Complications, Sequels and R.are Forms of Gonococcal Infection in THE Female 597 X CONTENTS CHAPTEH XII. Urethroscopy 616 CHAPTER Xlll. Cystoscopy 682 CHAPTER XIV. Thk Bl.\ddku 740 CHAPTER XV. The Ureters .\nd Renal Functional Test.s 812 CHAPTER XVI. Acute and Chronic Suppurative Inflammations of the Renal Pelvis AND Parenchyma 868 CHAPTER XVII. Diseases of the Prostate 943 A TEXT-BOOK OF UROLOGY. CHAPTER I. ACUTE URETHRITIS. Anatomy. — Importance. — In a work on the clinical features and treatment of disease detailed anatomy can have no place. The reader is therefore referred to works on gross anatomy and on normal and pathological minute anatomy. The basic principle must never be forgotten in dealing with infections of the sexual and urinary systems that there exists continuity of all the organs of both systems through continuity of their mucous membrane linings. This relation exists between the organs of each system in itself and between the organs of both systems in their correlation. Gross Anatomy. — In the urinary system are the excretory centers in the kidneys and a continuous passage from the pelvis to the meatus varied in caliber according to function. Dilatation for collection is seen in the renal pelvis and the urinary bladder and more or less cylindrical reduction for transmission is evident in the ureters and urethra. In the sexual system the secretory glands are the testes and may be regarded as possessing continuous canals from the epidid^mies to the meatus. The function varies with the caliber. Collection is slightly provided for in the epididymes and ampullse of the vasa deferentia and freely in the seminal vesicles. Evacuation is procured between these points by the vasa deferentia, ejaculatory ducts and urethra. This urinary and sexual correlation is shown in Fig. 1. Minute Anatomy. — The chief fact is the universal lining of mucous membrane, closely allied in structure from organ to organ. The epithe- lium varies with function. As in all other mucosae, those of the urinary and sexual systems are highly vulnerable to infection, have relatively low resistance and recuperation and a distinct tendency to chronic inflammation with temporary or permanent damage shown by epithe- lial substitution in mild cases and scar tissue replacement in severe cases. Definition and General Principles. — Inflammation of the urethra at any point and due to any cause may properly be described as urethritis. The general clinical features and treatment of urethritis are closely analogous among the usual varieties of the disease. It is therefore well to fix a general conception of the condition and then to distinguish each important kind, especially in the symptoms, diagnosis and treatment. IS ACUTE URETHRITIS Varieties. — ^'al•ieties of urethritis are recognized in accordance with course, extent and cause. 1. ,1* to oiisei and course: acute, subacute and chronic, relapsing, coni])lic'Mted and unc(>ni])licatetl; also ])riinary as a fresh infection and secondary as a consecjuence of preceding attacks, or of*a systemic disease. 2. As to location and extension: anterior, posterior, anteroposterior or general, and localized. 3. As to cause: nonbacterial and bacterial. The nonbacterial forms have no microorganisms as conspicuous elements, and include tramnatic, diathetic and eruptive urethritis. The bacterial forms ahvays \mxe microorganisms as the primary exciting factors and embrace specific or gonococcal urethritis and nonspecific or non- gonococcal urethritis under which are classed catarrhal, chancrous or syphilitic, chancroidal and herpetic infections of the urethra. AMPULLA OF VAS DEFERENS VAS DEFERENS EJACULATORY DUCT PROSTAT UTRI PR PERITONEUM CORPUS SPONGIOSUM CORPUS CAVERNOSUM HYDATID OF MORGAGNI Fig. 1. — Diagrammatic representation of the male organs of reproduction and their relations to the bladder and the urethra. Lateral view. (Toldt.') For general purj)oses the most important cUnical class if cation is iccording to course, into acute and chronic urethritis, as all the other varieties'may be brought under these two headings. Chronic urethritis is so extensive a subject that it is treated separately in subsequent cha])ters. Location and Extension. — Location and extension of acnte urethritis are, at tiie onset, at almost any ]K)int of the urethra, according to the * Gray's Anatomj-, Philadelphia, Lea & Febiger, 1913. ETIOLOGY IN GENERAL 19 cause, although most urethritis begins at the meatus because sexually infected. Anterior urethritis extends anatomically from the meatus to the triangular ligament, while jjosterior urethritis ])asses from the triangular ligament to the cutoff muscle. Both are simply descriptive terms in recognition of anatomical subdivisions. Primary nongono- coccal acute urethritis, sexually acquired, follows much the same rule as in chancrous, chancroidal, catarrhal and pyogenic urethritis; but if asexually acquired, it may begin at any point as in the gouty, rheu- matic, lithemic and exanthematous types. This variety is, therefore, as a rule, at first either anterior or posterior, extending to involve more and more of the canal. Varieties. — Varieties are clinical according to the kind of infection. Primary anterior gonococcal acute urethritis, sexually acquired, is in the male at first always meatal and in the female likewise, although the vulva, vagina and cervical canal may be attacked at the same time; but if instrumentally acquired, the organisms may be much more widely distributed at the outset. This variety is therefore at first anterior and extends backward, and as a rule an acute posterior gonococcal urethritis may appear, if primary, as a direct extension backward of anterior infection, or, if secondary, as a relapse of per- sistent chronic infection or as a reinoculation from an old dormant focus. ETIOLOGY IN GENERAL. The etiology of acute urethritis, in general, is recognized as: (1) specific, having the one definite unvarying cause, the gonococcus; (2) nonspecific, having variable causes, bacterial and nonbacterial, but never the gonococcus. In this work the terms gonococcal and non- gonococcal are standard. A bacteriologic differential diagnosis is always essential because the symptoms and courses of both forms are frequently duplicates. Nongonococcal Acute Urethritis. — Nongonococcal acute urethritis is variously systemic or local, predisposing or exciting, intraurethral or extraurethral, bacterial or nonbacterial. Systemic and local are the inclusive subdivisions. Classification of causes of such a condition as m-ethritis caim.ot well be inclusive or exclusive because causes which in some cases are pre- disposing and systemic may become exciting and local in other cases. The following may be regarded as a general perspective analysis. The predisposing systemic factors are low vitality, semi-invalidism and acute or chronic alcoholism. Conditions causing hyperacid or hyperalkaline, crystal-laden urine, as in gout, rhemnatism, diabetes, lithiasis, tubercubsis and the strumous state, all lead to the so-called diathetic urethritis. Toxemias act in the exanthemata, possibly through bacteria and toxins, and as in eczema through concentration of urine and in herpes progenitalis, chiefly through local irritation, all causing so-called eruptive urethritis. All these elements are usually predisposing, extraurethral and nonbacterial. 20 ACUTE URETHRITIS Predisposing local factors are a niucosa vuliierMl)lc hy ])rovi()us attacks and especially by tlie presence of the uninfective chronic lesions of gonococcal urethritis such as ulceration, granulations, polypi, fibrosis and stricture, and a nuicosa congested and irritable by alcoholism, hyper- acidity, alkalinity and sediment in the urine, sexual excess and sexual perversions. These are the predis])osing and intraurethral elements. Periurethral disease, ])articularly, prostatism in the male, and in the female uterine displacement, postpartum Aaginal laceration and deformity may be predisposing extraiu'ctin-al factors. U])on the mucosa, as on a soil so prepared any organisms may find ready growth. The exciting factors in nonbacterial lesions are: (1) traumatisms, thermal from too hot or cold irrigations, chemical from too concentrated ai)plications, (2) medicinal from drugs irritant after internal adminis- tration such as the balsams, cantharides, alcohol, turpentine, and after eating such vegetal)les as asparagus, rhubarb, tomatoes, strawberries and the like, and (3) physical from rough instrumentation. Traumatism may involve any healthy mucosa but is most potent in the unhealthy- cases and rests on the use of rough, rusty or ragged instruments as well as unskilled and forceful manipulation. The olVense of indwelling catheter is a familiar traumatism and in this class belong masturbation and sexual excitement without coitus. Caution should always be exercised to pass smooth instruments and with, gentleness, never to use api)lications of extremes of temperature or concentration, and never to repeat treatment at intervals too short for a recovery period. Exciting factors in bacterial urethritis are Micrococcus catarrhalis in true catarrhal forms, Treponema jjallidvm in syphilitic types, the Bacillus of Ducrey in chancroidal invasions, and the ordinary pyoge)iic organisms in simple pus cases. Bacillus coli communis is often seen. Bacteria are doubtless a factor in the majority of cases, hence the im])ortance of bacterial investigation. Catarrhal Acute Urethritis. — Catarrhal acute urethritis is caused by tile Microcomis cnforrhdli.s which, in mori)hol()gy, is the duplicate of the gonococcus. It is at first gram-positive, later gram-negative, chiefly extracellular, frequently intracellular, and cannot be distinguished from the gonococcus in these circumstances except by culture. Syphilitic Acute Urethritis.— Sy])liilitic acute uretliritis is chancrous and usually meatal or just i)osteri()r to it, nuirked with edema and infiltration even to stricture and stenosis, with seropurulent or sero- sanguineous discharge present only in the first glass of urine, and as a rule without any shred stage. Its resolution is slow without intensive antisyphilitic treatment. Occasionally subpreputial chancres and mucous patches may cause involvement of the meatus. The organism is the Treponema pallidum. Chancroidal Acute Urethritis.— Chancroidal acute urethritis is much the same as sy])liilitic urethritis in its location and effects. The organism is tlie Bacillus of Ducrey. BACTERIOLOGY IN GENERAL 21 Etiology of Gonococcal Acute Urethritis.— (gonococcal acute urethritis has invariably the gonococcus discovered })y Neisser' in 1870 and culti- vated by Bumm^ in 1885. This organism commonly exists in pure culture, in most cases of urethritis, but is often found associated with other organisms. BACTERIOLOGY IN GENERAL. Normal Flora of the Urethra and Prepuce. — Before comprehension oi the bacteriology of acute urethritis is possible, one must remember that these regions, like every other part of the body, are normally the habitat of various organisms whose exact influence on the physiology of the part is not absolutely understood. They doubtlegs serve a Fig. 2. — Nongonococcal urethritis. Smear from the urethra of a case of nongonococcal urethritis due to pseudodiphtheria bacilli (800 diameters). (After Lipschiltz.') benejBcent purpose, otherwise they would hardly exist there. Their importance arises from the fact that many of them are capable of vicious change upon the advent of pyogenic and gonococcal infection whose activities excite them and are in turn themselves frequently augmented. Familiarity with the general flora of these parts of the body in both sexes cannot be neglected. The following illustration indicates organisms in an ordinary specimen. Nongonococcal Acute Urethritis. — Nonbacterial Nong;onococcal Acute Urethritis. — In all subjects, the urethra, prepuce, vulva and vagina 1 Centralbl. f. d. med. Wissenschaft., 1879, xvii, 497. ^ Der Mikro-organismen der gonorrhoischen Schleinshant-Erkrankungen, "Gono- coccus Neisser," Wiesbaden, 1885. 3 Bacteriologischen Grundriss und Atlas der Geschlechtskrankheiten, 1913. 22 ACUTE URETIIRiriS are normally, in healtli, the habitat of various bacteria, as already stated. These are iimociioiis and attenuated through long residence and ])urposeful in unkntnvn degree, but they may become nocuous and h\'I)eraetive- under excitation from other sources. Thus nonbacterial nongonococcal acute uretln-itis of traumatic, diathetic or eruptive origin nia\- be converted into the bacterial tyi)e. Bacterial Nongoriococcal Acute Urethritis.^ — The organisms which cause l)acterial nongonococcal acute urethritis are streptococci, staphy- lococci, pscii(lo(lij)htlicri(i bacilli and Jhicillas coli coDnniniis in the pyogenic lesions, Micrococcus cafarrlialis in the true catarrhal iuHam- mations, Treponema pallidum in syphilitic and BaciUiLS of Dvcrey in chancroidal, and various organisms in herpetic urethritis. Luys^ on this subject says that the most important are the streptococcus, stajjln/lococois, pnciDiiococcus, Micrococcus fulla.v, Micrococcus pi/ogenes aureus, Micrococcus cercus alhus. Bacillus typhosus, Bacillus coli com- mvnis. Bacillus diphtherioe, Bacilhis tnhercidosis and various sarcinse. A small, thin bacillus in chains and clumps is, according to Finger,^ referred to by Luns,'' the common saprophyte of the i)repuce and very often in the urethra in long-standing cases. Moscato' reports a case of urethritis accom]ianying every attack of intermittent fever. Catarrhal Acute Urethritis. — Acute catarrh of the urethra is caused by the Micrococcus rafarrhalis and merits special consideration in all its clinical aspects. ""I'lie history of the Micrococcus catarrhalis is of interest. For years skilled urologists have been convinced that there is a diplococcus other than the gonococcus of Neisser capable of exciting acute inflam- mation in the sexual and urinary passages of both sexes. The general nature of such infianunation is much like that of true gonococcal im-asion, but the s\Tnptoras are less severe, the course less protracted and uncertain, the complications relatively unknown and the termina- tion in absolute recovery almost uni\'ersal. W. Ayres'^ has published the best brief review on this subject and ((notes in substantiation of his observations such authors as Watson and Cunningham/' E. L. Keyes,'' Mallory and Wright,^ Wood,^ Hiss and Zinsser/" Ghon, H. Pfeifl'er and Sederl,^^ Frosche'^ and Kolle, T^ibman and rdler''' and Park and Williams.i^ 1 Text-book on Gonorrhea, 1913, pp. 41 and 42. ' Discussion of Gross's jjaper, Arch. f. Derm. u. Syph., 1905, ixxv, 39. Adrian (reference to Finger): Die Nichtgonorrhoische Urethritis, Halle a. S., 1905, p. 58. ' Loc. cit. •• II Morgagni, 1890, xxxii, Parte I a, 627, 687-8. ' Am. Jour. Surg., March, 1912. ' Genito-urinary Diseases. ' Diseases of the Genito-urinary Organs. * Pathological Technic. • Chemical and Microscopic Diagnosis. '" A Text-book of Bacteriology. " Ztschr. f. klin. Med., 1902, xliv, 262* '^ Fliigge, Die Mikroorganismen, 1896, .3d ed., B. ii, p. 154. These men describe the coccus and state that R. Pfeiffer terms it kokk\is catarrhalis. What R. Pfeiffer states of its properties is derived from oral statement. Hence, R. Pfeiffer in Frosche and Kolle. " Reports of Mt. Sinai Hospital, 1903. " Pathogenic Bacteria and Protozoa. BACTERIOLOGY IN GENFAtAL 23 The morphology of the Micrococcus catarrhalis as descrihed by Lihman and Celler/ quoted by Ayres, is as follows: ". . . Almost identi- cal morphologically with the meningococcus, but differing from it culturally, is an organism found in normal and in some pathological conditions on mucous menit)ranes of the respiratory tract, in the eye, the ear and occasionally in the urethra. This is the Micrococcus catarrhalis of Pfeiffer. "In spreads this organism appears also as a diplococcus, with some flattening of the adjacent sides of the individual cocci. It decolorizes with Gram's solution. There is no capsule. In all its characteristics it bears so close a resemblance to the gonococcus that it can })e differ- entiated therefrom under the microscope only with great difficulty. " Points of Difference. — The tetrads formed by the meningococcus, as well as the large forms already mentioned, will sometimes, however, serve to differentiate this from the other two organisms. Further, the individuals of the Micrococcus catarrhalis are more nearly oval than those of either the gonococcus or meningococcus. "On agar the Micrococcus catarrhalis grows profusely — therein differing from both the meningococcus and the gonococcus — they show no growth or slight on this medium." The Micrococcus catarrhalis in its effects is relatively a less vicious organism than the gonococcus but potentially it is capable of exciting all the symptoms of gonococcal invasion. The symptoms of gono- coccal disease are fully described on pages 33 to 36. On this general subject Ayres draws the following conclusions, in the contribution already cited: "(1) Demonstration of a gram-negative diplococcus within the pus cells of a discharge from the urethra is net proof positive of a gonococcic infection. (2) The fact that a man has an urethritis which shows gram-negative diplococci is not proof positive of recent exposure to gonorrhea by copulation. (3) Not only is a microscopic examination necessary in all cases of urethritis, but in a certain proportion a culture is imperative. (4) All cases of urethritis beginning as a subacute inflammation should be regarded with suspi- cion. (5) Just because an urethritis is very mild at the start, it should not be classed as a Micrococcus catarrhalis infection until it has been proven so by culture — gonorrhea is too serious a disease to be excluded without thorough investigation. (6) The Micrococcus catarrhalis is not a germ of slight pathogenicity, but is capable of causing serious and even dangerous inflammation," Urethritis Due to Pfeiffer's^ Streptobacillus. — A peculiar form of non- gonococcal urethritis has been described by Pfeiffer. Its characters are typified by the following three brief case reports. The lesion as shown in the first case is practically autogenous. The second case features the appearance of the inflammation long after the true gono- coccal urethritis has ceased, and the third case shows its incidence very soon after the gonococcal infection. I. The man had obstinate iLoc. cit. 2 Pfeiffer, Engwes: Miinchen. med. Wchnschr., 1916, Ixiii, 1457. 24 ACUTE URETHRITIS acute gonorrhea posterior; it was nine weeks before a prostatic focus was removed. The urethra was now sterile and all treatment was suspended. On tlie seventh day ai>i)eiuvd siiontaneously a muco- purulent discharge. Smears showed puiv culture of the streptohacillus. Same also cultivated jnu-e from secretions. Conditions persisted for nine days and suddenly ceased. Diagnosis, streptobacillary in*ethritis in a urethra damaged by gonorrhea. Characteristic is the presence of very many bacilli in tlu> ])us cori)uscles which often appear c[uite dark in consecjuence. II. ]Man with alleged second attack of gonorrhea which had per- sisted for six weeks. First attack ten years before; whitish discharge. Urethra and ])rostate seemed normal. The secretion contained a pure culture of I'feifVer's germ for three weeks. No gonococci at any time. No treatment until urine in second test glass was clear. Weak sublimate injections given for four weeks when urine became quite sterile. III. First attack of gonorrhea. Gonococci in urine for five weeks. Urine then became sterile but discharge reai)peared just as he was about to be released. Pfeitt'er's bacillus present alone for ten days, then associated with gonococci from an overlooked prostatic focus. Gonococcal Acute Urethritis. — Gonococcal acute urethritis is con- fined sok'ly t(^ the (jmuivoccus, also known as Micrococcus hlennorrhceoe, Neisseria gonorrJiea, Micrococcus gonorrhocce or Diyhcoccus gonorrhoeoe. Gonococcus. — This organism is so essential to the purpose of this work that its bacteriology will be discussed under the headings of natural and m()r])hological characters, details of Gram's stain, cultural characters and culture on hmnanized and animalized media. Other gram-negative cocci will then be considered. Natural Characters.- — The gonococcus is a parasite. Its vitality outside the body is little and on the skin surface it will not produce lesions, but inside the body, in its normal habitat in the mucous and serous membranes, it will live for many years, often attenuated and harmless until excited by an outside cause precisely as in nongonococcal acute urethritis. Its virulence is well known and fully established and rapidly revives in A'irgin soil, that is to say — an infection without symptoms in man or woman transplanted to an uninfected member of the opposite sex will invariably revive in all its violence. Its habitat is the mucous and serous membranes primarily in the epithelial and endothelial layers and secondarily, by and after pene- tration, in the imderlying structures, especially the subepithelial and subserous layers, and e\'en the submucous tissue. By direct continuity of the mucous surface it will infect in the male the prepuce, urethra, Cowper's glands, prostate, vasa deferentia, seminal vesicles, epididymis and testis, and, in ecjual degree, in the female vulva, urethra, vagina, cerAxx, uterine lining, tubes and ovaries and ])eritoneum. Its destruc- tive activity may render either sex sterile and practically unsexed. By absorption into the system it will reach the serous linings of the joints, pleura and endocardium, not infrequently in association with BACTERIOLOGY IN GENERAL 25 other organisms. Septicemia from its constitutional activity is not uncommon. Immunity against it after an attack is nil hotli against a reinfection from a new host and against a relapse from excitation of an old focus within the same patient. In this it differs from very many other infections and is correspondingly more difficult to control. Simi- larly it does not lend itself to study through animal experimentation as its general characteristics change in the process. At least twelve different types of various virulence and potency have been isolated. Morphological Characters. — This organism is, in form, coffee-bean shape with the flat surface slightly concave, in grouping, pairs or fours with a distinct interval between the individual cocci, in multiplication, nonspore-bearing splitting taking place in one plane into the diplo- coccus, or very exceptionally, in two planes into the tetrad type, in position, intracellular within the protoplasm of pus and epithelial cells or extracellular within the general exudate, in staining, susceptible to the basic aniline dyes such as methylene blue, Bismarck brown and gentian violet, in microchemistry gram-negative, that is to say — it gives up the basic dye under the influence of Gram's iodin solution as a mordant and alcohol as a decolorizer. Details of Gram's Stain. — 1. With precautions against contamina- tion by washing the glans in the male and the vulva in the female for meatal or urethral specimens and by retracting the vulva and dilating the vagina in the female for access to the vagina and uterus and the labia according to the point from which the pus is sought, and by following every other detail for securing a proper specimen, spread a smear thinly upon a slide. 2. Dry in the air and fix with gentle heat or with equal parts of ether and 95 per cent, alcohol. Drain. 3. Stain two minutes with any 1 per cent, carbolic basic dye such as methylene blue or gentian violet. 4. Drain and absorb excess of dye with filter paper, gently applied as a blotter to ink. 5. Flood for two minutes with Gram's iodin solution, but do not use water after step No. 4, as water precipitates the iodin and hinders its action. 6. Wash for about two minutes with 95 per cent, alcohol until all color to the naked eye is lost. 7. Wash with water, drain and dry with filter paper. 8. Stain for about one minute with any contrast stain, such as Bismarck brown. 9. Wash with water, drain and dry thoroughly as before, and examine with a one-twelfth oil-immersion lens. The gonococci being gram-negative and having surrendered their original color will be stained brown or the color of any other coun- terstain used, but the rest of the specimen will have the color of the original dye employed. No organism shoidd be regarded as possibly the gonococcus which does not possess these staining qualities, but the ■Micrococcus catarrh alis is, in its early life-cycle, gram-positi"S'e and in its later development gram-negative. Culture alone will distinguish. 26 ACUTE URETHRITIS CuJfural ('A«;-ac/(7-.s-.— ('ultural cliaractcrs are i)eciiliar in tliat the organism is very difficult iiuleecl to gnnv artificiallx'. Attenuated specimens from cases of long stiinding luv said not to urow at all arti- ficially and yet when ini])lanted on viruin, that is, ])re\iously unin- fected soil in the mucous surfaces of cithei-niale or female sexual organs, they will rapidl>' accpiire their typical virulence. This is one of the facts which makes the decision of final cure so difficult to make abso- lute. Human blood seriun seems to be the best medium for the culture and the organisms must not be chilled in any way but nuist be trans- ferred from the host to the medium itself at body temi)erature and at once put into the incul)ator. Thus, either the patient shoidd be sent to a fully equipped laboratory for these steps, or the'])hysician himself nuist have a suitable incubator for protecting the inoculation until transferred to the laboratory, again fully protected. The sources of culture are the same as for slide specimens, namely, free pus, shreds and urinary sediment after centrifuging. Of course, every possible pri'cauticm against contamination must be exercised and several days allowed for the growth to apj)ear, which is invariably slow. Culture of the gonococcus is delicate and difficult, best on Inunanized media and least successful on animalized media. Solid slant medium in a test-tube seems much more advantageous than fluid medium. Humanized ^^reparations have the following formulas: Wertheim^ uses a solid media human serum from hydrocele ascites or blood, mixed with meat infusion agar two or three parts and glycerine (> per cent, or glucose 1 per cent. Fluid media contain human l)lood serimi mixed with meat infusion peptone broth having peptone up to 2 per cent. A dro]) of human Idood also may be smeared over a ])late as in Pfeiffer's method ftr the bacillus of influenza. Animalized media are agar mixed with natural rabbit's Idood or Wassermann's serum-nutrose of swine. wSurface inoculations show the organism to be aerobic; stab inocu- lations into solid media fail as the organism is not anaerobic and inoculations into fluid media are followed by growths only at the sur- face for the same reason. The temperature or growth is 37.5° C, death ensuing at 38.5° C. and at 30° (\ Colonies of the gonococcus are thin gray or o]:)alescent spots looking much like varnish dropped on the medium slightly "bloomed." (irowth should appear in about twenty- four hours. Merging of the colonies does not occur and stickiness of the growths is a diagnostic feature. Other gram-negative cocci when compared with the gonococcus in urethral infections become exceedingly important and their differential features in the laboratory are shown by the following table. It becomes extremely imi)ortant for the urologist to know the cocci in this group which includes the Micrococcus catarrhalis, Micrococcus intracellvlaris, Micrococcus gonorrhoccp, clear micrococcus and opaque micrococcus, both from Hartford's case of influenza-like e])idemic, micrococcus from the urethra. Micrococcus mcliiensis and ^lalta fever. Their character- istics should be similarly familiar. > Arch. f. Gynakol., 1892. PATHOLOGY IN GENERAL 27 CHIEF CIIARACTEKISTICS OF SIX GRAM-NEGATIVE COCCI. ^ Action of carbo- lydrates. -1- = acid. alkaline. O = no reaction. Growth on nu- Organism and source. trose acetic Growth on gela- Pathogenicity. u agar at 37° C. tin at 20° C. . i 6 t.4 o o a 1 3 -3 O "o o o S M. catarrhalis nasal Opaque; granu- Positive (grows Mice and guinea- and pharyngeal dis- lar. on ordinary pigs by intraperi- charge. agar at 37° C. toneal inoculations. — — — M. intracellularis Clear, smooth. Negative. In some cases mice (meningococcus) , and guinea-pigs by cerebrospinal men- intraperitoneal in- ingitis. oculations. + + + — M. gonorrhoeae (gono- No growth un- Negative. In some cases mice coccus) , urethral less blood and guinea-pigs by discharge. added. intraperitoneal in- oculations. + + o O From nasal discharge Clear, smooth Negative at first, Mice and guinea- from Hartford's and becomes later positive pigs by intraperi- case of influenza- yellowish. (grows on or- toneal inocula- + ■ — + — like epidemic. dinary agar at 37° C. tions. From nasal discharge Opaque, granu- Negative. Mice and guinea- from Hartford's ular. pigs by intraperi- case of influenza- toneal inocula- like epidemic. tions. + -f + -1- From urethra. Opaque; some- what granu- lar; smooth Negative. Mice and guinea- pigs by intraperi- toneal inocula- edges. tions. -1- -f- -1- + M. melitensis; Malta Creamy and Positive. Monkeys, also rab- fever. slightly yel- lowish. bits and guinea- pigs, by intracere- bral inoculation. O o o PATHOLOGY IN GENERAL. General considerations must include the fact that mucous membrane has comparatively little recovery power from the effects of a single severe attack, repeated invasions or a prolonged involvement. The surface epithelium is denuded readily and when restored may lack the original characters, being changed from cohmmar to squamous. The glands furnishing moisture to the membrane and the cavity of the urethra are readily changed so that their secretion instead of being thin and almost invisible becomes thick, tenacious and yellow, often mixed with pus cells and desquamated epithelium. Many glands lose their power of secretion and surrounding glands take up overactivity in com- pensation and the condition becomes chronic. Similarly round-cell and fibrous infiltration often replace the mucous membrane in its essence, and the condition remains chronic in character. Restitution of chronic lesions is never fully made, no matter what their nature is, and the 'various stages leading up to the permanent lesions are also very difficult to control or change. Nongonococcal Acute Urethritis. — Nongonococcal acute urethritis varies in pathological details with the forms previously enumerated, 1 Dunn and Gordon: British Med. Jour., 1905, ii, 427. -.^ ACUTE URETHRITIS namely — catarrhal, eruptive, iHathetic, i>yogenic, syphilitic, chan- croidal ami herpetic. Kach has its own i)athology. Catarrhal Acute Urethritis is in essence a local or general hyperemia, ^vith edema and occasionally slight hemorrhage. It has stages of onset, estahlishment and subsidence each in itself and all combined, as a rule, rather brief except with ])ersistence of the exciting cause. It may be anterior, j^osterior or anter()i)osterior in distribution. Its exndate is nuicus or serum in the mild cases, mixed with pus in the severe cases, each type having a i)rogressing degree of desquamation of epithelinm. Its involvement inchules the ei)ithelium and the glands of the mucosa and rarely the submucosa, in lesions which are tem])orary, and rarely with associated comi)licating or permanent factors. The lesions are located in the mucous membrane alone and distributed locally — ante- riorly, posteriorly, or anterojiosteriorly. The gross and microscopic features are those standard for catarrhal exudative inflammation. Bacteria may be jmictically absent or compnse chiefly the Micrococcus catarrJiaU.'f. Toxins, therefore, do not play an im])ortant role. Diathetic and Eruptive Acute Urethritis. — Diathetic and eruptive acute urethritis duplicate that of catarrhal forms adding the special urinary findings of the diathetic and the associated lesions, especially in the crui)tivc diseases, such as eczema, the exanthemata and the like. Pyogenic Acute Urethritis. — Pyogenic acute urethritis is that of a purulent mucous membrane inflammation, local or general in distri- bution. Its essence is infection with the pyogenic organisms. Its stages are those of infection — early and brief catarrhal inflam- mation, rapidly followed by purulent manifestations and extension from its early local site with finally slow^ recovery. Each stage in itself and all combined are prolonged and may leave behind a mucous mem- ))rane damaged as much as may gonococcal infection. Its exudate is finally pus in all cases with blood, mucus and ei)ithclium — all in quantity varying wdth the severity. Its invoh'ement includes the epithelium and the glands of the mucosa at first, then the submucosa and even the underlying tissues of complicated cases. The lesions are temporary only in the ^•ery mild cases but severe forms by the exten- sion of the infection lea\-e permanent sequels in the mucosa and compli- cating results m surrounding organs. The gross and microscopical features are those typical of suppurative mucosal inflammation, com- monly located in the mucous membrane alone in all its layers and distributed locally or throughout the urethra. Bacteria are always present, especially Bacillus coli communis, Streptococcus pyogenes and StcqjJn/lococciis pyogenes, w'hose toxins excepting in the complicating cases a])pcar to ha\'e little effect systemically on the disease. Syphilitic Acute Urethritis. — Syphilitic acute urethritis is the path- ology of chancre, meatal or intrameatal in its location. Its essence is invasion by the Treponema pallidum with the .small, round-cell infil- tration in the effort of nature to combat the process. Its stages are those of nodulation, superficial or deep ulceration and slow healing. Each period is in itself and all combined are rather prolonged and leave PATHOLOGY IN GENERAL 29 behind a scar-like mass which rarely fully disappears. Its exudate is serum, not autoinoculable, in all cases mixed with blood during deej) ulceration and with pus if an associated organism is present. Its involvement includes the mucosa in all its layers and the submucosa, so that more or less obstruction of the canal results. Its gross features are those of pure or mixed infection in an ulcer having a definitely, though variably, infiltrated base, and its microscopical features are those of small round-cell and fibrous infiltration in the base and necrosis in the ulcer. The organism is the Treponema pallidum alone or asso- ciated with various pyogenic organisms. The organism of syphilis, its circulation through the system and its toxins with their effects are foreign to the purpose of this work or further discussion concerning temporary complicating and permanent lesions. Fig. 3. — Treponema pallidum from a chancre. The figure reveals a dark field illumi- nator picture with the organisms moving across it. (After Lipschutz.i) Occasionally mucous patches in the second stage or in the uncleanly in any stage of syphilis may appear in crops under the prepuce and one or more of them locate in the meatus in the male or similarly m the female about the vestibule and meatus. They then behave in pathology much as the chancre in causing acute urethritis. The presence of the Spirocheta halanitidw in the normal and inflamed prepuce renders its distinction from the Treponema pallidum necessary at times by culture. The following illustration t^'pifies the general charac- ters of the treponema after the recognized method of the dark field illumination and merits study. 1 Loc. cit. 30 ACUTE URETHRITIS Chancroidal Acute Urethritis. — The ])ath()logy of cliMiicroidal acute uivthritis is that of c-haiicroid, luoatal or intraiiicatal in location. Its essence is infectit)U with tlie Ihtcillius- uj Ducreij with necrotic ulceration. Its stages are those of early ulceration, circumscribetl cellulitis, slow liealing at some points with extension at others and final healinj!; with excavated scar. Its exudate is autoinoculahle pus mixed with blood anil detritus. Its involvement includes the nnicosa in all its layers and the underlyuig structures so that deformity of the canal or, less fre- quently, stenosis is produced by the scar. Its gross features are those of pure or mixed infection in an ulcer with an excavated, und(>rmin(>d, sloughing base, and its microscopical features are those of iuHltration, Fig. 4. — Chancroid or venereal ulcer. Smear from the secretion of the depths of a soft sore (8U0 diameters). (After Lipschiitz'). edema, necrosis and fibrous healing. The organism is the Bacillv.s of Ducrey, often mixed with pus-producing germs. The chancroid itself is usually a temj^orary lesion but may show rapid and widespread l)hagedenic (jualitics. The ])ermanent lesion is the scar after healing and lyni])liangeitis and inguinal adenitis are frequent associated lesions. Further discussion is unnecessary for the purposes of this work. Herpetic Acute Urethritis. — The pathology of herpetic acute urethritis includes the features of the herpetic vesicles situated at or within the meatus. Its essence and stages are the formation of infiltrated papules which soon show a little vesicle on their sunuiiit filled at first with serum, then with pus, spontaneously bursting and Iea\ing a superficial ulcer unless invasion with pyogenic organisms now occurs. Its exudate is at first serous, then purulent, and its involvement hardly more than the ' Loc. cit. PLATE I FIG. 1 Transverse Section through Entire Urethra and Tunica Albuginea with Round-cell Infiltration of the Urethra and Mucous Follicles. (After Taylor.^) The whole folded lumen of the urethra is surrounded by a deep ring of small round cells (zj, which seem mainly to have eonie fronn the superficial vessels of the nnucosa, while a part of them may be proliferated connective-tissue cells. The epithelial lining of the urethra is desquamated, and is entirely absent in places {x, X, x) , while in other places (,y,y) it is still in proper position, although infiltrated with pus cells. In the roof of the urethra, in this section, the duets of the mucous glands at various depths are also surrounded by a heavy infil- tration of sniall round cells which indicate an extension of the inflannniation along the mouths of the glands from the surface of the urethra [w, «■). FIG. 2 Ulcer of the Urethra with Round-cell Infiltration of Floor and Erosion of Epithelium of its Surface. Ne\^dy Fornied Capillaries are in Red. (After Taylor. i) Genito-urinary and Venereal Diseases, 3d Ed.. 1914 PATHOLOGY IN GENERAL 31 epithelial layer with a little firm edema beneath. Its gross features are those of a superficial sore with reddened base, or a small vesicle or pustule on such a base according to stage, and its microscopic features are those of epithelium detached into the vesicle or pustule .^/ -^11*. Fig. 5. — Section of urethral roof with round-cell infiltration of mucosa and follicles, more highly magnified than the Fig. 1 in Plate I. "Fig. 5 shows the invasion of the urethra by the gonorrheal process still more plainly. The drawing includes the whole thick- ness of a segment from the roof of the urethra, corresponding to the rectangular area indicated by p, q, in Plate I, Fig. 1. With this higher magnifjdng power in Fig. 5, the infiltration of the mucosa and tissue surrounding the tubidar ducts of the mucous glands is shown in detail. With the exception of the patches denoted by x and y, the epithelial lining of the urethra is absent, so that there are extensive areas of erosion of the infiltrated mucosa. Lying free in the uretlu^al lumen near the denuded surface is a flake of the gonorrheal exudation (z, z. Fig. 5). This flake is quite identical in structure with the ordinary gonorrheal discharge as seen on a cover glass, and consists mainly of pus cells lying in a fluid or granular matrix. The mucosa just beneath what is left of the epithelial lining is very densely crowded with small round cells to the extent shown in the figure at v, v. In the same way the ducts of the mucous glands u, w, and r, and in places the gland acini themselves (t) are similarly infiltrated ■with the small round cells. The ducts w and r have their lumina partially filled with desquamated cells and graniilar material." (Taylor.i) and the surrounding edema and infiltration. No definite organism has been isolated and the lesions are temporary without permanent or associated elements, scarring occurring only after mixed infection. Gonococcal Acute Urethritis. — Gonococcal acute uretlii-itis is a superfi- cial or penetratmg suppurative inflammation of the mucosa according to 1 Genito-urinary and Venereal Diseases, Philadelphia, Lea & Febiger, 1904. 32 ACUTE URETHRITIS intensity. Primary cases conijn'iso the first attack and secondary cases are subsequent fresh reinfections of cured cases or sequels of uncured cases or relapses of tlie latter without the element of reinfection. Its essence is infection hy tlie gonocoecus and its stages are incubation of catarrhal ty]x\ early estal)lishnient of desciuaniative character and full invasion or acme of suppurative features with death of epithelium and leukocytes. Its exudate is autoinoculable and heteroinoculable pus containing ei)ithelium, white cells, red cells (all degenerated into pus cells) and nnriads of gonococci — all luixed in a fluid basis of serum and mucus. In distribution it regularly liegins at the meatus in the male, if sexually acquired, and in the female at almost any point but usually the urethra and vuh'a are early involved or the vault of the vagina and cervix through intimate contact with the infecting ejaculation. Relap- sing cases begin at any focus and progress therefrom. Extension follows rapidly in continuity of surface so that in the male the lining of the foreskin and the urethra from end to end suffer, making the so-called anterior, posterior and anteroposterior cases, and so that in the female the external genitals, urethra, vagina, endometrium, oviducts and peritoneum may become involved. The lesions are deepest where oldest with rare exceptions. The gross features of the disease are in regular sequence catarrh with edema, followed by more or less hemor- rhagic suppuration. The microscopic features are hyperemia, denuda- tion, hemorrhage, pus-cell and tissue-cell infiltration, with gonococci in the pus cells, epithelial cells and free in the pus and tissues. All these features are found in the mucosa in various and every layer and in the periurethral structmes in severe cases and in surrounding organs in complicated cases. Penetration into the depths of the mucosa precedes and accompanies extension along the surface. The first thirty-six hours are concerned with the incubation, during which the superficial cells are passed and the subepithelial connective tissues reached. The second thirty-six hom-s reach the stage of invasion with early exudate and are characterized by desquamation, pus-formation, diapedesis of leukocytes, capillary congestion, arteritis, phlebitis and lymphatic and glandular envolvement. Termination is marked by the subsidence of active hy])eremia, decrease and finally disappearance of gonococci and repair of the damaged mucous membrane, if recovery is complete; but if incomplete the disease may be protracted at almost any focus and in any degree, thus constituting gonococcal chronic urethritis. The pathological varieties are therefore acute, subacute and chronic, primary and secondary, uncomplicated and complicated. Nature's combat against the disease is shown in the hyperemia, in the dia]:)edesis and phagocytosis of the leukocytes and in the serimi of lymphatic activity and shown in the exudate by the casting off of dead and dying epithelial and white bloodcells and the fluid elements of the pus, all containing the gonococci, and shown in the repair process of tissue proliferation to restore the loss and again shown in the resistance of the serum to the disease for the destruction of the organism and the neutralization of the toxins. The systemic effects of gonococcal acute SYMPTOMATOLOGY AND STAGES 33 urethritis, unless pyogenic organisms are associated, is relatively little when compared with those of other infections. This pathological fact accounts for the peculiarity that in the treatment antigonococcal serum and bacterin are distinctly likewise of less value. 'J'here is, how- ever, a complement deviation test, also called complement fixation test, perfected by Schwartz,^ similar to the Wassermann complement fixation test in syphilis in its general nature and interpretation of the disease. Pathologically, therefore, a positive test denotes presence of the disease while a negative may mean its absence whose definiteness and permanence, however, are as yet less understood than those of positive reactions and can be interpreted only after years of further observation. The temporary lesions of gonococcal acute urethritis occur only in mild cases or in areas of mucosa least involved. In severe cases, its permanent lesions are almost inevitable and comprise destruction of the mucosa and its glands in varying degree along with similar processes in an organ secondarily attacked in complicated cases and result in the lesions of chronic urethritis which must be discussed as a separate subject (see page 263). Its complicating lesions when localized in the sexual organs of both sexes involve the mucous glands and follicles, periurethral tissues and lymphatics extending in the male to Cowper's glands, the prostate, vasa deferentia and testicles, and in the female to the vulvovaginal glands, vagina, endometrium, tubes, ovaries and peri- toneum, and when reaching the urinary organs in both sexes involve the bladder, ureters, and kidneys. The process is in every pathologic feature the same in glands or organs secondarily and complicatingly attacked as in the urethra itself in primary uncomplicated acute urethritis. Its lesions of absorption or penetration of the organisms involve serous membranes other than the peritoneum, notably endo- cardium, pleur?e and joints. Death from gonorrhea is by no means unknown, although rare, as a process of general septicemia. Lesions predominate in any part of the canal and constitute in this manner anterior, posterior and anteroposterior urethritis, each having its appro- priate symptoms under the same titles as described hereinafter. Gonococcal Chronic Urethritis. — Pathology of gonococcal chronic urethritis, on account of its many important clinical factors, is treated as a separate subject in Chapter IV, page 265. SYMPTOMATOLOGY AND STAGES. Point of Onset. — The disease regularly begins at the meatus in both sexes in sexually acquired primary cases and in the female also at the vulva, vault of the vagina or cervix in accordance with the various points of inoculation. It is, therefore, at first always anterior in the urethra. Secondary or relapsing acute disease may begin at any point of the urogenital tract in either sex from a focus of chronic infection; » Schwartz, H. T., and McNeil, A.: Am. Jour. Med. Sc, 1911, sci, 693. 3 34 ACUTE UJiETIIRITIS thus in the male the posterior uretlira or tlie sinToiiiuling organs and in the female the internal sexual organs may first light up in a relapsing attack before the distal parts are engaged secondarily to it. The chief local symptoms are much alike in both primary and secondary cases, namely — discomfort, ])ain, ])ollakiuria, hemorrhage, exudate and chordee. The follmving general facts of each symptom are noted: General Clinical Features.^All the usual symptoms of inflammation of any mucous membrane are present, varying in character and degree with the attack itself. All elements which excite simple catarrhal urethritis tend to arouse and augment all other forms. The symptoms are subjective, objective and systemic, concerned with the system at large and local, iuA'olved with the urogenital system in particular. In the afl'ectcd organs pathological processes in the mucous membrane give certain clinical features and functional derangement causes still other signs. Subjective Symptoms. — The subjective sjTiiptoms are greatest when the deci)er layers of the mucosa are exposed and the tissues infil- trated and hemorrhagic. Extension into complications always means increased as well as new symptoms and often the advent of subjective s.Mriptoms if previously absent. Objective Symptoms. — The objective symptoms are concerned in the immediate lesions and results in the mucosa itself, the discharge and the bacteriology in all cases, to which is added the symptoms of compli- cations when they arise. Systemic Symptoms. — The systemic symptoms are those of infection, occurring only in severe cases, chills, fever, malaise, prostration, anorexia and the like. Complications are also apt to be associated with these signs. Local Symptoms.^ — The local sj-mptoms should be described in detail and are comprised in discharge, urinary disorders, functional derange- ment in all cases and numerous complications, often simple, but in many cases severe. Discomfort and sense of heat are rarely present during incubation but appear ^^^th the his-peremia of the invasion and its early serous dis- charge, which gra\'itating to the floor of the urethra is felt there. Vulvar and vaginal infections closely imitate these conditions. Pain of dis- tinct and progressing irritating character marks the extension of the disease along the passage and into the depth of the mucosa. Its sources are denudation, pressure of infiltration and distention of edema in both sexes anrl in any membrane attacked. Bacterial growth and toxins are also sources of pain. Pollakiuria is due to reflex disturbance in the urethra in the anterior canal of the male and in the Avhole passage of the female, by all the pathologic activities, and due to direct irritation of the sphincter vesicae in the posterior urethra in the male. The hyperemia is the early and the exudate the later factor. In the female this symptom is rather independent of vulvar and vaginal involvement, and again it is related SYMPTOMATOLOGY AND STAGES V^h to the cutoff muscle. Hemorrhage, in streaks through the exuilate f)r in drops with the terminal urine, is a rare symptom except in severe cases, while free terminal bleeding is not unknown. Intense congestion and minute tears through chordee are the common caus(;s. lilood as a factor under the microscope is often seen. Exudate is seriun in the late incubation and early invasion, seromucus, mucus or mucopus in the later invasion and early establishment and pus throughout the full virulence of the disease, while termination is marked by a return to the normal, if at all, in the reverse order from fluid pus to pus shreds, then from free mucus to mucous shreds or mucus apparent only on chilling the specimen, and finally no exudate at all in complete cure. Chordee is confined to the male and is very painful erection, which is excited by the irritation within the canal of extensive urethritis reflexly upon the spinal cord. Distention of the bladder with urine in the early morning excites chordee also precisely as it does erections in normal men. The pain is due to the fact that the congestion, edema and infiltration of the corpus spongiosum urethrse deprive it of extensibility, so that while the corpora cavernosa penis distend and extend into the erection the urethra remains inelastic as a thick cord (whence the French term chordee) along the venter of the penis, compelling the organ to take a curve downward instead of upward. This strain on the urethra is excessively painful and may tear the mucosa at numerous points, thus setting up hemorrhage. Stages. — Four stages are recognized for convenience of description: incubation, invasion, establishment and termination. Incubation. — Incubation is marked by hyperemia and edema with few and slight subjective and objective symptoms. Invasion. — Invasion adds to all these conditions. The latter is, there- fore, the stage during which most patients present themselves. It is distinguished by desquamation of epitheliimi and the exudation of mucus and serum, with progressively greater subjective symptoms, pain being due to the denudation and infiltration. Establishment. — Establishment adds free discharge, pus formation and extension along the canal until the whole urethra may be involved in the male and until either or both the external and internal sexual organs may be compromised in the female. The last condition is regarded as a complication exactly as is similar extension in the male of the disease into periurethral structures and organs. The coviplications are appropriately a separate subject and are treated in Chapter II on page 82. Termination. — ^Termination is distinguished by subsidence of all symptoms, often in a comparatively brief period in mild and uncom- plicated cases, but usually in a really prolonged period, even months and years, in severe and complicated cases, which constitute chronic urethritis — a subject for individual discussion in the following chapters. The symptom last to leave during the termination is in most cases the discharge, w^hich gradually decreases in amount and thickens in con- sistency exactly like the mucus from the bronchi after mfection there . 36 ACUTE URETHRITIS Tims are ])ro(hiPiHl tlio various kinds of slircd in the urine in both sexes and striuiTs of nnieus in lencorrhea in the female. Nongonococcal Acute Urethritis. Nonbacterial Nongonococcal Acute Urethritis. .Nonitacterial noni;dnococcal acute urethritis shows no niii-ro()ri;anism at all or noni' of importance as distinunished from the bacterial forms to he presently descrihed. Primary disease is the rule, secondary forms are less common. Incuhatiou is absent or short within a very few hours or a day and without definite symptoms. Invasion is very ])rom])t after traumatism, physical by instruments, thermic by heat or cold, chemical by concentrated solutions, or early dnrinj;' an exacerbation of f^out or rheumatism in diathetic urethritis, an outbreak of eczema or an attack of herpes in eru])tive urethritis. Onset is also autofjenous, self-induced by excess in venery, eatinj? and (lrinkinoth by referred pain process. It tra\'els down the urethra, with the stream of the urine, until the whole canal seems afire. Pain during the quiescent state is present day or night, more or less constant and varying with the severity of the inflammation. The nrinary disturbances are regular accompaniments of the pain and due to the same general causes. Frequency may be very trouble- some at first by day, later by night, particularly if the posterior urethra is even sympathetically congested. The stream is altered in size in any degree from normal to literal dribbling, and in form to forking, twisting and spattering, all due to the degree of edema and its effect on the course and caliber of the canal. Acute retention of urine is in intense cases often seen due to muscular spasm or extreme edema, or both, in the region of the compressor urethrse muscle. Moderate bleeding may be present. The chordee or chorda venerea is a troublesome symptom commonly late in the establishment ^^■hen the corpus spongiosimi urethras is widely and dee})l\' infiltrated and the mucosa greatly irritated. Both these factors stinnilate erections, esi)ecially \\ith even a small quantit}^ of urine in the bladder. The corpora cavernosa become turgid, firm and erect, while the corpus spongiosum urethrje, having lost its extensi- bility', elasticity and distensibility temporarily through the disease, can hardly alter its form, and therefore the attempt to stretch it causes it to stand out prominently as a thick cord along the penis, whence the term chorda venerea. The pain proceeds from the great tension on the inflamed tissue by the corpora cavernosa. The discharge is augmented from the mucoi)urulent moderate drop of the invasion to a florid copious flow thickening from the stringy condition in the preceding period to that of cream and changing in color from a watery white to yellow then greenish, staining the cloth- SYMPTOMATOLOGY AND STAGES 41 ing of body or bed with a thickish incrustation at the center, tliitininj^ out at the the margins through the watery elements. The systemic subjective symptoms vary widely, are absent in mild cases and pronounced in severe cases, especially with mixed infection, and are chiefly those of any septic absorption, anorexia, constipation, anemia, depression, prostration, chills and fever and insomnia. They need no detailed discussion. The objective symptoms should be noted in regular anatomical order and are due to the inflammation and its accompaniments in the mucosa, bloodvessels, lymph vessels, discharge and urine. Redness and edema affect the lining of the foreskin and the glans, which may become greatly excoriated, wdth blotches of shining red scattered over pus-covered surface. The foreskin as a whole may be almost densely infiltrated and phimotic. Lymphangitis may early be visible, palpable and tender but is more often buried in the edema. The meatus is reddened for a variable zone over the glans, very edema- tous even to eversion and sometimes excoriated. The urethra is infil- trated thick, inelastic and tender and often show^s its involved mucous glands as shot-like spots along its course. The discharge is a constant dropping of pus changing in amount, color and consistency as just noted under local subjective symptoms. Owing to the hours of sleep, the early morning flow of pus represents the all-night accumulation and is, therefore, the most copious except when severe disease dis- turbs the patient for frequent nocturnal urination. The urine in test glasses is very turbid in the first and clear in the second glass in the mild cases or slightly turbid in the severe cases, depending on the thoroughness with which the urine washes the pus before it into the first glass. It is obvious that a copious flow of urine even in a severe case will tend to produce a clear or nearly clear second glass while a scanty flow will have the opposite effect. A practical point of importance therefore is to have the patient call with as much urme in the bladder as may be retained without pain — four or five hours' urine is a good supply wdien possible. The termination usually begins after the establishment has run a course of about two weeks, rarely less, not uncommonly more than two weeks. It is broadly true to say that the average case not char- acterized by severity or complications recpires about tw' o weeks each for the incubation and invasion together, the establishment and the termination each, in all six w'eeks, although the term "termination" may thus only mean the disappearance of active subjective s%Tnptoms, because very few cases are without a semichronic or chronic " shred'' stage. As previously stated, chronic manifestations will be discussed separately. The local and systemic subjective SAmptoms are a gradual but unmistakable decrease, usually in the reverse order of their appear- ance. The discharge becomes more watery and sometimes more copious in this thin condition, then changes from the green to the white mucoid consistency and finally thickens into shreds, w'hich may be the last of all sjTiiptoms to disappear. Chordee is quickly decreased 42 ACUTE URETHRITIS in severity aiul frequency, a fact which usually initiates the period of improvement. Urination is much less frcciuent first at night, then hy ilay, and is soon normal. Pain loses its agiiravating (lualities and is iinally a mere discomfort. The general health imjiroves, fever and chills subside, appetite returns, better spirits replace depression and prostration and disappearing absorption corrects the anemia. The objective symi)toms are a thimiing and decrease of the pus from the ])urulent through the mucous and serous stages to shreds. Gonococci are progrcssi\cly fewer and harder to find without and with associated organisms in the so-called mixed infections. Epithelium in flakes and single cells is more abundant, the pavement type around the meatus, rei)lacing the cohunuar tyi)e of the canal as a whole. All test glasses of urine are clear, the first alone contains heavy shreds of mucopus, which sink, and lighter shreds and clouds of mucus which float; both are germ-laden at first and finally may be germ-free as the case becomes cured. The author's seven-glass test is of great value in the diagnosis of this stage. Its details are given under the subject of Posterior Urethritis and Diagnosis on page 75. Duration of the Disease. — The persistence of symptoms varies with the severity and nature of the infection, the resistance of the patient, the attention given ])y himself and the treatment prescribed. Infec- tions in which the gonococcus is associated with the pyogenic organ- isms are apt to be long cases. Broadly speaking, the average case lasts for six %veeks, at least so far as the obvious symptomatology is concerned; many cases, however, which have given the patient little or no distress will last as many months before cure. Relapses. — Recrudescence of symptoms is by no means uncommon from foci chiefly in the glands of the mucosa, through unusual penetra- tion of the disease or anatomical complication of the glands, or both whence arise chronic forms of the disease. Although in very many cases the mucosa as a whole recovers in a much larger number locali- ties of deep damage or destruction persist for many years of life. DIAGNOSIS IN GENERAL. Basis. — Independently of whether or not the lesion is nongono- coccal or gonococcal, the diagnosis rests on four elements: history, symptomatology, physical signs with laboratory findings and treat- ment, as fully set forth in Chapter YIII, on the General Principles of Diagnosis. The chief element of diagnosis and differentiation is the recognition and demonstration of the infecting organism. All varie- ties of nongonococcal and gonococcal urethritis may and usually do give a sexual history concerning which denials are commonly false- hoods. Catarrhal and diathetic urethritis may legitimately have no sexual history. In the symptomatology all forms agree as to the kind of s^Tnptoms, as has already been fully discussed. The degree of suffering, however, is severest in the suppurative and gonococcal infec- DIAGNOSIS IN GENERAL 43 tions, which are almost indistinguishable on this point. The loca- tion of the symptoms may be meatal or i)rei)utial in the cliancroidal and syphilitic types but urethral in all the other forms. 'J'he physical examination serves to verify the situs of the lesion and urinary study in the Thompson two-glass test or the author's seven-glass test closely resemble each other. Pus is most abundant in the sui>purative and gonococcal forms and usually least in the syphilitic and chancroidal lesions, leaving catarrhal, diathetic and traumatic urethritis as the usual mean. The laboratory findings must determine by smear and culture the infecting organism or other definite cause. Catarrhal urethritis arises from the Micrococcus catarrhalis and diathetic chiefly from diabetes and lithiasis. Suppurative urethritis predominates in the pyogenic organisms, chiefly the Streptococcus and Staphylo- coccus pyogenes, while traumatic may be without pathogenic germs and abundant in exfoliating epithelium and detritus. Syphilitic urethritis must show the Treponema pallidum and sooner or later a positive Wassermann reaction, and chancroidal lesions contain the Bacillus of Ducrey. Gonococcal infections must show the diplococcus of Neisser in smear and culture and in the severe and complicating lesions a positive gonococcal complement-fixation test. The treatment serves to emphasize the correct findings. Tonics are a local and systemic aid in catarrh of the urethra. Relief of the diabetes and lithiasis reaches the diathetic type and removal of offending causes demonstrates traumatic urethritis. Antisyphilitic measures, surgical attention to the chancroid and the means of treatment hereinafter set forth are all indices of the nature of infection in syphilitic, chancroidal and gonococcal disease. Differential Diagnosis. — Gonococcal urethritis is distinguished from the various nongonococcal varieties, comprising catarrhal, diathetic, pyogenic, sj^hilitic, chancroidal and traumatic, as most important. Nongonococcal Acute Urethritis. — General differentiation respects history, subjective and objective symptoms, laboratory examination and treatment exactly as in gonococcal invasion. The technic is the same for securing and preparing smears for specimens on the micro- scopical slide and cover glass and on culture media for groT\i:h in the laboratory, whether from free discharge or drops or only shreds in the urine. The author's seven-glass test is available for demonstrating the site of the urethra involved but only in prolonged and complicated cases. The gonococcal complement fixation test is of value in the same general type of disease for proving the absence of gonococcal absorption, but is of no value in mild forms. The Wassermann reaction becomes of value when syphilis is suspected. The special features of each form are outlined as follows: Catarrhal Differs from GcnccGCcal Urethritis in the etiological factors stated in the clinical section, page 23, having a history of low vitality, alcoholism, frequent catarrhal disease elsewhere in the body and per- haps many previous urethrites of gonococcal or other nature. These are admitted causes of frequent congestion in alcoholism, hyperacidity 44 ACUTE URETHRITIS or hyperalkalinity of the urine, sexuality ami even infection. Peri- urethral disease, especially })rostatism, nuist be remembered. The sub- jective and objective symptoms rule as those of a mild urethritis with little discomfort on the i)art of the patient except the nuicopurulent discharije and include the diathesis or disease underlying the outbreak. In the laboratory there are no gonococci but only the Micrococcus catarrliaJis and occasionally no organisms at all in the simi)le indolent nnicous discharge. The blood tests are negative for both gonococcal and syphilitic infection. Treatment completes the diagnosis in that mucous membrane restoratives internally administered and in that attention to the underlying diathesis both help more than local application which not infrc(iuently increases the discharge and the discomfort. There are no complications or sequels. Diathetic Differs froDi Gonococcal Urethritis in having gout, rheuma- tism, intestinal toxemia and disease, constipation, diabetes, lithiasis (gravel) or the strumous state prominent in the history. Many of these cases admit frequent attacks of l)alanitis in the midst of such sickness associated with the urethritis. The subjective and objective symptoms relate chiefly to the antecedent attack of the disease and to a peculiar relaxed mucosa perhaps with discharging balanitis. The discharge is mucopurulent or purulent according to severity. There is much more suffering from the antecedent systemic disease than from the urethritis. The laboratory proves no gonococci present and occasionally no organisms but much more commonly the pyogenic germs and others common in the urethra occur. The Bacillus coli may be expected in intestinal cases. Both blood tests — gonococcal and syj)hilitic — are negative and the treatment requires relief of the underlying disease with immediate benefit to the urethritis which is cured by mild local injec- tions or irrigations of astringents at suitable temperature. The mucosae of these subjects are so irritable that only the simplest means should be initiated. There are no complications or sequels. Pyogenic or Purulent Differs from Gonococcal Urethritis in its infec- tion with soiled instruments or other failure of asepsis or from a pus focus elsewhere in the urogenital tract in the history. Many of these cases are infected from perverted intercourse and show the pus found in the mouth while others are evolved from normal intercourse. The subjective and objective symptoms always duplicate in kind and fre- quently in degree those of gonococcal urethritis, so that every element is present except the gonococcus and all the findings in the author's seven-glass test or other multiple-glass tests are the same. Fever, absorption and prostration are by no means uncommon in many of these patients. Laboratory examination reveals a multitude of pyo- genic organisms in smears and culture, J^ut no gonococci. The blood test is likewise negative and reliable in the prolonged and complicated cases. Treatment by relief of the primary focus aids all the local measures already mentioned under the treatment of gonococcal urethritis (page 47). Not infrequently the same sequels and compli- cations occur as are found in the latter disease. DIAGNOSIS IN GENERAL 45 Syphilitic or Charicrons Differ.s from fJonococcal Urethritis in its long incubation, in the history and tlic situation of the lesion at the meatus or inside the urethra and the subjective and objective signs are those of a slight stricture at the meatus or fossa nnvicularis, a thin discharge with a little blood or pus, usually hard insensitive lymphatics and rarely chordee. Ardor urinse may be the sole complaint. The multiple glass tests show little or no discharge. Secondary lesions are present in cases six or eight weeks old. The typical chancre and usual varieties are fully described under Balanitis and need not be repeaterl here. The urethroscope, preferably the short open end Chetwood Fig. 6. — Phagadenic paraphimosis. The peculiar destruction of the foreskin and glans is apparent. The lesion contained no tubercle bacilli, no treponema pallidum and seemed to be made up of indolent granulation tissue on pathological examination. (Unpub- lished case of Dr. C J. Seay.) tube (Fig. 145) or the meatoscope (Fig. 136) will often make the diag- nosis of the lesion within the canal. In the laboratory the Treponema pallidum is recognized readily from the secretion of accessible lesions, but is secured with difficulty from those within the canal. The Wasser- mann blood test appears about the second week, occasionally earlier. The gonococcus is absent in the specimen. Treatment locally and sys- temically directed against the s^^philis gives very rapid and wonderful relief still further completing the evidence of this special infection. Chancroidal Differs from Gonococcal Urethritis in showing a painful actively inflammatory and extending sore in its history, situated at the 46 ACUTE URETHRITIS meatus or within the canal and causing the subjective and objective syni})toms of a "mouse-eaten" base, undercut and overhanging edges, inflamed annexa and often ])ainful lym])hatic vessels and glands. There are i)urulent discharge and detritus whicli show in the first glass of the nniltiple-glass tests but rarely sufHci(Mitl\' to make a large specimen turliid. Artlor in-in;v is common and rather distinct at tlie meatus. For the laboratory the bacillus of Dticrey is recovered from curettings. There is no Treponema pallidiiDi or Wassermann test and no gonococcus or gonococcal fixation test and the treatment with antiseptic dressing, washing and ointment will relieve and show the sim])le surgical char- acter as compared witli the chancre as a port of entry of systemic infection. The sequel is deformity and sometimes stenosis of the meatus and the com])lication suppurative inguinal adenitis. Traiiniotir Diffei\s- from Gonacoceal Uretliriil,s in cmj)hasizing injury in its histors^ as the cause, due to instruments, caustics, heat or electricity, and in having as the subjective and objective symptoms mild or severe hemorrhage, catarrhal or purulent discharge, marked ardor urinje and chordee according to the nature and se\'erity of the excitant. Instru- ments usually cause hemorrhage from their mechanical irritation, fol- lowed by catarrhal urethritis unless the instriuuents were infected. The other causes named produce superficial destruction of the mucosa and ])us with all its other symi)toms. In the laboratory s])ecimen there may be no organisms at all or the Micrococcus catarrhal is or the ])N'o- genic group according to their entrance after the traumatism. There are, therefore, no gonococci, no Treponema pallida and no bacilli of Ducrei/, no Wassermann blood test and no gonococcal fixation test unless the traumatic urethritis was induced during the treatment of any of the other forms. Treatment by removal of the cause makes the diagnosis immediately. This should be followed by the simpler means of controlling the rest of the reaction. Severe cases have the sequel of stricture as in the author's case of biu-n of the urethra referred to in the chapter on Stricture, and some patients may have such complications as extension of the inflammation outside the urethra in rare examples. Gonococcal Acute Urethritis. — General differentiation is exactly the same as that described for nongonococcal acute urethritis in the earlier paragraphs of the subject of diagnosis. The reader need be reminded only of the four general factors of history, symptomatology, labora- tory investigation and treatment. Attention to these details will readily establish the diagnosis and the minute distinctions from the other forms of acute m-ethritis are already gi^'en under each such form in the paragraphs on the differential diagnosis. It must not be forgotten that the gonococcus must be searched for in smear and culture, repeatedly if necessary, and that in severe or conijjlicated cases the gonococcal complement fixation test must be performed. TREATMENT IN GENERAL 47 TREATMENT IN GENERAL. Gonococcal Acute Urethritis. — Prophylaxis. — The cntin; subject of prevention is treated 'in the Chapter on the General Principles of Treatment under the subheading Prophylaxis (page 483), to which the reader is referred. Management. — General Principles of Treatment in Chapter IX, on page 483, embraces all the procedures of management. Abortive Treatment. — Definition.- — Abortive treatment may be regarded as immediate cure of the infection when only the early sub- jective symptoms are present and when the sole objective signs consist of few intracellular and extracellular gonococci with scattered des- quamated epithelia and still fewer pus cells but no fluid pus and no true exudate of leukocytes. Tlie period for the application of the treat- ment in most patients is preferably the first twenty-four hours, rather than the second twenty-four hours. Limitations. — The limitations arise from the difficulty of having patients respect advice to call at the earliest moment, or of having them rightly perceive and interpret the early symptoms and then come for aid at the golden moment of slight exfoliation rather than at the later time of exudation and discharge. Technic. — The technic is threefold, as generally recognized of rea- sonably reliable results: 1. Application method. 2. Irrigation method. 3. Instillation and retention method (Ballenger). 4. Disapproved methods, such as dressings, bougies and scrubbing of the urethra. 1. Method of a-pplication implies one treatment as sufficient and embraces the following steps : The patient evacuates his bladder, thus washing the urethra from behind forward tliroughout under Nature's own method. Cleansing is further assured by filling a 150 c.c. Janet- Frank syi-inge with 2 or 4 per cent, boric acid water at 100° to 105° F. and connecting it with a soft, short 12 French catheter inserted for about 3 inches into the canal and then by flushing the urethra from behind forward while the patient is in the recumbent position. A short Chetwood urethroscope is passed into the canal, its obturator removed and then its sheath slowly withdrawn wliile a cotton applicator dripping with from 1 to 3 per cent, nitrate of silver solution is gently rubbed on the mucosa, or a few minims may be left free in the bottom of the tube during its deliberate removal. Either application should stain the mucosa a faint white. The immediate results are sterilization of the infected area and a secondary chemical urethritis of mild degree and brief duration having a mucopurulent or purulent discharge and moderate ardor urinse which steadily decrease under rest in bed, light diet, free bowels, cold locally, neutral urine and anod}iie mixtm-es, exactly as suggested in fully established cases of acute m-etlu-itis in the 48 ACUTE URETHRiriS followiiiij: ])nni;j;ra])lis. A sootliing astrinuviit liand injection of lialf- strcngth ritzniann is occasionally necessary. The final result is destruc- tion of the gonococcus pro\'ed by smear and culture exactly as was their presence recognized at the first call, also a restored mucosa proved by the absence of desquamaticm and red and white blood cells. The A\lu)le procedure is strictly an analogue of C'rede's method of treating the eye of the newborn infant. The 1 per cent, silver nitrate dropped into the eye causes death of any organisms present and induces a moderate catarrhal conjunctiNitis ^^■hose irritation is allayed by local a])plications of normal salt solution or boric acid water. '2. McfJiod of irrHjatiun requires one or two treatments a day for two or three days in accordance with the microscopic findings and the activity of the response. The patient passes his water to remove all ])ossible material and the urethra is further cleansed by the boric acid water irrigation of its terminal three inches, as detailed in the method of a]ii)lication. A 150 c.c. Janet-Frank syringe and catheter are now filled \\\X\\ antiseptic solutions at 100° to 110° F. and flushed through the meatal three inches of the canal from behind forward. Suitable strengths are somewhat stronger than those employed in the irrigation method of the early stage of true exudation because the disease has not >et penetrated deeply. Examples are: Silver nitrate solution 1 in 5000 to 1 in 3000 ArgjTol solution 3 per cent, to 10 per cent. Protargol solution 0.5 per cent, to 1 per cent. Potassium permanganate solution 1 in 2000 to 1 in 1000 Bichloride of mercury solution 1 in 5000 to 1 in 3000 The stronger solutions are best on the first day and the weaker selections on the second and third days, if the reaction j^ermits. In general the earlier the case, the stronger and less frequent the irriga- tion within the foregoing limits which are always safe. If the case is seen later but still before the true exudation of leukocytes comes with pus cells more numerous, epithelia more frequent, a few red blood cells and a mucopurulent instead of a mucous stickiness, as is the case on the second or third day, then the irrigations may be a little weaker, more copious and given twice daily. The immediate results should be disappearance of the gonococci with a secondary mild catarrh, exactly as in the method of application in its nature and treatment and the end-results are complete restoration of the mucosa. If the gonococci persist after the third day of such treatment it may be regarded as a failure and the standard continuous method of treating the disease should be undertaken. The author's experience \\\t\\ social prophylaxis duplicates that of every other observer to the ett'ect that printed circulars or leaflets of instruction are of benefit and that cases within A\'edlock are usually successful, especially among intelligent patients who after explanation comprehend and remember instructions and then follow them out. It is impossible to say an\thing worth vAvXa about the unintelligent. TREATMENT IN GENERAL 49 Janet Method. — This is also an irrigation method and is fully described under the standard treatment of urethritis by irrigation (page 64). Its cautions are four — which are that the patient must always urinate first, that the irrigation must reach only the anterior urethra, that the temperature must be moderately hot, from 100'^ to 110° F., and that the concentration must be relatively weak, 1 in 8000 to 1 in 4000 watery solution of potassium permanganate in water, and that the repetition should be not more than twice daily. Fig. 7. — Assorted syringes. A, triumph two-dram asbestos packed all glass syringe for patient's use, with box, B; C, patient's urethral hand syringe, with rubber bulb ejector; D, acme subpreputial syringe, with long rubber tip, glass barrel, metal cap, glass piston and cotton packing; E, triumph all glass asbestos packed, long tip model; F, Hayden metal mounted glass barrel leather packed cone point instillation syringe, with shoulder made fiat by the author to prevent roUing. 3. Instillation and Retention Method. — ^Ballenger^ denominates this the "Sealing-in Abortive Treatment of Beginning Gonorrhea," seems to be the originator of it and claims that " we have probably adminis- tered 4500 of these treatments during the past four years and have never seen a stricture or any other harmful results produced b}^ them." Its basis of success is application during the first twenty-four to forty- eight hours of the disease of 5 per cent, freshly prepared arg;yTol solu- tion once daily for five days with retention for at least six hours by 1 Genito-urinary Diseases and Syphilis, 1913, pp. 15-21. 50 ACUTE URETHRITIS means of a collodion cap ni)on the ijlans. The organisms are reached and destroyed tliroughout the length and depth of the infected area at this early stage and gonococci, staphylococci, colon bacilli and psendogonococci are equally well destroyed. No harm to the intiam- niation occurs if the method fails. Its basis of failure is intercourse during the incubation period, a prolonged incubation, early follicular abscess or in^'olvement, and any form of other treatment such as irrigation, instrumentation and deep injection, because such invite extension of the infection beyond the zone benefited by the sealed-in instillation. Ae. Oor.oo. Ant-Poot. nrcthrltls. rcteo iORCH 191 J ^P''^ Halts 1 4 7 10 IJ 16 19 2C 25 28 1 2 3 5 7 10 13 15 >fcalilinE 4-H IS + :* ; - > t , ■ , „ . , , Ih^liarct' = = ** = 1C< = ? 1 " = +>7 ± = = = droj = l)„-^.,nt Cc 1 1 ci ..j:. : t 77 i c l-t'!^lhr.,l/'^' :!:- " I) U t".H^ X. 1' 1 - C. rd 10 20 ft ; = 12 e 5 Coiilrol 1 ■.«,!« + t* f =<. + +-^ *I = Tv..oni.i. Illnr.1 7 ■»■■»■ = + 7' >7 ± I S.,.„n,. ^ ^. ^ ^ ^ ^ . m .• v..ininlu.Hi..ns " rr.-oo. * t> t zi " / ? ,«rt Strap. \ ^ ^ ^ • V C lVd.-«n-. V. C IVilcrscn ^ Irricalint; SJ- Kolilr..in Vrsicol Irrir llano' Inilill SiniKht Sd Irrlhrol Irrii i r'u 'I'r' ] 7> ^ ^ , U? 1 M 1 M ,.r J, i-a = = = = = = = = = = = := = = = 5 Carbotuto g I'll* Shrcil- '•^ MlK-Ollil"* \ ; Fig. 8 In the technic the patient's bladder must be empty and kept as little active as possible by greatly limited fluids and food during the period of retention, which is about six hours each day for five days. In the recumbent position, the glans penis is carefully cleaned, dried and surrounded with a sterilized towel. With a cone point urethral syringe 25 minims and no more of a 5 per cent, watery solution of argyrol are gently instilled into the anterior urethra in all cases except those which are seen on the second or third instead of the first dav. In these TREATMENT IN GENERAL 51 patients the medicine is gently massaged backward in order to provide contact with the more extensive infection of the mucosa. As the syringe is removed, and while, the massage is i)erformed if dorif;, the meatus is compressed shut from side to side, dried carefully with the towel and then covered with a plug of noncontractile collodion (U. S. P.), which dries while the urethra is still kept closed. The patient is now allowed to go home and to observe the following strict precautions: abstinence from violent exercise, fluid and food, except in moderation, and sexual stimulation. At the end of about Char t 4. 1 1 ' Fig. 9 six hours the collodion plug is removed by softening it with acetone or by pulling it off by means of the cotton handle secm'ed at one edge but always Siway from the meatus because if the cotton handle reaches the meatus it will drain off the arg}Tol. Mter the plug is removed, the patient drinks copiously of alkaline water so as to flush out the canal with neutral urine and to relieve the chemical and mechanical hrita- tion essentially secondary to this procedure. The following day for a brief period he takes little fluid or food so as to limit the excretion of 52 ACUTE URETHRITIS iirine and so as not to interfere with the treatment and then reports for the second appheation. This proce(hn-e is rej^eated once a day for five days. The presence of the gonococcus at this time usually indi- cates failure and resort to the standard methods of treatment. AVhile tlie arg\Tolis retained it is well to have the patient wear a light cotton dressing for the discovery of leakage if the collodion breaks or loosens. Beginning the treatuient with .1 per cent, solution, gradual decrease in the strength to :> or 2 ]ier cent, may he followed esi)ecially if the chemical reaction seems acti\"e. Relapses of the urethritis after the five days of treatment are over mean failure of penetration or extension of the arg^^'ol to coincide with the zone of infection and may be checked, if not violent, by a repetition of the jirocedure before the standard treat- ment is undertaken. The technical difficulties of this method are not insurmountable and Ballenger recommends that the beginner acquire skill by trying it on chronic cases which are in no wise ad^'ersely influenced l\v it. Aftertreatmcni — These measures in Ballenger's method are only observation to see that the medication has not induced a chemical urethritis Avhich should be treated as shown under the subject of Trau- matic Urethritis (page 305) . Cure. — This term iuA'oh'es relief of the infection and therefore freedom from any of its developments. 4. Disapproved Abortive Methods are the urethral dressing, as recom- mended by Boureau/ and urethral bougies. Both these are medicated, but the cotton or gauze in the former and the gelatin in the latter act as foreign bodies, irritate the mucosa and excite rather than check the infection. Scrubbing of the urethra with a brush, such as is used for tubes, suggested by Huguet,^ only denudes the epithelium, which is exactlv ^^■hat the gonococcus does and therefore only leads to its rapid extension, although the theory was that of affording ])enctra- tion of antiseptics to the deeper laj'ers of epithelium into which this organism penetrates. Curative Treatment. — Classification. —As in e^'ery chapter concerned with clinical features and complications, anterior and posterior ure- thritis \\\\\ be separately considered and the gonococcal infection will be regarded as the type and other forms will be described thereafter, with their variations. Case Records. — Xo case may be comprehensively and systemically followed without office records. The author's^ history charts are shown in Figs. 8 and 9. Symptoms and remedies appear in the left-hand column, dates are at the top of the small columns and progress is algebraically indicated in them. Methods are two — (1) the conservative expectant or antiphlogistic method, A\hich is the older, and (2) the irrigation or Janet treatment, which is the newer. Each has its strong advocates. ' Moscow International Congress, 1897. ' Thfese de Paris, 1888. 5 Tr. Am. Urol. Assn., 1913, p. 163. TREATMENT IN GENERAL 53 Anterior Gonococcal Acute Urethritis. — Conservative Method. — 'i'his treatment is also called expectant because the various stages of the dis- ease are awaited in their development before additional measures are adopted, likewise antii)hlogistic because it gives particular attention to the local and systemic febrile characters of the lesion. Its aims in general are those of treating the acute and early establishment diiVcr- ently from the subacute later and declining period, to the degree that in the former no antiseptics are locally applied to the urethra by .hand injection or irrigation while these measures feature the latter period. The advantages are that it is the method of least disturbance of Nature's processes concerning the inflammation, the plan of fewest complica- tions induced by overtreatment, the procedure of greatest safety for the inexperienced nonspecialist, the treatment of least meddling and the management of fullest respect for the course and stages of the disease, with minimal interruption and interference. Its disadvantages^ are delayed antiseptic attack on the gonococci, the relatively slower though more gentle uncomplicated course of the disease and the dis- satisfaction of many patients, with the fact that "nothing is being done" during the first two weeks. Stages of incubation and invasion are managed as set forth in the paragraphs on Prophylactic and Abortive Treatment on page 47, and will not be further discussed here. Stage of establishment requires attention to the general details of management and internal and local medicinal measures. The dressing of choice is a piece of gauze about 6 inches square, with a small hole cut at its center through which the glans penis is passed after retraction of the foreskin. With the gauze resting in the corona the foreskin is replaced, thus leaving a loose apron which does not im- prison the discharge within the urethra. The preliminary and final adjustments of this dressing are shown in Figs. 10 and 11. This dress- ing should not be allowed to adhere to the meatus and glans and should be changed approximately at every urination, at least e^'ery t^'o or three hours by day and once or twice at night during wakefulness. In the circumcized and patients without average foreskins a larger piece of gauze may be prepared with a hole through which the penis passes freely, whose margins are pinned on each side of the penile opening in the suspensory bandage. The wearing of a cotton plug inside the foreskin and against the meatus is to be condemned because it holds the discharge inside the urethra and directly defeats Nature's aim at cure of the disease by the free production and .dis- charge of pus and gonococci which by retention are favored in their characteristic powers of penetration. The patient cannot understand this result too well. So-called " gonococcal penUe bags" are not advised unless several are purchased so that only clean ones, free of dry or moist pus, are in use and also unless they are large enough and hung lou- enough to prevent the meatus from resting on the cotton at the bottom and thus again being plugged. Muslin or linen bags do not sweat the 54 ACUTE URETHRITIS l)art8 as much as ruhbcr ones. It ij; wi'U known that hi>at and moisture favor nuiltiplication of orijanisms. rroi)hyhixis is important and in this coiUK'c'tion (UlVcrs from that introducinu' this chaiJter and is conc-crnod witii the eyes of the j^atient and infection of innocent, associates. The eyes are guarded from con- tamination by the simple rule of great cleanliness of the hands, especi- ally the finger-nails, which should be carefully cleaned whenever the patient uses the toilet or in any way treats his dis(>ase. A curious error to be corrected is that by ^^■hich many patients wash their hands before they adjust their clothing, which is at least theoretically always con- taminated, and tlioreforc attain renders their fin<::crs dangerous to the Fig. 10. — Gauze dressing during the acute stage; the glans is passed tlirough the gauze to the sulcus with the foreskin fully retracted. eyes. The hands should be washed last after every other detail has been provided for. The patient's associates are protected by having him, as far as possible, sleep alone and use separate toilet articles, especially such as come into contact with his hands, body and face, notably towels, wash-cloths, handkerchiefs, napkins and the like. All dressings should be placed in cheap bags or envelopes and burned — a plan which permits the business man to seal his dressings up until he reaches home for their destruction. Nothing that is insoluble in water should ever be thrown down a toilet, so that such disposal of cotton and gauze should never be attempted because they stop up plumbing work. Similarly, sja-inges and other appliances should be kept apart, and the TREATMENT IN GENERAL 55 best type of the former is now sold in wooden boxes, which keep them away from the lining of pockets and handkerchiefs therein (Fig. 7, AandB). Management. — This topic is discussed and detailed in Chapter IX, on the subject of General Principles of Treatment on page 483. Leaflets and pamphlets of instruction such as the following cover all this ground clearly. It has been used by the author for many years in clinical practice and is founded on one by the late FoUen Cabot.^ In private practice a reprint of the author's article is given to patients, "Instructions on Gonorrhea. "2 Medicinal measures include those for local and systemic adminis- tration and for pathologic and symptomatic indications. Fig. 11. — Represents the gauze gathered in front of the glans, and when thick for a copious discharge held closed for receiving the pus. The foreskin is shown pushed for- ward over the glans and the gauze to hold it in place. Local subjective symptoms have been given in the cHnical sections (page 34) as pain, urinary disturbances, chordee and discharge. The following suggestions apply to each in turn: The pain, by local treatment, is relieved by hot baths to withdraw congestion from the urethral mucosa, consisting in penile, sitting and 1 The Importance of Systematic Education of Hospital and Dispensary Patients Afflicted with Venereal Disease, 1907. 2 Long Island Med. Jour., October, 1907, i, 411. 56 ACUTE URETHRITIS CM O X o LU h— CO _ >- •— «t CO Q cr z 3 « <: H I— I Ph CD O Pi 02 o o o o Pi Q d 2 if ^ d a • « Is r' » W S z. o CJ c H Eb O £ E S « - © S-2 1 -3 C ^ «> to C o cS S O O m ^ g .9 » -o *^ _ -= 1 s ^ 4) rt * e 5 J=1S s-^ P ^ £ ■ft C3 >. O ^ CO C rt cS d £ *i C) O — 'o 2 ^ •S § S S Q -2 •O — « o S -^ u n - ^ - _! « S-^-s O 8J • t. 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P to c ■o o :a -3 o „ c rt p P ? «^ rt *- g c 2 p o rt •" P fT'-Ti CJ TD P "a *" p "o in '^ -•So rt J«! a a o p 'i^ .2 Si rt * SZ. p P 'T? :0^-3 o tjM 3 ) P, (H p Q ^ •> o o « .a rt o n ©P p.2'^P .a -^ a a 7 rt in .S I - c P P -tJ a p tn to •^ Ti P rt P ft .2 « .2 "^ m a p -3 4, >, rt X^ i|rt^s P -^ ^ aj Ji -M S CO -"5 — * ?s ^ (u a a p ^ ^-3 .9 fe tn 2-0 CO "3 .a +j O C o -3 ,0 a c ' ^ a p p O " 2 -T3 _> CO tn X <" a 2 '-' p a <^ -^ rt 9 "^ rt rt ,„ 2 E-o a .9 ^ p to ''3 a p p o ■^ Si;23^ •o a-^-S *^ a p •r| <« 2 a o B o p _a s ipfegs p ^ rt p o *-• > p l> TREATMENT IN GENERAL 57 even })ody baths, of a temperature to j>roduce redness of the skin and contmued fifteen to thirty minutes until pain is alleviated. When a special tub is not available the effect of a sitting bath is obtained by drawing twelve inches of hot water in a common tub anrl ])y having the patient sit in the water with his legs extended. All baths should be taken at night, so that the patient may step from the tub into bed, othenvise chilling of the surface will augment the disease and perhaps add a severe cold. When heat fails, cold in the form of an ice-bag applied to the pubic region or perineum or of a wet dressing kept on the penis is of service. Through internal administration neutral copious urine avoids the pain caused by acidity, tends to limit the inflammation, so that chordee may be escaped, and flushes out the discharge. Litmus paper must be used to show neutrality. The following formulas are of service in neutralizing the urine and increasing its flow in addition to the various drinks stated under that heading: I^— Bicarbonate of soda, in tablet or powder, grains 5 to 20 three times a day. I^ — Bicarbonate of potash 30 grammes (1 ounce) Tincture of hyoscyamus 15 grammes (^ ounce) Distilled water up to 240 grammes (8 ounces) Mix, make a solution and mark: One tablespoonful in a small glass of water three times a day, two hours after eating. I^ — Salicylate of soda 0.75 grammes (12 grains) Bicarbonate of soda 0.75 grammes (12 grains) Benzoate of soda 0.75 grammes (12 grains) Mix, make a powder and mark: Take 1 powder mth a glass of water three times a day, two hours after eating. Such combination may be directed as a powder three times a day, or with any one or two of the ingredients omitted, it is very serviceable, or it may be made into a solution with a tablespoonful dose. ^Nlilk, either ordinary, predigested or fermented, and alkaline mineral waters, such as Vichy, are very acceptable and useful either alone and separate or mixed in equal or other proportions. Avoidance of sexual excitement, direct and indirect, by eliminating its congestion reduces the pain of erection and of ejaculation and blood-letting in the form of several leeches applied to the perineimi but not to the penis or scrotum may be employed in extreme pain of con- gestion and edema, with obstruction and retention of urine. Urinary disturbances are frequenc}^ altered stream and acute reten- tion. Frequency is benefited by limiting the intake of fluids to moder- ation, so that lu^ination occurs not more frequently than once every hour or preferably every two hours. Constipation by congesting the prostate may also cause frequency without the presence of posterior urethritis. Altered stream is usually due to edema and is benefited by hydrotherapy — penile, hip and body baths — in the earlier periods and in the later periods by properly selected and applied hand injections. Acute retention is dealt with in its own section (page 78), but in mUd forms is released by the hot baths and anod^^les and antispasmodics, of 58 ACUTE URETHRITIS which none are better than Magendie's solution of morphin, minims 6 to S, hy])oderniieally, for definite eases, or codein suli)hate, grain ^ to 1, by mouth, every fi\e hours, or an o])ium suppository, grain \ to 1, once or twice a day. The advent of intense retention requires relief of the bladder by suprapubic aspiration with a long medium caliber needle. Catheterization in any form whate\"er is absolutely forbidden, for fear of infecting the bladder. The chordee is possibly pre^•ented by all the means suggested for allaying inflannnation and edema in the prevention of pain, of which chordee may be regarded as one manifestation. Cleanliness of the foreskin, freedom from tight gauze dressings about the glans, proper fittuig of the suspensory bandage, regular easy evacuation of the bowels, rest and quiet in avoidance of the congestion of exercise and that of errors in diet, drink and sexuality, and finally the use of light and loose sleej^ing apparel and bed-clothing, all remove sources of reHex disturbance and irritation, and with these the tendency to partial or complete erection. It is alleviated by hot baths applied to the penis and hips as decongestants and sometimes by the ice-bag when heat fails. Of sen-ice are the opium suppository, grain | to 1, before retiring, and anodynes, such as the bromide of camphor, grains 10 to 15, at night, or smaller doses three times daily; codein, grains | to 1, before bedtime, or less at regular diurnal intervals, and the bromide of soda and bromide of potash, grains 10 to 20 each, an hour before bedtime. Antipyrin, with or without opium ])ro(lucts, l)oth in moderation, are recommended such as: I^ — Autipyrine 0.2 to 0.3 gramme (3 to 5 grains) Codein sulphate 0.016 to 0.032 gramme (grains ^ to |) Mix, make one pill and mark: One pill three times a day or two or three pills before retiring. I^ — Bromide of potash 1 .0 gramme (15 grains) Bromide of soda 1 gramme (15 grains) Distilled water up to 8 c.c. ( 2 drams) Mi.\, make a solution and mark : Two teaspoonfuls at night before retiring or one three times a day in a half-glass of water, two hours after eating. Phenacetin in doses of 0.3 to 0.6 gramme (grains 5 to 10), once or twice a day, is a good anodyne and circulatory sedative, and the author has had excellent results in sthenic patients, with tablet triturates contain- ing from ] to 1 minim of fluidextract of aconite, every one or two hours, until the slightest sign of physiological action, as sweating, relaxation or tickling of the finger-tips or tongue appears or until three or four doses have been taken. Inhibition of the erection is sometimes possible by grasping the thighs near the groin over the adductor muscles in which the crural branch of the genitocrural nerve 1 ies imtil slight pain is ])roduced. Thus inhibitory impulses are set up in the genital branch, which often checks the erection at its very onset. The discharge in the acute period is left alone locally in the expectant treatment until the severity of the symptoms begins to decHne, but TREATMENT IN GENERAL 59 is influenced, of course, by the general management and methods just described. Therefore the local measures against this symptom are noted in later paragraphs. Systemic subjective symptoms have been listed elsewhere (page 34), as anorexia, constipation, anemia, depression, prostration, chilliness, fever and insomnia, varying in severity so that in mild cases they are hardly discernible. Anorexia, constipation and anemia are all benefited by good diet and rhubarb and soda mixture (U. S. P.) in 1 to 2 teaspoon- ful doses three times a. day. The soda is of benefit to the acid urine, but the rhubarb may irritate the inflammation. In such event simple bitters or digestants and cathartics are required. This old-time remedy is a good corrigent of the digestive disturbance of many of the other medicines required by the symptoms. Depression and prostration call for moral assurance, establishment of confidence of relief and either mild stimulation, with strychnin, for example, or sedation with bromides. Chilliness and fever suggest rest in bed, evacuation of the bowels, opening of the skin, light diet and Dover's powder, grains 5 to 10, at night, and insomnia is reached with the hot or cold bath and very mild hypnotics, of which none is to be preferred to increase of the bromides, perhaps already being administered for the pain and chordee. Overmedication may easily ensue upon too much attention to these subjective sjinptoms, which commonly last a few days at the most and disappear under nature's own processes. Intense infection, however, may require great judgment in these as well as other particulars. Objective local symptoms have been detailed in other pages as red- ness, edema and infiltration of the meatus, foreskin and urethra, lymphangitis and discharge. Eedness and edema are not preventable, but greatly benefited by cleanliness and all the measures previously described for the pain and congestion. Lesions of the foreskin may be prevented by prophylactic measiu-es of cleanliness and antiseptic washing. Lymphangeitis and l}Tiiphadenitis commonly rest on lesions of the foreskin, such as phimosis, paraphimosis, excoriating balano- posthitis and the pocketing of pus. Soap and water and antiseptic cleansing are preventives if the foreskin is retractable, followed by the application of drying powders, of which none are better than various combinations of thymol iodid, boric acid and bismuth sub- gallate. If the foreskin is not retractable, then subpreputial irrigations as described on pages 86 and 97, under the complication phimosis and hand injections of mild antiseptics are indicated. Tincture of iodin painted lightly over the inflamed trunks and glands is of service if applied in the morning, as in the evening the irritation may cause wakefulness. Discharge is so largely a local condition that it is hardly influenced directly by internal medication. The urinary antiseptics, therefore, largely fail against the gonococcus because the organism is beneath the surface of the mucosa, where it does its harm and from which it is cast off by the exfoliation of epithelia and the diapedesis of leukocnes in the formation of pus. These urinary cleansing agents are available only in the kidneys, where the pus is present at the point of secretion • lO ACUTE URETHRITIS of the urine or in the pelves of the kidneys and the bhuhler, wliere for a relatively long time they are in contact with the infecting organisms, hut in the urethra the outfioAv of urine is so brief that the contact between the two is insufheient. The following are the antiseptics usually employed: R — Hexanicthylenamin 0.5 gramme (7.5 grains) Alone or combined with Sodium benzoate 0.5 gramme (7.5 grains) Distilled water up to 4.0 grammes (1 dram) Mix, make a solution and mark: One teaspoonful in a iialf-glass of water every four hours or three times a day, two hours after eating. The benzoate of soda is an adjuvant of the germicidal action and a corrigent of the irritating action of the hexamethylenamin. 1$ — Salol 0.3 gramme (5 grains"! Mark: One tablet or powder witli a glassful of water every four hours. I^ — Sodium salicylate 0.3 gramme (5 grains) Distilled water up to 4.0 grammes (1 dram) Mix, make a solution and mark: One teaspoonful in a half-glass of water every four hours or three times a day, two hours after eating Benzoate of soda or salol may be added, either or both, if desired. The stage of decline is marked by definite subjecti^'e relief and objec- tive impro\-ement in all symptoms, especially that of the urine in the multii)le-glass tests. In a word, it is the time of i)rogressing quies- cence and beginning control of the infection by nature's own processes. It is also the preferred period for instituting local treatment of the urethra as a diseased anatomical entity. The local measures are either hand injections, office irrigations or both combined and are employed in the urethra only in the declining stage, when both the suffering and the pus are definitely less acti\'e, which means toward the end of the second to the third Aveek in mild cases and of the tliird to the fiftli week in severe cases. It is the symptoms and not the elapsed time which determine, and there must be fewer gonococci, pus and exfoliated epithelial cells under the micro- scope, and glass 1 of urine must be less densely turbid and glass 2 clear or nearly clear respectiA'ely in the mild and marked cases. The methods are, as stated, three: (1) Hand injections, by which the i^atient with a small syringe medicates his own urethra; (2) irri- gations, with catheter and bladder s>Tinge, by w'hich the physician from behind forAvard flushes the urethra; and (3) both hand injections and irrigations combhied, because it is rarely possible to have the j)atient call with sufficient frequency to have the irrigation alone of terminal value. The local action is antiseptic, astringent and stimu- lating, which succeed each other as the case progresses, so as to cor- respond with the periods of infection with gonococci numerous, then that of declining symptoms and mucopurulence, Avith fcAA^er or absent TREATMENT IN GENERAL 61 gonococci, and finally that of more or less indolent mucous discharge, constituting the terminal period and requiring stimulation for cure. The indications are therefore: (1) To interfere with and depreciate least Nature's own processes of repair dm-ing ull i)eriods of the disease; (2) to promote and stimulate most Nature's defensive properties against the organisms and their toxins; and (3) to determine the limits of beneficial influence of treatment as to the disease process as a whf>Ie. If these three elements may be met then rational treatment will be the result. Fig. 12. — Anterior irrigation. The patient holds tlie basin and his penis while the Janet-Frank syringe rests on the basin and is connected with the catheter passed into the urethra to tlie desired distance and held from slipping by the forceps. The layer of gauze thrown over the penis and catheter prevents all splash and spatter and conducts the return flow into the basin. (Original.) Hand injections have very definite restrictions and service. The preliminary instructions are contained in the following rules in the author's article published elsewhere:^ First, always urinate before taking the injection, in order to wash as much pus from the m-ethra as possible. Second, never use force in taking the injections, but rather, on the contrary, be as gentle as possible. Third, never use a syi'inge that does not work smoothly, because a "kicking" syringe prevents gentleness. 1 Pedersen, V. C: Instruction on Gonorrhea, loc. cit. 62 ACUTE URETHRITIS Fourth, never use more than one syrini;vfiil at one iujcetion unless specially ordered by the doctor. Fifth, fill the syrin<:;e, hold it tightly against the mouth of the penis and .gently fill the ])a.ssage until it feels as full as it does when urine is passing thnnigh it. In other Avords, no pressure greater than Nature's own during the act of urination is either necessary or desirable. Sixth, hold the injection in five or ten minutes by the watch (time to be specified by the physician). Fig. 13. — Anterior instillation. The patient holds the basin beneath and free of his penis, which rests against the scrotum. The hands of the operator support the syringe and catheter, with the forceps against slipping during the instillation. (Original.) Seventh, after cure, never loan the syringe to anyone else but rather destroy it in order to avoid poisoning anyborly Avith it. Eighth (omitted from the article quoted), beghi with one or two injections a day as directed by the doctor and do not increase the number of injections without his knowledge or orders. These eight simple rides should be printed on a slij) of paper and handed to the patient, with suitable explanations and injunctions when the proper time for beginning this treatment is at hand. If they are included in the original circular of instruction many patients of " fresh and previous dispositions" begin to use the hand injections too early and then blame the physician for the results which they themselves invite by such self-treatment. TREATMENT IN GENERAL 63 The special syringe insisted on i)y tiie author is flepicted in I^'ig. 01 . Its size is so small (2 drams) that too much fluid cannot be injected into the average urethra. Its all-glass construction renders it steriliz- able by boiling and its wooden container is a prophylactic against contaminating pockets and their contents or other utensils on shelves besides the syringe. The limit of injections is to the anterior urethra alone so far as j^ossi- ble. Hence the patient should understand that his disease is located in the anterior urethra which alone should be injected with the medi- cine and that this result is obtainable by the use of small quantities and great gentleness, leaving Nature to carry the fluid along the mucosa as she will by capillary attraction between the walls which are in apposition. He should also comprehend that forcible injection traumatizes and irritates the mucosa and extends the infection. His "frenzy for quick cure" should be quieted in every possible way. The frequency of injections in the author's practice is at first twice a day for one or two days, then three times, and by slow increase finally six times a day — in other words, about every two or three hours of the waking period or, what is usually the same thing, after each urina- tion unless there are contraindications. Office catheter-and-syringe irrigations are given properly balanced between these jiand injections. Each irrigation is regarded as supplanting one hand injection. If therefore the patient is taking four injections at home and one office irrigation these measures are regarded as the equivalent of five similar treatments in a day. If more than one office irrigation is desirable, for example, one each night and morning, then the patient omits the hand injection for the corresponding time. This is important espe- cially when the activity of treatment is decreased, otherwise over- treatment w^ith all its disadvantages will result. The retention of injections for five to ten minutes augments the ger- micidal function of the injection by bringing the antiseptic into pro- longed contact with the organisms as they lie upon the epithelia and by permitting it to soak into and between the epithelia, where they lurk, and also fulfils the indication of persistent gentle action exactly like that of the protective faculties of the blood, which are chemically not strong but act persistently. The urethra may be closed by the fingers of the patient or by use of one or other of the various urethral clamps, of which one of the best is that of Chetwood.^ On these points Taylor^ has the following apt dictum : " It is a good rule to begin with the slow injection of about 1 dram of fluid, and then to increase as the tolerance of the urethra will admit, until a syringeful can be throwii into the canal without any resistance what- ever. In this way the urethra becomes accustomed to the operation, and its walls can be well acted upon by the medicated fluid." In the technic the first step is to evacuate the bladder, cleansing the urethra. The patient rolls his shirt to his armpits and his trousers 1 Practice of Urology, 1913, p. 17. ^ Loc. cit., p. 62. 64 ACUTE URETHRITIS and tlrawt'i-s tt> liis kuoes and protects the latter with pajx^r or linen towels from leakage, as many of the Naluable drugs stain. Towels should also cover the utensils used. He stands over a basin or the urinal of a water-closet, \\'ith his legs conveniently separated, or sits on the cilge of a chair with a receptacle on the floor or sits far back on a toilet seat — all so that leakage may be received. The penis is grasped between the fourth and fifth fingers and the palm, leaving the thmnb, index and middle finger to manage the glans and meatus. A smoothly working cone-point syringe is jiressed into the meatus watertight, aided by the tlnmib and forefinger, which first open the canal and then close it against the tip of the syringe. The direction of the instrunuMit for outflow and the pressure against leakage must be ■ m ■* \k E ^L^ 1 ■ 1 t' **^ »**^... Fig. 1-4. — Irrigation for the anterior uretliral glass in the aulliur's seven-glass test (original). After standard drapery (Fig. 15) a large sterile glass is held by the strap at the upper end of the Wolbarst basin. The left hand supports the catheter within the penis and makes it coil -within the glass. The right hand makes the irrigation with a Janet-Frank syringe and the outflow is conducted by the course of the catheter directly into the glass as shown. The author's seven-glass test is fully described on page 455, in Chapter VIII, on General Principles of Diagnosis. acquired only with practice, as few patients ha^•e the knack without it. Gentle slow pressure to fill the urethra exactly as it is dm-ing urina- tion without pain or discomfort is the next step followed by the final detail of retaining the fluid for five or ten minutes actual time "by the watch" by closing the canal with the finger or a clamp. Catheter irrigations constitute the office treatment as soon as the hand injections have been ordered and therefore begin with the declining period of symptoms and organisms. The in.struments are a 150 c.c. Janet-Frank or equivalent syringe and a reflux, size 12, French, soft-rubber catheter, illustrated in Fig. 14, or a short velvet-eye soft- rubber catheter, size 10, French, a suitable graduate for mixing the injection and the necessary towels and other dressings. The limit of the inigation is to the anterior urethra exactly as that of the hand TREATMENT IN GENERAL 65 injection, because the disease is at least, so far as the infection is concerned, confined to the anterior urethra, althouj^li the posterior portion may have a sympathetic congestion without symptoms. In good technic the patient always urinates in the presence of the urologist, cleansing the urethra as a preliminary, and then standing with his clothing adjusted exactly as for the hand injection, and preferably reclining on a couch or operating table, with the Woll^arst basin or other receptacle between his separated thighs, is ready. The urologist passes the catheter for only three or four inches, or until he feels the slight resistance of the bulb of the urethra, and then attaches the previously filled syringe. Two or three small pieces of gauze are laid over the glans and catheter loosely, so that the penis may be held and the catheter retained with the fingers without infection of the Fig. 15. — Standard drapery in the reclining position (original). The patient is on an operating table, with leggings (Fig. 193) up to the groins and the Wolbarst basin between his thighs. The author's perforated towel (Fig. 196) is passed over the penis so that its short end covers the upper portion of the basin for antisepsis, and its long end covers the abdomen. hand, and next with great gentleness and with no further distention than the urine itself makes, the urologist slowly irrigates the canal for about five minutes — thus fulfilling the indications of mechanical cleansing, gentleness without irritation and prolonged influence of the antiseptic or astringent. The fluid should be warm or comfortably hot. The standard drapery of the patient differs in the reclining and the standing positions for the various methods of treatment. In the reclining posture the patient is on his back on a suitable urological table, with his shirt rolled up to his arm-pits in front and behind and his trousers and drawers rolled down to his knees, or if prolonged irri- gation is to be done they had best be removed and the leggings sho-mi in Fig. 193 (page 721) put on in their stead. The warmed Wolbarst basin is placed between the thighs, and then the perforated towel detailed in Fig. 727 is passed over the penis, with the long portion 5 ■ C^C^ ACUTE URETHRITIS upon the chest and the short i)avt Ix'tAveen the penis and tlie basin for cleanliness and elegance. Any treatment ^vhate^'er may now be developed without soiling the patient's clothing, because the basin and draperies receive all splash. If instrumental treatment is to be performed the basin is not used except Avith the author's irrigating sounds, when it is i)laced in position during the ])eriod of washing just at the knees to correspond with the outlet of the sound. If the Wolbarst basin is not at hand a douche-pan may rest beneath the patient's hips and well down toward the knees, or the return flow may be received into the dou^'he-i)an of the urological table, as usually provided. In the standard posture the clothing is arranged in exactly the same way and the perforated towel is used with the long part over the thighs and the short i)ortion held by the patient over the abdomen. Another towel is spread over the edge of the basin or sink in the office, against which the patient leans or the hand basin may be held as shown in Fig. I'.]. These basins are readily sterilized, so that an experienced patient and a skilful operator make the towels unneces- sary. Fluids for hand injections and irrigations should always be selected with reference to heat and the a\'oidance of overaction. The object of freeing the surface of clinging pus, of mild penetration of the medi- cine, with hj^eremia rather than irritation, must be borne in mind, and when in doubt weaker solutions and less active agents must first be tried and strength and action augmented by graduated steps. The following list is suggestive : ArgjTol 3 to 10 per cent. Protargol § to 1 per cent. These newer silver salts have stood the test of >'ears with decided satisfaction. The former is rather the more commonly used because much the less irritating. For reasons unknown both these salts are of value in the body in controlling the infection and its results, although in the laboratory their germicidal power is ver^^ little. They probably act in three ways: (1) By penetrating the diseased epithelia they hasten its exfoliation, (2) by entering betw^een the epithelia they destroy the gonococci and (3) by causing hyperemia aid both these processes on Nature's part. When these silver salts are not tolerated or not available or when additional measures are indicated, the following solutions are advised : Normal salt solution 0.6 per cent. Boric acid water 2 to 4 per cent. Liquor plumbi subacetatis half to full strength (U. S. P.) Potassium permanganate solution 1 in 8000 to 1 in 4000 Sulphate of zinc solution 1 in 500 to 1 in 250 Alum solution 1 in 500 to 1 in 250 Sulphate of copper solution 1 in 10000 to 1 in 2000 Chloride of zinc solution 1 in 10000 to 1 in 2000 Nitrate of silver solution 1 in 10000 to 1 in 1000 TREATMENT IN GENERAL 67 In general the concentration is from 0.5 to 1 per cent, for all the weaker salts and a tenth part or a twentietli part of these stn-n^tlis for the three stronger solutions headed by nitrate of silver, at the bot- tom of the list and including potassium i)ermangana,t(;. 'J'he normal salt, boric acid and weak lead-water are mechanical cleansing agents, while the potassium permanganate is one of the best antiseptics and astringents, followed by the other salts, which are valuable chiefly for their astringency and stimulus of the mucosa in the strengths commonly used. Thus the list presents the order of choice from the onset of local treatment in the early decline to its cessation in the ter- minal weeks. Formulas for hand injections and irrigations are chiefly combinations of the foregoing solutions and should be applied according to the rules already detailed. The following examples are very valuable, similarly prepared and marked : I^ — Zinc acetate 0.75 grammes (grains 12) Liquor of lead subacetate 4.0 grammes (dram -1) Distilled water up to 180.0 grammes (ounces 6) I^— Sulphate of zinc 0.375-0.475 gramme (grains 6 to 8) Magendie's solution of morphin . . . 8.0 grammes (drams 2) Distilled water up to 120 grammes (ounces 4) I^ — Zinc sulphate Lead acetate of each 0.375 to 0.75 grammes (grains 6 to 12) Distilled water ....... up to 180 grammes (ounces 6) I^ — Potassium permanganate 0.03125 gramme (grain J) Distilled water 180 grammes (ounces G) Mix, make a solution and mark: External use as a hand injection from three to six times daily as directed. Internal Measures. — During the period of decline with its local treat- ment neutralization of the urine is a much less important indication than soothing the mucosa and stimulating it to a more normal secre- tion. The varieties of drug are the blennorrhetic oils and oleoresins, the anodynes and sedatives and finally the urinary antiseptics — separately but more commonly combined in prescriptions. The oils preferred are sandalwood, cubeb, turpentine, wintergreen and olive oil, which are administered in soft, soluble capsules, contain- ing from 5 to 10 minims each, three times daily, so that the patient by slow increase receives from 15 to 60 minims in the twenty-four hours. The chief cautions are not to disturb the digestion, evidenced by eructations, or the kidneys, suggested by dull, dragging distress in the renal zone. Some patients break out in violent rashes after these medicines. The oil of wintergreen is of service when rheumatic signs begin to appear. The oleoresins are copaiba, cubeb and matico, but for many diges- tions are less readily assimilable. Formulas combining the oils with each other and with the oleoresins follow. For patients who cannot afford these refined medicines, and when they are not readily and 68 ACUTE URETHRITIS consistently obtainaMc, tlie so-oallod co])ailia ccMiijioiuul {" Lafaycffe mixture') is advisetl: I^ — Copaiba 0.5 gramme (minims 8) Spirit of nitrous ether 0.5 gramme (minims 8) Compound tincture of lavender O.S gramme (minims 10) Liquor of potassium hydroxide 0. 13 gramme (minims 20) Tragacanth sufficient Distilled water up to 4.0 gramme (dram 1) Mix, make a solution and mark: One teaspoonful three times a day, with a glass of water, two hours after eating. ^ — Copailia 0.25 gramme (minims 4) Oil cubeb . 0.125 gramme (minims 2) Oil turpentine 0.25 gramme (minims 4) I^ — Copaiba 0.4375 gramme (minims 7) Oil cubeb 0.1875 gramme (minims 3) I^ — Copaiba 0.4375 gramme (minims 7) Oil santal 0. 1875 gramme (minims 3) I^ — Copaiba 0.4375 gramme (minims 7) Oleoresin cubeb . 125 gramme (minims 2) Extract of buchu 0.125 gramme (grains 2) I) — Copaiba . 375 gramme (minims 6) Tincture ferric chloride (equivalent) . . 0.125 gramme (minims 2) Oleoresin cubeb . ^ 0.125 gramme (minims 2) I^ — Copaiba 0.1875 gramme (minims 3) Oleoresin cubeb 0.1875 gramme (minims 3) Oleoresin matico 0.0625 gramme (minims 1) Oil santal 0. 1875 gramme (minims 3) I^ — Copaiba 0.375 gramme (minims 6) Oil cubeb 0.125 gramme (minims 2) Oil santal 0.125 gramme (minims 2) The urinary antiseptics are usually given alone in tablet or powder form, but preferably in solution and choice seems to remain with hexamethylenamin, grains 5 to 7h, salol, grains 5 to 10, sodium ben- zoate, grains 5 to 10, sodiimi salicylate, grains 5 to 10, and sodium biborate, grams 5 to 15, acid phosphate of soda, grains 5 to 20 — dissolved in 1 or 2 drams of water, and taken three times a day, two hours after eating. The benzoate of soda is advan- tageously combined with the formaldehyde preparations, of which hexamethylenamin is the most reliable, and both drugs are em- ployed in equal quantities to the teaspoonful dose, grains 5, 7^ or 10. Good combinations of the blennorrhetics and urinary antiseptics are the following two formulas for soft soluble capsules, of which one is to be taken three times a day, two hours after eating: I^— Salol . . .0.228 gramme (grains 3.5) Copaiba 0.625 gramme (minims 10) Oleoresin of cubeb 0.3125 gramme (minims 5) Pepsin 0.0625 gramme (grain 1) I^ — Salol . . .• 0.25 gramme (grains 4) Oleoresin of cubeb 0.3125 gramme (minims 5) Pepsin 0.0625 gramme (grain 1) Oil of sandalwood 0.3125 gramme (minims 5) Olive oil 0.3125 gramme (minims 5) TREATMENT IN GENERAL 69 The sedatives and anodynes are invariably given alone for incidentally severe symptoms which last at the most a few days, as a rule, or even less, and therefore coutraindicate continued administration in these compounds. A sufficient number have already })cen named mulcr the; subjec tof Chordee. The disadvantages of the internal medication are that all the oils, oleoresins and urinary antiseptics have a more or less disturbing influence on digestion, especially if taken too soon after eating. The proper interval is about two hours after the meal, when the stomach is about to empty itself. Many also irritate the kidneys, especially the antiseptics, which may cause renal hematuria, and the oils, character- ized by lumbar discomfort, if not pain. And finally the oils and oleo- resins cause rashes of the skin, of almost alarming severity, resembling scarlet fever. All these incidents indicate temporary cessation and thereafter alternation to avoid a return of these symptoms. Stage of Termination. — In the last period of the disease the subjec- tive symptoms are little or absent and the objective signs show the dis- charge thin and scanty or absent, except for shreds in the urine, so that glass 1 is clear, with shreds or slightly turbid with mucus, which contains shreds, and glass 2 is clear, with no shreds or a very few. The lesion is therefore catarrhal rather than suppurative, although pus under the microscope may still occur. The incidence of the catarrh is diffi- cult to explam to many patients who cannot comprehend that catarrh is both the preliminary manifestation before the pus appears and the terminal manifestation after the pus disappears. Often patients will seek the services of another practitioner because they regard the terminal catarrh as a new disease, which incompetence has rendered possible. Local measures are the hand injections, irrigations and instillations, employing by preference only astringent and stimulating rather than purely antiseptic combinations. The hand injections are the same as those recommended for the earlier declining period, but w^eaker strengths, so that quarter-strength or half- strength solutions are employed of the newer silver salts, when germi- cidal influence is still called for, and of the zinc and alum formulas as corrigents of the silver nitrate combinations. This last drug is the best of all in this period. The irrigations, with the same equipment as described on page 64, are begun with silver nitrate solutions, 1 in 10,000, gradually increased to 1 in 1000, employing from 100 to 150 c.c. at one treatment, with the reflux catheter to confine the application to the anterior urethra. Irri- tation from the nitrate of silver indicates dividing the given strength into halves and also decreasing the frequency, which, according to the response, is every other day, until fluid pus disappears. Then both the hand injections and the irrigations are discontinued. The slight- est tendency tow^ard persistence of shreds after a short period of rest foretells chronicity and requires the next step in treatment. Instillations. — The small, 4-dram instillation syringe of Hayden (Fig. 7-F) , with the short, velvet-eye soft-rubber catheter, size 10 or 12, French, 70 ACUTE URETHRITIS cannot be inii)rove(l as instruments, because the syringe is so small that undue (juantity of tkiid cannot be enii)loyed and the catheter is both too short and too tiiin to extend the fluid beyond the anterior urethra or preAent it from escaping at tiie meatus. The strengths of silver nitrate solution employed gradually increase from the lowest to the highest, with recessions to weaker solutions should any be found to cause irritation. The percentages reconnnended are as follow: 1 to 5000 1 to 2000 1 to 750 1 to 125 1 to 4000 1 to 1500 1 to 500 2 to 100 1 to 3000 1 to 1000 1 to 250 5 to 100 The frequency is every other day, with, as anile, one ascent in strength at each visit until about 1 in 1000 is reached, because the higher con- centrations are liable to irritate so that the increase must be much more slow. The quantity is 1 to 2 drams except the 2 in 100 and 5 in 100, of which only a few drops may be emi)loyed at points of soreness com- plained of by the patient. Force is reduced to great gentleness, so that the fluid runs in and out along the catheter, and retention, while the patient counts thirty slowly, of the last dram or half-dram, is a good rule and accomplished by ha\'ing him squeeze the meatus shut while the catheter is slowly withdrawn. With scientific observation of the progress of the disease by stages, accompanied by judicious progress in the treatment, very frequently no true chronic stage with prolonged and \'arial)le s^'mptoms and perhaps with absorption ensues. Internal measures duplicate those for the ])revious period, with the tendency to decrease quantities and frequencies and to substitute tonic measures. Full diet without high seasoning and alcohol and moderate exercise are permissible. Sexual excitement, direct and indirect and with or without intercourse, is forbidden through the trel)le risk of relapse or reinfection of the patient or transmission of the disease to the woman. Aftertreatment. — ^Yhen all symptoms have disappeared and active measures have been abandoned, a short period of aftercare is necessary for the severe cases. This involves a few weekly visits in order to be sure that signs of disease do not appear without attracting the atten- tion of the patient and in order to build up the patient should his illness have dejireciated his physical and nervous state. All normal habits of life are slowly resumed. After treatment is stopped a month or two of observation and frequent tests must all show absence of the gonococcus and then cure is pronounced. Irrigation Method. — Definition. — A local antiseptic attack against the infection is the predominant feature of the irrigation treatment irrespective of the \'arious stages of the disease and, to less extent, of the various internal and other local measures, such as hand injections. For this reason, whether the patient is seen first in the invasion, early or late estal)lishment or declining period, the washings of the urethra are begun, but are always graduated carefully in accordance with the response. TREATMENT IN GENERAL 71 Purposes. — All comprise prevention of possible infection within a few hours of suspicious coitus, as discussed in the general topic of Prophylaxis (page 483), and of inoculation with instruments of any part of the urethra de novo or by passage through an infected to a healthy portion, and likewise include actual cure of infection recently or remotely established. Internal Measures. — Internal measures are the same as those employed in the conservative method and are varied according to the stages, so that early dilution and neutralization of the urine are sought and later soothing and stimulation of the urethral mucosa. No further discussion of the means and formulae employed is necessary beyond that just given in the previous paragraph. Local Measures. — Local measures are comprised in urethral irriga- tions of three kinds: (1) syringe and catheter method, already fully described, which is rarely extended to the activity implied in the irri- gation treatment, but is commonly restricted to correlation with hand injections; (2) the Janet method devised by Janet^ in 1892, but modified by Valentine and Swinburne chiefly in the details of nozzles, cutoffs and reservoirs; (3) the Chetwood double current method. Janet-Valentine^ method requires as its equipment a wall bracket with pulleys, over which runs a chain or cord suspending a glass reservoir, with conical bottom, attaching a long rubber hose leading to a special cut-off and shield, and which receives one of four varieties of glass tip, respectively for the normal, large or small male and the female urethra. The patient's preparation involves adjustment of the clothing, with the shirts rolled to the breasts and the trousers dropped to the knees. He may assume sitting, reclining or standing posture, having the following details: The sitting posture is with the sacrum at the edge and the shoulders upon the back of a strong chair and the feet on the floor. The reclining position involves the ordinary operating table and the standing attitude is in front of a sink or other fixture. Towels or an apron protect the clothing from splash and a scalded and cleansed receptacle, by preference the Wolbarst basin, is placed between the thighs, with the penis over its edge, so that the return flow is readily received into it. A bed-pan or Kelly pad may be used instead under the patient on an operating table, but usually soils the buttocks so that the basin is much preferred. The technic begins and ends with sterilized utensils and instruments and requires the urologist at the side of the patient. All surfaces of the penis, foreskin and glans are cleansed wdth antiseptic wash and cotton swabs or with the irrigating fluid played first over the organ, and then in order over the foreskin and glans, with its folds and sulci, and finafly the meatus held open by digital pressure. The stream is next turned into the urethra by holding the nozzle against the meatus tightly enough to permit inflow, but not to exclude outflow, which is imme- diately favored by slight withdrawal as soon as the urethra seems 1 Ann. de dermat. et de syph., 1893, iv, 1016. 2 Irrigation Treatment of Gonorrhea, its Local Complications and Sequelse, 1913. 72 ACUTE URETHRITIS distended. Force is ileterniined by the lieight of the irrigator above the patient's head, and should be sufficient to fill but not stronfjly dihite the canal, and always without ])ain, bleedinji; or other irritation. The author believes that the niaruin of safety re([uires a ])ressure only equal to that of the m*ine, and therefore does not elevate the reservoir above the patient's ear. Duration of from fi^•e to ten minutes is usually sufficient, although the longer the irrigation the better if gentleness and relative dilution of the fluid are observed. Teni])erature is within tolerance and ranges from 105° to 120° Y. Avithout secondary irritation. The greater the heat well borne the higher the astringency and anti- septic value, as a rule. Limitation of the irrigation to the anterior urethra is recommended b>' \'alentine^ in the special method of holding the shaft of the penis and urethra in the third, fourth and fifth fingers, which are released, one at a time, as the fluid reaches it, until finally it passes to the bulb. Frequency is outlined by the following table of Valentine, modified from Janet, containing allusion to intravesical irrigations discussed under this form of treatment of posterior urethritis. First day, first ^^sit Anterior irrigation 1 to 3000 First day, 7 p.m. Anterior irrigation 1 to 4000 Second day, 9 a.m. Anterior irrigation 1 to 3000 Second day, 7 p.m. Anterior irrigation 1 to 4000 Third day, 9 a.m. Intravesical irrigation 1 to 6000 Third day, 7 p.m. Anterior irrigation 1 to 5000 Fourth day, 9 a.m. Intravesical irrigation 1 to 5000 ■r, ., J - / Intravesical irrigation 1 to 5000 ifourtn day, 7 p.m. { a , • • ■ .■ i >. oa^a ( Anterior irrigation 1 to 2000 Fifth day, noon Intravesical irrigation 1 to 5000 Si.xth day, noon Intravesical irrigation 1 to 5000 Seventh daj', noon Intravesical irrigation 1 to 5000 Intravesical irrigation 1 to 5000 Anterior irrigation 1 to 3000 Intravesical irrigation 1 to 5000 Anterior irrigation 1 to 2000 Intravesical irrigation 1 to 4000 Anterior irrigation 1 to 1000 xt:^+v ^„,, T ,, ,, / Intravesical irrigation 1 to 4000 JNinth day, 7 p.m. < a ^ ■ • • x- ■, ^ iaaa ' Anterior irrigation 1 to 1000 Intravesical irrigation 1 to 5000 Anterior irrigation 1 to 5000 Eighth day, 9 a.m. Eighth day, 7 p.m. Ninth day, 9 a.m. Tenth day, 9 a.m. The Chetwood^ double current method also demands sterilized instru- ments and utensils, before and after, but has a somewhat different equipment in the bracket, pulleys, chain and jar, but chiefly in the double current, scissors handle, cut-oft' and Y-shaped glass nozzles adapted for the various sizes of meatus and urethra. The patient's preparation is exactly the same as just detailed, in the standing, sitting or reclining postm-e. Force is again limited to that of the normal urinary stream, in the author's opinion, and in his practice is detected by holding the penis against the palm of the hand, with the finger-tips over the urethra in order to feel the resistance. Discomfort or pain immediately requires lowering the irrigator even below the ear of the patient. > Loc. cit., p. 18. 2 Practice of Urology, 1913. TREATMENT IN GENERAL 73 The technic consists in holding the correct size of nozzk; water tight against the meatus, gently filling the canal to the bulb, and then by closing the scissors handle cut-oft' allowing the charge of fhiid to escape into a receptacle. This process is alternately continued until the canal is suitably cleansed. All the other features are the same as in the Janet- Valentine method, especially preliminary washing of the organ, duration, temperature, limitation and frequency of the irrigation. Solutions for irrigations do not depart in constituents or strengths from the formulas for hand injections, but may have fewer elements and much greater quantities. Stock solutions ready for dilution in varying strengths up to full concentration are convenient as follows: IJ — Crude alum 1 part Zinc sulphate 1 part Distilled water up to 500 parts Mix, make a solution and dilute according to table. IJ — Permanganate of potash 1 part Distilled water up to 500 parts Mix, make a solution and dilute according to table. I^ — Nitrate of silver 1 part Distilled water up to 500 parts Mix, make a solution and dilute according to table. The first formula is chiefly astringent and the least active; the potas- sium permanganate adds antisepsis, with little astringency, while the silver nitrate possesses both actions in marked degree so that increases in strength should be slowest with it, but may be more rapid with the other two solutions, always according to reaction. TABLE OF DILUTION OF STOCK SOLUTIONS. Quantity of 1 to 500 stock. Quantity of water. Total irrigation. Strength of irrigation. 3 c.c. 97 c.c. 100 c.c. 1 in 15,000 + 5 c.c. 95 c.c. 100 c.c. 1 in 10,000 10 c.c. 90 c.c. 100 c.c. 1 in 5,000 20 c.c. 80 c.c. 100 c.c. 1 in 2,500 30 c.c. 70 c.c. 100 c.c. 1 in 1,500 50 c.c. 50 c.c. 100 c.c. 1 in 1,000 100 c.c. c.c. 100 c.c. 1 in 500 In the terminal stage of acute disease solutions stronger than 1 in 2500 or 1 in 1500 are rarely necessary. Resistance to these strengths foretells chronic conditions. Cure. — Cure cannot be pronounced until the m'ine is clear of mucus, pus or shreds, and has remained so for a long time, and so continues in the presence of irritation by intentional errors of diet, the beer test and mildly irritating instillations. A few mucous shreds, with minimal pus, are allowed provided in any and all circmustances the gonococcus is absent, after repeated search by both smear and culture, through a month or more of examination. Fm*ther details are fomid in the para- graphs on Prophylaxis (page 483) . Examination of the semen, secured 74 ACUTE URETHRITIS in a condom, worn at night, which soon stimnlates an emission, must always be the hist test. Absohite rehef from the disease is present when there is no longer any infection and when all symptoms are absent and no chronic or comi)licating lesions appear. POSTERIOR GONOCOCCAL ACUTE XJRETHRITIS. Significance. — Extension of the organisms into the posterior urethra is a condition of great clinical importance, owing to the severity of the infection, which causes invasion beyond the compressor urethrce muscle into the posterior urethra and owing to the number and viciousness of the complications usually associated with it. A distinction must be drawn between real infection of the posterior urethra and a sympa- thetic congestion without infection, such as is i)robably common for a day or so in every case of severe true anterior urethritis. The former has a definite symptomatology, but the latter, only temporary urinary disturbance. Etiology. — The etiology is the same in predisposing factors as in anterior disease and the exciting factor is the gonococcus, with or with- out other organisms. The extension into the deep urethra by the organ- isms, ho\\'eA'er, may be secured alone by the intensity of the infection or also by mechanical means, such as injections im])roperly or too frequently taken, irrigations too concentrated or forcible in applica- tion, instruments such as catheters and sounds prematurely passed, indirect tramnatism of exercise or travel, and perhaps most common of all hypercongestion of sexual excitement and dietetic indiscretions. S3nnptoms. — Local Subjective Symj^toms. — These have their onset at the end of the first or second week of establishment of vicious anterior urethritis or later in the less severe cases, and show varieties of intensity from simple hj'peremia to florid and complicated types. The chief symptoms are decreased discharge and increase of frequency of urination, followed by tenesmus and augmented pain during urina- tion or seminal emission and terminal hematuria. The decreased discharge is due to temporary withdrawal of the blood from the anterior urethra to the new zone of disease, so that the exudate from the former is for a brief period less copious. The pollakiuria is due to the direct in\ohement of the mucosa around the neck of the bladder, and the tenesmus rests on the same basis, with still deeper penetration, followed by spasm of the sphincter vesicae. Terminal hematuria is explained in the same manner, with ruptured capillaries and denuded epithelium added. Emissions of semen are much more frequent than in anterior urethritis, because the outlets of the ejaculatory ducts and the prostate are both more or less involved and their pain is caused by all the inflammatory conditions present. Systemic Subjective Symptoms. — These are alike in kind as but more intense in degree than those in anterior infections — namely, anorexia, chills, fever, depression, prostration, and pallid, haggard, worried appearance. Nervous irritability is common. POSTERIOR GONOCOCCAL ACUTE URETHRITIS 75 Local Objective Symptoms. — All rest on the urinary and rectal exami- nation. Every specimen of the two or multiple glass-test is turbid, owing to the fact that the pus now lies throughout the canal from sphincter to meatus and the urine of the first glass is insufficient to clear the urethra. Often the last glass is equally as or more turbid than the first glass, owing to the fact that the contraction of the posterior urethura in carrying the urine outward expresses more pus than the first flush of urine washes before it. The last glass may also contain prostatic elements for the same reason. Rectal examination must reach the prostate, seminal vesicles and ampullse of the vasa deferentia as any or all these structures are involved at least in secondary con- gestion if not complicating infection. The former lesion may give an almost negative finding or merely softness, succulence and slight tenderness, with increased pus in the test-glass after manipulation. The sulcus of the prostate marking the general course of the urethree through it between the two lateral lobes is usually the point first and most affected. Infection of these structures belongs to the subject of Complications under which it is treated. Termination. — Posterior gonococcal acute urethritis is very apt indeed to become chronic, especially in the marked cases, and therefore to have no stage of termination, strictly speaking. The mild cases, however, last a short time — one or two weeks — and then subside in much the same manner as anterior disease. Pollakiuria, tenesmus and terminal hematuria all gradually subside, likewise sexual excitement, with emissions. The discharge previously decreased in the anterior urethra lights up anew and the urine finally becomes clear except in the first glass, while shreds and slugs are in the second and later glasses derived from the posterior canal. Irrigation of the anterior urethra copiously may so cleanse the lining that all the glasses will be practi- cally clear when the posterior lesion has fully recovered. Complic ations .■ — Complications of posterior gonococcal acute urethritis are noted for their frequency and presence rather than for their rarity and absence, and almost always initiate lesions of chronic tendency, such as urethrocystitis, retention of urine, funiculitis, epididymo- orchitis, seminal vesiculitis and prostatitis. Less commonly the dis- ease extends into the bladder and causes cystitis, ureteritis, pyelitis and pyelonephritis. Absorption of organisms and toxins leads to gono- coccal endocarditis, sjaiovitis, pleuritis and not commonly septi- cemia. The occurrence of complications is due to the complexity and delicacy of the mucosa and its annexed glands and organs in both sexes and to the penetrating destructive characteristics of the gono- coccus and its associated organisms. Variability of clinical features of all such complications requires their discussion in a separate chapter, devoted to the subject of Complications (Chapter II). Preventive and Abortive Treatment. — Preventive and abortive treat- ments are in the strict sense impossible beyond carefid and judicious measures applied to anterior m-ethritis. There is almost always at least a sympathetic congestion of the posterior urethra in every well- 76 ACUTE URETHRITIS established example of the anterior lesion, which leads to mild symp- toms of brief duration, and in practically every severe urethritis the posterior canal becomes acti^•ely involved, usually Avithin two weeks ixnd sonu'tinu's a few days. Curative Treatment. Conservative Method.— *S/«(/f^v. — The usual four periods are noted. The incubation is really in the transit of the infec- tion into the posterior segment of the canal, and is so masked by the anterior symptoms as to be indistinguisliable, and hence beyond defi- nite treatment. The invasion for the same reason is practically absent, although mild irritation about the neck of the bladder is a forewarning and may be regarded as marking this period; but by no means invari- ably because only sympathetic congestion and not infection may be present. Good management alone is the required treatment. The details of management are described in full in Chapter IX, on the General Principles of Treatment (page 483.) Local subjective symptoms, already stated in tlie clinical paragraphs, are temporarily decreased discharge, pollakiuria, dysuria and tenesmus, all due to irritation, and terminal hematuria and sexual emissions, both due to extreme congestion. The irritation and congestion indicate cessation of blennorrhagics and stimulants and return to sedatives, diuretics and neutralizers such as: I^ — Citrate of potash 30 grammes (ounce 1) Tincture of hyoscyamus . . . . 8 to 12 grammes (drams 2 to 3) Fluid extract of kava kava .... 15 grammes (ounce 5) Distilled water up to 240 grammes (ounces 8) Mix, make a solution and mark: One tablespoonful in a half-glass of water two hours after eating and once during the night. When vesical irritation is marked one may order: IJ — Fluidextract of triticum repens .... 45 grammes (ounces I5) Fluidextract of uva ursi 45 grammes (ounces I2) Citrate of potash 15 grammes (ounce ^) Distilled water up to ' . . 120 grammes (ounces 4) Mix, make a solution and mark: One to two teaspoonfuls in a half-glass of water two hours after eating and once during the night. For cases with great pain and disturbance, the following is valuable: I^ — Fluidextract of triticum repens ... 45 grammes (ounces 1 J) Fluidextract of uva ursi 45 grammes (ounces 1 J) Liquor of potash 15 grammes (ounce §) Tincture of opium 4 to 6 grammes (drams 1 to 2) Distilled water up to 120 grammes (ounces 4) Mix, make a solution and mark: One teaspoonful in a half-glass of water every three or four hours as needed, then three times a day, two hours after meals. Systemic subjective and objective symptoms have been stated as intensifications of those in anterior conditions: Anorexia, chills; fever, POSTERIOR GONOCOCCAL ACUTE URETHRITIS 77 depression, prostration, nervous irrita})ility, pallor and worry. "^I'lieir treatment is along general lines of good management, diet and suitable support. Further details are unnecessary. Local objective symptoms are the discharge figured in the i)us in all glasses of the multiple glass test and the findings on rectal examina- tion. Discharge as a subjective symptom properly })elongs under this heading for its treatment. The question of local treatment in pos- terior acute urethritis may be answered as follows : If the disease has followed quickly upon anterior treatment it is well to regard the latter as causative through undue severity or frequency and posterior meas- ures as unwise. If the posterior disease is present at the first visit or arises in the absence of anterior interference it may be regarded as a pathological extension and as an indication of properly selected treatment. Local measures, as hand injections or syringe-and-catheter irriga- tions in the office, are in all cases to be discontinued, and peremptorily must be in severe cases. In mild attacks hand injections may be continued at greatly reduced strengths, but only by very intelligent patients, and the irrigations are preferably boric acid water or normal salt solution for the benefit of the heat. Hydrotherapy is highly advis- able in the form of ice-bags to the perineum and pubic regions, and hot or cold rectal irrigations, with double current tubes, permitting the fluid to bathe the mucous membrane, or with the psychrophore, which applies the temperature only and not the water, or with simple enemata, which the patient takes in small quantities, holds as long as possible while straddling the toilet, and gently repeats several times at each sitting. Such enemata are least advisable, but must be used by patients who cannot afford the rectal tube or psychrophore. Nor- mal salt solution at 105° to 120° F. is best to avoid irritating the rectal mucosa by any method. Hot sitting and body baths increase the decongestion instituted by the rectal hydrotherapy. Opium suppositories, grain | to 1, may be judiciously used in the right type of patient for great pain, otherwise the formula with laudanum is used. Massage and electrotherapy are both contraindicated, but examination of the prostate is advisable every few days in order to detect its earliest involvement, through enlargement, tenderness, tension, edema and the like. Deep instilla- tions of nitrate of silver solution, 1 in 1000 up to 1 in 500, may be applied through a 16 French soft-rubber catheter most gently passed into the prostatic portion. Tenesmus and bleeding may be alarming and severe. Only a few drops should be used, and not repeated unless benefit results. The weaker solution is the better for the first treat- ment. Stage of Decline. — ^This period is as in anterior acute urethritis, that of Nature's success against the disease and the time of local treat- ment, and its management remains the same except that diet may be slightly increased and in the mild, uncomplicated cases the patients may go outdoors, but in the severe cases remain resting in easy chairs^ 78 ACUTE URETHRITIS and in the complicated cases arc still confined to bed. The ingestion of fluids is still alh^wed in sliohtly increasing quantities. Systemic administration is rolietl on to relieve all the systemic subjective symp- toms and most of the local subjective symptoms. Such as are not reached by, these methods are benefited by the treatment of the dis- charge. Blennorrhetics are again used for stinnilant efl'ect, but never to extremes, and always associated with urinary antise])tics as ])reven- tives of infection of the bladder by the irrigation of this viscus. The local treatment is in the form of weak and then slowly increased fornuilas, previously given for hand injections, made first once or twice and then more frequently each day, and in the form of syringe- and-catheter irrigations, preferably in the reclining position, beginning with normal salt solution and boric acid water, then continuing with the milder antiseptics already detailed and ending with the stronger solutions. The urethra is first flushed by urination and then its anterior segment is tlioroughly cleansed, and last a small soft-rubber catheter is very gently passed into the bladder, which is immediately thoroughly irrigated in order to prevent infection and left comfort- ably distended so that the patient washes his posterior urethra with the antiseptic fluid exactly as with urine. After further decline, and with a tendency to indolence, mild and ascending strengths of instil- lations are applied to the deep urethra, always without tenesmus resulting. Nitrate of silver is the choice in strengths from 1 to 10,000 or 1 in 5000, slowly increasing to 1 in 1000 or more cautiously 1 in 500. Failure with these measures forewarns of the chronic period, which is discussed in subsequent paragraphs. Stage of Termmation. — This period in uncomplicated cases under expectant treatment is reached in from a few days to two or three weeks, but in uncomplicated severe cases the chronic lesions appear and persist for weeks or even months. Complications always involve long continuation, and their presence is detected by rectal and urethral exploration, urethroscopy and cystoscopy, and their treatment belongs to su])sequent paragraphs on each separate complication. Complications are fully treated each under its own heading in Chapter II, pages 82 and 106. Retention of urine may be classed either as a symptom or a com- plication, and should be mentioned here. It should be managed by absolute rest in bed, free e^•acuation of the bowels and very light fever diet. Systemically, morphin, with the needle or a Dover's powder by mouth or an opium suppository, in selected cases, is given as an antispasmodic and sedative, and locally heat as a decon- gestant is applied by urethral irrigations of boric acid water, and pro- longed sitting and body baths and rectal irrigations almost always relieve, so that the patient may urinate into the bath water. Instru- mentally a size 14, 16 or 18 French soft-rubber catheter may be passed, with great gentleness, to avoid all spasm, and the bladder emptied, in whole if moderately filled, but in part if much distended, in order to avoid passive hemorrhage from sudden release of pressure. With the POSTERIOR GONOCOCCAL ACUTE URETHRITIS 79 catheter in place the viscus must be irrigated to avoid inf(!ction, using potassium permanganate, 1 in 8000 to 1 in 4000, or nitrate of silver, 1 in 10,000 to 1 in 5000, or one of the newer silver salts, such as argyrol, 2 to 5 per cent. A little of the weak solution must be left in the bladder if the distention was marked, in order to avoid passive hemor- rhage. The catheter is slowly withdrawn, and at the moment outflow ceases its eye is in the deep urethra, where a little nitrate of silver solu- tion, 1 in 1000, may be deposited as a corrector of the edema. Pre- vention of relapse requires repetition of the Dover's powder or supposi- tory, hot pack, baths, rectal irrigations and urethral irrigations, while prevention of onset rests with proper care of the posterior acute urethritis; but the retention may supervene notwithstanding every precaution and measure. Irrigation Method.^ — Cautions. — Undue force of the irrigation may penetrate the crypts of the mucosa, the acini of the prostate with their ducts and the ejaculatory ducts, of which the majority face forward and all are minute and tender structures. Chemical inflammation and positive traumatism even to rupture, similar to the rupture of the urinary bladder by distention, may result, thus causing compli- cations directlj^ Undue frequency, excessive concentration and idio- syncrasy of the patient to the solution may also cause secondary irri- tation and add to the inflammation. It is 'possible to do as much damage with a stream of irrigation as with an instrument — both unskilfully handled. Definition, purposes and preliminaries are the same as in the irriga- tion method in the anterior urethra and vary from this only as to the site. It may be used as a preventive of infection after the passage of instruments, but is probably less advisable than the passing of a soft catheter for the purpose, and is much less convenient than the author's irrigating sounds and similar instruments, which permit the bladder to be filled at the one incursion and before withdrawal. The patient should always urinate in the presence of the surgeon before the irriga- tion. Internal measures are the same as in anterior irrigation, with the detail that blennorrhetics are somewhat more reservedly employed. Local measures are of three kinds: (1) syringe-and-catheter method, (2) Janet-Valentine method, (3) Chetwood double-current method. The application of each has the following restrictions: Syringe-and-catheter posterior irrigation is undoubtedly the safest in the posterior urethra, and is defined by the passage of a catheter into the posterior urethra and bladder f oho wed by irrigation of both parts. Its preliminaries are the standard preparation of the patient, com- plete sterilization of all instrmnents and utensils, evacuation of the bladder by the patient before passing the catheter and irrigation of the anterior canal before the posterior portion is invaded. Its equip- ment is an assortment of soft-rubber, velvet-eye or new smooth wo\-en catheters, sizes 14, 16 and 18, French, a 150 c.c. Janet-Frank syringe (which is preferred to the irrigating jar), a Wolbarst or other basin 80 ACUTE URETHRITIS and assorted towels and similar dressings. Its technic is the passage of the catheter, cleansing the anterior urethra as it progresses and then without the Huid running the posterior urethra and bladder are entered so gently that no spasm occurs. The bladder is filled to comfort and evacuated several times and left filled at the last step. As the catheter is withdrawn the posterior m-ethra may recei^•e instillations or mild irrigation if no spasm is present, and finally it is washed by ha^'ing the patient pass the antiseptic fluid left in the bladder. Force is unnecessary beyond that for filling the bladder, and duration ends with several distentions of from 150 to 500 c.c. always W'ithin toler- ance, and frequency is like that of anterior irrigation, at first daily, then every other day and finally temperature rests on comfort, but ranges from 100° to 120° ¥., by the thermometer. Fluids are the standard solutions and combinations already detailed. Valentine-Janet posterior irrigation^ in the prostatic urethra has the same equipment, preparation, preliminaries and postures as in the anterior treatment. Fully sterilized instruments, utensils and external organs and urination of the patient in the presence of the urologist are basic principles. Its technic requires position^at the side of the patient, irrigation of the penis and external genitals and then tight ap])osition of the nozzle into the meatus, so that outflo\\" is prevented. The force is sloAA'ly increased by raising the irrigator up to a head of six to eight feet as the urethra distends. While the patient breathes deeply and tries to urinate, the fluid is felt to start into the bladder by both the urologist and the patient. Then the force of the fluid should be decreased by pressure on the stopcock and checked before pain. The basin and nozzle are now removed and the patient's genitals dried. He then passes the contents of his bladder into test-glasses, either sitting or standing, at once or after waiting, according to the presence of infection in the bladder. Duration is only to fill the bladder with from 150 to 500 c.c, once or several times, according to the condition of the organ and irritation and tolerance. The latter increases with experience in the patient and gentleness in the urologist. Temperature rests on the same basis, varying from 100° to 120° F., by the thermometer. Fre- quency begins with once a day and then every other day, and at each treatment several distentions of the bladder are possible imtil the return flow is clear of pus, when a final distention is left for evacuation. Spasm is usually overcome by starting with a fully empty bladder, reducing the force of the stream, diverting attention of nervous patients and using the reclining position. The fluids are the duplicates of formuUe previously described. Chetwood double-current posterior irrigation shows no changes in the deep m-ethra from that in the anterior portion as to all the preliminaries discussed under that subject. Sterilization of all instruments and utensils and passing of the urine in the urologist's office are axioms. Force from an elevation of the irrigator, six to eight feet, is necessary ' Loc. cit. POSTERIOR GONOCOCCAL ACUTE URETHRITIS 81 and the technic is the same as in the Valentine method, with the added advantage of the double current cut-off, with which the fluid is applied to the sphincter muscle until the bladder is filled with small quantities at first and then with larger supplies up to tolerance, and always with gentleness to avoid spasm. Final details, such as duration, temperature, frequency and repetitions, are the same as in the other procedures. There is no change from the standard fluids designated in earlier paragraphs. Aftertreatment and cure are the same in posterior gonococcal acute urethritis as briefly noted under the heading of Anterior Gonococcal Acute Urethritis (page 70) . Further note is therefore here unnecessary. Treatment of Nongonococcal Urethritis. — The brevity of this subject in this work, owing to the fact that gonococcal urethritis is presented as the typical inflammation in all its phases, has made it advisable to consider the treatment of nongonococcal urethritis of both acute and chronic forms after the treatment of gonococcal chronic urethritis as part of Chapter IV. CHAPTER II. COIMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS. General Considerations. — Anterior and posterior acute urethritis have acute complications which possess distinct tendency to become chronic, owing to the coniplexity and dehcacy of the organs and the destructive and penetrating faculties of those organisms which commonly provoke the severe infections, notably the pyogenic and gonococcal forms, in pure or associated culture. On the other hand, complications may arise in any of the other nongonococcal urethrites in patients of lowered vitality and with intense invasion. Complications are also not uncom- mon in relapsing nongonococcal disease, such as catarrhal and diathetic, while they are very common indeed in relapsing gonococcal acute urethritis. General Clinical Features. — In all acute complications of acute urethritis of any origin whatever the clinical characters are much the same according to the special part involved. Inasmuch, however, as gonococcal acute urethritis is most prone to develop the complications, and as their symptoms are the most t^Tpical and severe, it is best to regard them as the standard of comparison for the other forms. The best is the clinical classification into acute and chronic as to course, and anterior, posterior and anteroposterior as to location. The chronic complications belong to the subject of chronic uretlu-itis, hence only the acute forms will be considered in this chapter. I. COMPLICATIONS OF ANTERIOR GONOCOCCAL ACUTE URETHRITIS. Varieties. — Two general subdivisions are recognized: (a) local, affecting the urogenital organs alone, and {b) systemic, affecting the body at large. In anterior acute disease systemic complications are rarely seen, are somewhat more common in posterior acute urethritis and still more usually occur in anteroposterior chronic urethritis. For this reason they will be discussed as essential to posterior lesions rather than anterior disease. The local complications had best be arranged in their anatomical order, and in the nature of things are only sexual and urinary in their location. They are: ])himosis, ])arai)himosis, lymphangeitis, lymphadenitis, littritis, folliculitis, cowperitis with reten- tion and co\\'peritis without retention. Complications in the sexual, urinary or general systems arising cephalad to the triangular ligament are considered under posterior urethritis (pages 115, 201), PHIMOSIS AND PARAPHIMOSIS 83 A. Urogenital Group. 1. Sexual Forms. PHIMOSIS AND PARAPHIMOSIS. Definition and Etiology.^ — Phimosis and paraphimosis are two compli- cations which are caused by a long and a tight foreskin. Redundant prepuce leads to balanitis and balanoposthitis, while the tightness adds phimosis and irreducibility of a retracted tight prepuce causes paraphimosis. In all these three the inflammatory lesions are much the same. Symptoms.^ — The subjective symptoms of phimosis are ardor urinse within the cavitv of the foreskin and not the course of the urethra, often Fig. 16. — Method of reduction of reducible acute paraphimosis, showing position of foreskin and glans, respectively, witliin the grasp of the fingers and pressure of the thumbs. (Taylor.i) with "ballooning" of the foreskin, due to back pressm-e during m-ination. Pain in the foreskin and glans is due to excoriation of the lining, reten- tion and decomposition of urine, pressure of the edema, tension during erection and irritation by contact with clothing and fingers. Objec- tive symptoms of phimosis are tenderness over the glans penis away from the course of the urethi-a, generalized over the whole glans and the foreskin and not localized as in chancrous phimosis. Retractible foreskin reveals a tj^jical balanoposthitis, with redness, excoriation, maceration, edema and sometimes lymphangitis, everywhere distrib- uted and a discharge which wells up from the recesses and folds about the corona and is therefore distinct from that which oozes from 1 Loo. cit. S4 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS the uivtlira. lrrotra(.'til)k' foreskin rt'ciuiri's dilatation of the outlet and eavity with a thive-])hide nasal spt'cnhnn and illumination with a urethroseopie lamp or examination ^\■ith a Chetwood urethroscope, and will show much the same features. The edema, as a rule, is local- ized to the foreskin and solans and not to tlie penis as a whole; excep- tionally, however, the edema is generalized throughout the penis or a large })art of it. Lymphangitis may often be traced along the dorsum and sides of the organ into the groins, where lymphadenitis may be present, both with moderate tenderness. rarai)himosis is regarded as of two varieties: acute reducible or without gangrene, and acute irreducible or with gangrene. The reducible form is characterized by enormous infiltration of the foreskin with serum, so that it retracts beyond the glans and remains in this situation as a rather imiformly distributed mass of edema without any pressure or necrosis. The irreducible tyj)e is characterized by a definite fibroelastic band of tissue, not unconunonly constituting the original outlet of the redimdant foreskin, which when passed beyond the glans is normally sufficiently tight to constrict, and to set up edema of the parts distal to it, and thereafter through the pressure of both the band and the edema to cause localized ulceration and gangrene. Rarely death of the glans in part or whole is seen. The objective symptoms are that the retracted foreskin constricts the corona. The pressure leads to congestion, lividity and edema of the glans and then of the constricting band. Ulceration, as a rule, occurs only in the foreskin at its tightest point, so that Nature's tendency is spontaneous di\ision of the fibers and release of the glans. Reten- tion of urine, except reflexly, does not occur. Beneath the folds of the foreskin, and especially within the pocket behind the constriction, a characteristic retention pus is secreted, produced by balanoposthitis. The characteristic organisms of this pus decide the nature of the infection. The subjective symptoms are the pain due to the constriction, inflammation, and retained pus and fear through the unnatural, severe congestion, lividity and swelling of the glans. Diagnosis. — Phimosis in its history presents the acute swelling, irretractible foreskin which was previously retractible, and in chronic cases a foreskin which could never be reduced in which inflammation is persistent or acutely apparent. Paraphimosis in its history is never chronic, always acute, but may appear during a chronic ureth- ritis with acute exacerbation. Subjective symptoms are chiefly those of the balanitis, posthitis and balanoposthitis, which are discussed under the next heading, and their origin in urethritis, ulcers or trau- matism may sometimes be described by the patient. Objectively the condition of the foreskin and its lining is demonstrated by the palpation and inspection, with or without meatoscopes or urethroscopes, within the cavity of the foreskin, if irretractible. Laboratory findings are most important and must demonstrate the gonococcus from within the urethra and the cavity of the foreskin recovered from the latter, with PHIMOSIS AND PARAPIIIMOHIH 85 the platinum loop and endoscopic tiihc, at points of maceration or excoriation of the modified skin. Other organisms causinjf this com- pHcation must be excluded. The importance of laboratory findinjijs is most emphatic in all cases, and more so in the extragenital complications, arul must include in bacteriology smear, culture and animal inoculation and in hematology the various fixation tests, of which two are recognized, syphilitic and gonococcal, with tuberculosis in the course of development and j^rob- ably those of other diseases to be added later. Fig. 17. — Author's case of phimosis due to advanced cardiorenal disease. This patient was in the last stages of cardiovascular and renal disease with marked edema of both lower extremities and the lower half of the abdomen. The penis was phimotic and the scrotum was enlarged by edema to three or four times its natural size. Marked balanoposthitis was absent. On account of ob'\'ious intraabdoniinal pressure and muscular atony the truss was not removed for the photograph. In diagnosis treatment must result in prompt relief of the balano posthitis independently of the urethritis. The following subjects further clear up the differential diagnosis : Clii'onic phimosis presents frequent acute attacks, and finally the persistent or relapsing condition resting on anatomical defect or such diseases as diabetes. The symp- toms are usually a thickened irreducible skin, with cracks and fissures 86 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS about the opening. The anatomical defect may be the only symptom in patients who have escaped inliammation within the foreskin. Treatment of Gonococcal Acute and Chronic Phimosis.- Thimosis and l)arai)liini(»sis arc in their signiticance usually minor comi)lications, but may become major by existing lymphatic and other sequels. Prevention is circumcision, a racial custom in a large portion of the human faiuily aiul indicated whenever there has been repeated non- gt)n()C()ccal balanitis, which ])roves an easily ali'ected modified skin lining the foreskin anil covering the glans, and whenever the ])himosis is a real congenital defect and whenever paraphimosis has occurred. Abortive treatment consists ()nl>' in energetic measures at the earliest sign of swelling or discharge of the same kind as curative treatment. Curative Treatment. — Curative treatment is synoinjnous with symp- tomatic and is interested in the ardor urinoe, ])ain, tenderness, edema, inflajnmation, retractibility and irretractibility of the foreskin. Cleanliness, rest in bed, continued attention to diet and drink arc the management and a\'oid any increase in the inflammation. Preputial Fig. 18. — Author's subpreputial irrigation (original.) The putieut is draped in the standard method (Fig. 1.5) and then a female silver catheter mounted in the Valentine cut-off is passed under the foreskin of the penis, held for cleanliness and against all splash in gauze, while the high head of fluid l)alloons and washes out the prepuce into the Wolbarst basin. irrigations, hot penile baths, and when the foreskin is again retractible, hot washings are included under hydrotherapy for the infection and its result. The author's method of irrigating the foreskin is shown in Fig. 18, and will be found most efficient with the usual antiseptic, astringent and stimulating solutions. Its technic is fully detailed on page 97, under the treatment of Balanitis. The means are irrigations and hand injections, with the subpreputial syringe with a long tip (Fig. 7, D and E), with exactly the same drugs as employed for urethral treatment, .such as hot potassium perman- ganate, 1 in 4000 to 1 in 1000, which in the author's opinion is the best of all for the foreskin, or nitrate of silver, 1 in 5000 to 1 in 2000, or w^eak bichloride of mercury, 1 in 5000 to 1 in 2000. Medicinal measures in astringent and antiseptic fluids at first twice, then once, daily using from a half to a whole gallon each time. If the foreskin is PHIMOSTS AND PARA PUT MOSIS 87 irretractible it is tlic only means avai]a}>l(; aided by hand injections by the patient in the intervals, using only the long, soft-rubber or glass- tipped syringe for the foreskin. If the foreskin is or becomes retractible the glans may be painted with nitrate of silver solution, 1 in 250 to 1 in 125, every day, and the penis soaked in a tum})ler of hot perman- ganate of potash solution, 1 in 4000 to 1 in 1000, all according to reac- tion; or wet dressings every two to four hours of aluminum acetate, black wash, bichloride of mercury, 1 in 5000, or lead and opium wash are serviceable against edema and a tendency to cellulitis. Relapse is guarded against by careful washing, dressing and powdering of the glans and foreskin during the rest of the urethritis. A good powder is the following: I^ — Thymol iodide, Boric acid, Bismuth subgallate equal parts Mix, make a fine powder and mark : Apply locally three times a day, washing the old powder off carefully each time. Surgical measures are nonoperative and operative. Among the nonoperative means are the irrigations and applications through the short urethroscope or meatoscope already spoken of. The operative step is circumcision performed by the following technic: Circumcision should be accepted as a preventive in every male, and in the selection of case is applied to all rebellious cases of chronic phimosis. The instruments and supplies include a phimosis clamp, scalpel, scissors, forceps, hemostats, ligatures, needles and dressings and the prepara- tion of the field is irrigation and washing with soap and water and of the patient is for a minor operation under local anesthesia in most adults and adolescents and general anesthesia in small children. The posture is supine and the glans is the one landmark, and must not be injured. It is protected by stretching the foreskin after anesthesia so that it may be retracted and its relation with the glans determined, which in children is often that of adhesion, requiring freeing. There are two methods, the clamp and the open. In the clamp method, the clamp is applied in the middle line, slightly obliquely, in order to spare the frenum and give a good posterior flap. The incision is made either distal to the clamp or, as the author prefers, proximal to it, drawing the foreskin forward, dividing it, layer by layer, and catching each prominent bloodvessel before it is divided, spm'ts, retracts into the cellular tissue and starts a hematoma. One side at a time is thus divided from the outer to the inner skin. When the foreskin is ablated all bleeding is stopped, the inner flap trimmed if necessary and then the edges are sutured with fine silk or horsehair in the adult, but fine catgut in the child, beginning by uniting the freniun with raphe and then the midpoints on the dorsum. These sutures are left long and held by the assistant to support the organ in the vertical position and appose the cut edges for the other stitches, placed every quarter-mch with great care not to infold. The dressing is a wick of iodoform gauze held against the suture line by the long ends of the stitches tied over it. 88 COMPLICATIOXS AXD SEQUELS OF ACVTE URETHRITIS Tlu' (>]>eii mt'thod omits tlio daiii]). and after all the f()ivji;()in»>' pre- liminarios makes a dorsal inc-ision to the corona and then trims and removes the two flaps down to the frenum. The other steps of the o])eration dnplicate those already given. The innnediate aftertreatment is to inspect for abont an honr for bleeding and hematoma and to kee]) the organ sn])i)orted on cotton and ])roteeted from the weight of bed-clothing. In children the application of boric acid ointment prevents wetting the dressing with urine. The adnlt should be directed not to soil the dressings in any way. If the case is ambulant, a ])ad of cotton is ])laced n])on the abdomen to receive the ])enis and another upon the penis itself, and over all a well-fitting prize-fighter's cotton trunk is worn. In order to urinate the patient must remove and then replace this dressing. The remote aftercare allows the catgut stitches in children to dro]) away, but the silk or horsehair in adults to be cut out on the seventh to the ninth day and suitable stimulating dressings to be applied to granu- lating spots. The glans often remains extremely sensitive for many weeks in adults and must be soothed with ointment and cotton. Cure in nonoperative cases is the relief of the edema and infection and the restoration of retractibility of the foreskin, which is always possible except in cases of congenital abnormality. The cure in operative cases should show a penis with the glans fully exposed but with the stump of the foreskin not tight but slightly loose behind the corona without cohering the same. Treatment of Gonococcal Acute Paraphimosis. — K^ignificance, usually of minor importance, occasionally major through ulceration and local gangrene. Prevention directs no attempt at retraction of the foreskin when either it or the glans has been obviously inflamed and suggests prom])t and proper attention to a phimosis so that the paraphimosis will not develop. Immediate replacement of a retracted foreskin, showing constriction back of the glans, with swelling and edema, is the only abortive measure, and is done by massage, as shown in Fig. 1() and the following paragraphs: Ciirafire Treaiment. — Curative treatment requires cleanliness, rest in bed, with the penis supported, and nonirritating diet and drink as the hygiene against increasing any of the factors of inflammation and ulceration. Decongestion is found in hot antiseptic penile baths and hot sitting baths among the physical methods, and digital reduction of the deformity is the massage of these cases. Local wet dressings of hot lead and opium wash, aluminum acetate or bichloride of mercury, 1 in 5000, for sedative, antiseptic and astringent effects, introduce the medicinal measures. Early cases may be reduced by massage in the following nonoperative surgical procedure: edema is gently pressed from the glans and foreskin, so that each becomes soft instead of tense. Acupuncture of the foreskin, with a needle under antiseptic precau- tions, may be necessary for the evacuation of serum. The two thumbs are then placed against each other for support on the glans while the two index and middle fingers seize respectively the dorsum and venter BALANITIS, POSTIIiriS AND BALANOPOSTHITIS 89 of the penis well back of the constricting band. By j)iishing the glaris into the ring of the paraphimosis and pulling the ring over the glans at one and the same time, a coordinated motion of thumbs and fingers toward one another, the paraphimosis will often be reduced. The con- stricting band must finally be felt free of the glans in the foreskin in front of the meatus. An antiseptic wet dressing should be used immediately after successful restoration, also subpreputial irrigations and hand injections. Older and irreducible cases require operative measures after a local anesthetic of cocain, novocain, stovain or their analogues injected into the midline of the dorsum above and through the constricting band, and after sterilization of the ulcer with tincture of iodin, the band is divided, layer by layer with a scalpel until it is fully cut through and the tunica albuginea is seen at the depth of the wound. Such incision is usually three-quarter inch long and permits immediate restoration of the parts, followed by wet dressing. The dorsal vein of the penis is sometimes cut in this operation and will bleed unduly unless ligated. An equally good technic is to buttonhole the skin in the normal zone above the constricting band and then pass a blunt grooved director down to and along the tunica albuginea and beneath the band so far as the corona glandis. Upon the director the band is then cut through in its entire thickness and breadth with one stroke of the knife. The author prefers this method because the director isolates and retracts the band away from the body of the organ. A wet dressing is again the immediate aftertreatment, which is con- tinued on surgical lines until the little wound is healed and the remote aftertreatment is summed up in the toilet of the foreskin against return of the paraphimosis and in circumcision as permanent relief of the underlying and resulting deformity. Cure requires recovery from the infection and gangrenous ulcer without any or much deformity*. Reparative measures against unsightly flaps complete the case. BALANITIS, POSTHITIS AND BALANOPOSTHITIS. Defiiution. — The glans is covered with and the foreskin is lined not by mucous membrane, as formerly supposed, but by modified skin which is capable of infection and inflammation, When the glans alone is affected the lesion is known as balanitis, and when the foreskin is chiefly involved the term posthitis is used, and finally when the inflammation is generalized it is called balanoposthitis. Varieties. — The following types may be distinguished: (1) as to site, balanic and posthic as localized and balanoposthic as generalized; (2) as to course, acute, subacute, chronic and relapsing; (3) as to foreskin, retractible and irretractible ; (4) as to degree, mild, marked and severe; (5) as to infection, suppurative, croupous or diphtheritic, syphilitic, chancroidal, gonococcal, diabetic and herpetic. Distinction as to the course, retractibility of the foreskin and form of infection is 90 co^[PLICATInxs axd sequels of acute urethritis iniportant. aiul this work is c(»iicenie(l with the gonococcal, whicli is taken as a type. Etiology.- — Etiok^gy is predisposing and excitinu'. 'i'he i)redisposmg cause is peculiarity or defect of the foreskin sunnned up in ])hiniosis and deficiency, riiiniosis with its lonji' or redundant, straight or angulated, tight or flaccul, small or strictured outlet and deficient or elongated freniun, imprisons the normal smegma in its folds, stimulates its decomposition and invites infection from any source, so that in gonococcal in^•asion the ]>us from the urethra easily travels into the recesses and produces characteristic inllammation. A deficient fore- skin may by exposure to irritation also predispose. Traimia in causing loss of epithelium is an important predis])osing cause, such as arises during excessive coitus, masturbation and the friction of warts within the foreskin. Intercourse with a woman having too small genitals for the penis of the man acts in the same M'ay, and the acridity of leucorrhea and of the normal vaginal secretion just before, during or just after the menses may also prepare the modified skin for infection. The exciting cause is therefore penetration of any organism into the fa^•orable soil tlnis prei)ared, or in virtue of the decomposition of smegma the change of organisms normally present, from innocuous to nocuous types, occurs. According to the variety of organism gaining access the t^pes of disease are recognized. The pyogenic germs evolve suppurative, the gonococcus, gonococcal; the Treponema jxtUidum, syphilitic; the bacillus of Ducrcy, chancroidal; and the decomposition and infection of sugary urine diabetic balanitis. Herpes progenitalis may cause active lesions in the same manner as chancre and chancroid. Pathology. — All ages from infancy to advanced life have the same essence of process, which is infection of the modified skin of the glans and foreskin, with suppurative, gonococcal, sj'philitic, chancroidal and diabetic inflammation. The temporary lesions are the commonest and comprise superficial desquamation or erosion and ulceration in accordance with the activity of the process. In the suppurative and gonococcal lesions, ulcers are relatively uncommon, but are the nature of the chancre in sj^hilitic and of the soft venereal sore in chancroidal disease, and are by no means rare as gangrene in diabetes. Permanent lesions are absent except as the scars of deep erosions in the violent suppurati^'e and gonococcal cases and of chancres, chancroids and gangrene. The associated lesions do not occur in suppurative and gonococcal balanoposthitis unless -extreme, but in syphilis the systemic pathology of the disease may be already present or soon appear, and in chancroid an active hinphatic involvement may be present and in diabetes gangrene of the foreskin. The complicating lesions are usually h-mphangeitis and lymphadenitis. These may be absent or very marked. In suppuration and gonococcal disease of the foreskin and glans they are rare — if marked, then a mixed or associated infection must be looked for. In syphilis the vessels are cordlike and the glans indurated, discrete and movable and in chancroid the vessels are inflamed and tender and the nodes indurated, matted and fixed to the BALANITIS, POSTHITIS AND HALANOPOSTIIITIS 91 skin and deeper parts. Abscess of the glands is not uncommon in chancroid. Diabetic gangrene may have much the same complications. Herpetic lesions show the papular, pustular or ulcerous spots, imJivifiu- ally or collectively, with tlie other signs of .balanitis and posthitis. These lesions are all mild and temporary. According to the tyi^e of disease, the infecting organisms are regularly: the normal flora of the foreskin (evolved to vicious activity), the gonococcus, the Treponema jjallidum, the bacillvs of Ducrey and a variety of organisms in decomposing dia- betic subpreputial deposits. No definite organisms are identified with herpes. Symptoms. — These vary with the degree of the disease and not mate- rially with its distribution as balanitis, posthitis or balanoposthitis, and are purely local because in the strict sense subjective and objective systemic signs are absent. Exceptions to this rule are manifestations of the constitutional disease in syphilitic and diabetic patients and of active general absorption in chancroidal and gonococcal infection. Symptoms of the invasion, establishment, termination and complica- tions are seen. The period of invasion is usually very mild in the simple cases and masked by the gonococcal urethritis in this form of balanitis. If present in this period at all the signs are extremely mild and of the same kind as in the establishment of the process. The local subjective symptoms in gonococcal balanitis are more violent than in the simple suppurative form, but the former is the more common and directly in our interest. The chief complaints are sensations and discharge. The sensations vary among itching, pain, burning, feeling of foreign body under the foreskin and desire to rub or pull the foreskin about. These sjTnptoms are known by the intelligent patient not to be in the urethra, because they continue after the urethra has been cleansed by the act of m-ination. In retractible foreskin, the discharge is noticed only from the folds and not from the urethra, and in irretractible fore- skin it appears on pressme on the prepuce rather than on the urethra, after the canal is freed of gonococcal pus by urination. If erosions and superficial ulcers are present the patient wall often seek advice for these after neglect of the stage of discharge, on the theory that he has chancres or chancroids. The local objective signs are determined by the degree of the attack, being few in mild, many in marked and many and severe in extreme cases. I. Cases ivith Retractihle Foreskins. — ^The glans alone or with the foreskin in part or whole is red, glistening and edematous in mild cases and early stages of severe forms. ^Maceration, desquamation and erosion in spots, large areas or miiversally mark further progress. Vesicles and pustules are frequent, which break under retraction of the foreskin and simple cleansing of the parts, leaving behind erosions or ulcerations at their bases. The discharge is either characteristic of gonococcal urethritis or modified by the addition of the balanitis and foul smegma. It is milky and has a disagreeable penetratmg odor, regarded as diagnostic of the simple cases. Gonococci are present in 92 CO^[PLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS the (Iiscliarc:e combined with the organisms of sui)piiration, catarrhal itiHanimation ami of the normal flora of the i)repiice. The discharge wells up from the folds of the foreskin and especially back of the corona. Severe types are the extremes of the disease and occur in patients with ])oor health and without resistance to disease and in l)ersons witli uncleanliness from hal)it or occupation. Tlcerations may extend like ami must be distinguished from chancroid and ncoi)lasm, and the lymphatics may be involved in acute inflammation of ^-essels and glands and even inguinal abscess. II. Cdfieft with IrreirariihJe Fnrcshin. — Inspection of the jiart is possible only with urethral specula, of which none is more convenient than the Skcne-Folsom, short Chetwood or Buerger. The outlet of the foreskin is dilated with the blades of the Skene-Folsom speculum and its cavity illuminated with a lam]) and head mirror or a urethro- scopic lam}) and the i)us carefully wi])ed from the urinary meatus. Pressure on the foreskin then brings into the field \()lumes of pus which do not come from the urethra. The Chetwood or the Buerger urethroscope may now be inserted to the corona for determination of the other conditions described. In both forms of the disease, ])alpation of the foreskin and glans is usually very painful, in(lei)endently of the urethral inflammation, of Avhich the balanoposthitis is a complication. When these special instruments are not at hand the following procedure serves: A pledget of cotton may be inserted into the meatus in order to retain the gonococcal pus of the urethritis, after having cleansed the tip of the glans, as seen through the opening of the foreskin, (lentle pressure upon the penis back of its head and away from the urethra will always bring away pus into the field, which obviously cannot come from the urethra on account of the plug of cotton which is then removed. The stage of termination in gonococcal balanitis is not as well marked as in the simpler forms, because masked in exactly the same way as the invasion. It may be said, however, the subjective symptoms decline and sensations of the balanoposthitis slowly merge into those of the persisthig urethritis if this is acute, but if chronic then the distinction between the two processes is marked. The objective symptoms also disappear. The discharge lessens and rapidly ceases under cleanliness, dresshig, drainage and treatment, so that again only the gonococcal discharge from the urethra is present. Erosions, desquamation and maceration of epithelium soon heal, leaving normal modified skin. Ulcers heal more slowly and leave scars of various number, size and depth behind. If severe complications have been present in lymph vessels and glands these will heal slowly also. Full reccnery is the rule without permanent damage in the gonococcal and sui)])urative types. But in the ulcerating lesions, such as chancroid and chancre, and in diabetes, destruction of glans and foreskin may be extensive. The symptoms of the course and terminaticm of the other forms of balanitis have l)een sufficiently discussed under the subjects of ])himoses of the same varieties — namely, s}i)hilitic, chancroidal, diphtheritic and diabetic. BALANITIS, POSTHITIS AND BALANOPOSTIIITIS 93 Complications. — Complications of gonococcal balanitis occur less frequently tlian with the ulcerating forms and are of the same types as follow: Phimosis and paraphimosis are not only causes hut also complications or sequels of balanitis, and a careful history of the case alone distinguishes the onset. Lymphangitis is usually indolent and cordlike, but may be active and tender, and lymphadenitis may like- wise be subacute and scarcely painful or acute active and painful, with outcome in abscess. Cellulitis of the skin sheath of the penis in whole or part as a universal or localized inflammation may follow the lymphatic involvement or occur more or less without it. The gono- coccal urethral lesions from which the balanitis proceeded are associated rather than complicating lesions. Gangrene arises in diabetic balanitis and is worthy of separate note. On this point Taylor^ says: "Not infrequently, particularly in uncleanly persons, in diabetics, also in those debilitated by disease or excesses, gangrene of the prepuce occurs from balanitis. Owing to the inflammation of the parts and the swelling of the glans, a black spot forms about the middle of the prepuce and through the buttonholelike opening which results, the glans protrudes." That which is said concerning the lymphatic system of the penis in the following paragraphs under the subject of lymphangitis and lymphadenitis applies to all these foregoing conditions and these anatomical facts should always be borne in mind. Diagnosis. — Balanitis, posthitis and balanoposthitis are lesions diflFer- ing from each other simply in distribution as noted in the definition of the acute and chronic forms in their appropriate sections on pages 89^97. Balanitis is limited to the glans penis, posthitis to the lining of the foreskin and balanoposthitis to both regions combined. Dis- tinction between the acute and the chronic form is one of activity of pjrocess and history, because the diagnostic procedures are the same for each. The history acknowledges any or several of the following causal elements: Phimosis, paraphimosis, excessive or unnatural inter- course or union with a woman having undeveloped external sexual organs, acute or chronic urethritis especially with relapses, and indo- lent sore suggesting syphilis or a more active ulcer indicatmg chan- croid, warts with their irritation and discharge, and perhaps pruritus of the genitals common with diabetes. The subjective symptoms concern the degrees of itching, burning and discharge, primary or secondary to any of the foregoing causes and, especially for our pur- poses, to acute and chronic gonococcal infection or otherwise conse- quent upon sores, warts and sugar in the urine. Presence of the gonococcus may be an intercurrent factor and not either exciting or complicating the lesion. The objective signs determine the source and bacteriology of the discharge and its effect on the cavity of the foreskin and settles the relation of possible etiologic data as just 1 Loc. cit., p. 246. 94 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS stated. The treatment of the case is of vahie in setting apart from each other the various recognized forms, most especially the s>'philitic, chancroidal, true diphtheritic and diabetic. Differential Diagnosis. — The diiVcrential diagnosis contains the history of anlor, pain antl tenderness only about the foreskin and glans and not within the urethra and in showing only the first glass of urine slightly turbid. Posthoscopy shows the cavity of the foreskin alone to be involved and the urethra to be normal. Differential diagnosis of the varieties of Ixilanitis from our chief sub- ject, gonococcal manifestations, must include suppurative, diphtheritic, syphilitic, chancroidal, diabetic, papillomatous and cancerous disease. Siippurniirc differs from gonococcal baJcmifis iu its history of frequent, often unexplaincnl attacks or otherwise origin from sunple causes; in its freedom from the gonococcus and abundance of catarrhal or sup- purative organisms; in its subjective symptoms often mild, simple and brief and independent of urethritis or its complications and sequels; in its objective signs of chiefly redness and edema, rarely excoriations, and of pus from the folds of the foreskin and not from the urethra; in its prompt and complete response to simple cleanliness, antisepsis, stimulation and dressing; and finally in its termination in full recovery as the rule with rare exceptions and without persistence of urethral lesions thereafter. Diphtheritic or croupous diff'ers from gonococcal balanitis through its record of no gonococcal disease but of infection of a wound or opera- tion on the foreskin or of involvement during acute systemic disease or its prolonged convalescence, such as scarlet fever, measles, small- pox, diphtheria, typhoid and the like; in its subjective symptoms of severe reaction to operation and intense involvement of the cavity of the foreskin showing severe pain, bleeding and discharge and in its objective signs such as scales and flakes of false membrane w^hich are shed from the surface of the glans and lining of the foreskin with absence of the gonococcus but presence of the bacillus of diphtheria or other organisms; in its response to antidiphtheritic sermn as treat- ment and to other active antiseptic measures and finally in its termina- tion without the persistence of urethral lesions of gonococcal nature and at times with the sequels of diphtheritic infection. In typical cases the membrane is the duplicate of that seen in diphtheria of the throat, grayish- white or reddish-white in color, leaving ulcers behind and haA'ing tendency to early involvement of the inguinal glands exactly as the cervical glands are comprised in lesions of the throat. Syphilitic diff'ers from gonococcal balanitis in its acknowledgment of slow invasion in the third to the sixth week of chancrous and the sixth to the twelfth week of macular and papular lesions of the second stage; in its subjective symptoms of comparative painlessness and unimportance until the discharge appears as chief complaint; in its objective findings of no gonococci, of a chancre or papule seen under or felt through the foreskin with the Treponema pallidum; in the foul- smelling serous or serosanguineous discharge and tissue and of other BALANITIS, POSTHITIS AND BALANOPOSTHITIS 95 signs of syphilis, such as characteristic lymph vessels and glands, generalized rash of the skin and moist papules of the mucosae and positive Wassermann test; in its prompt response to local and sys- temic antisyphilitic measures of treatment and finally in its termina- tion at the same time as the other signs of syphilis, if present, or mer- gence with them at their appearance as part of the general syphilitic process. Balanitis may appear in the stage of erythema in the very early secondary period or in the gumma of the tertiary period. Mani- festly retractible foreskins permit a prompt and accurate diagnosis while irretractible ones limit examination to palpation and inspection through a speculum. The varieties of a chancre described by Taylor^ must not be for- gotten: Chancrous erosion, silvery spot, dry papule or patch, umbili- cated papule or nodule, purple necrotic nodule and ecthymatous chancre as typical forms, and ulcus elevatum, multiple herpetiform chancre, parchment chancre, annular chancre, indurated nodule or mass, chancre with cream-green membrane and infecting balano- posthitis as atypical forms. As a source of error the infecting balano- posthitis is highly important but usually shows at one or more points diagnostic infiltrations of syphilis. A section, however, of every sus- pected lesion must be sent to a pathologist. Chancroidal differs from gonococcal balanoposthitis in soon after intercourse giving a history of active ulcer, neglected until pain and discharge appear; in its subjective symptoms of pain, bleeding, acute discharge and early involvement of the inguinal glands, with, on objective examination of the retracted foreskin, a characteristic soft venereal ulcer, containing the bacillus of Ducrey and without urethri- tis unless the chancroid is at the meatus, and then without gonococci and with early acute tender involvement of the inguinal glands and penile vessels; in its rather slow response to treatment with tendency to extension and autoinoculation even during applications and finally in its termination in excavated deforming scars of glans and foreskin and not uncommonly in abscesses of the groins. As stated in the previous paragraph on syphilitic balanitis, cases with retractibility of the foreskin permit immediate diagnosis while those with irretract- ible phimosis render the process much -more difficult. In the late untreated cases signs of pus in the lymph glands of the groins are important — namely, redness, glossiness, edema, fixation of the skin, swelling, tenderness and tension or fluctuation of the glands. Diabetic differs from gonococcal posthitis and balanitis in its knowl- edge of sugar in the urine with absence of gonococcal or other urethral lesion, except at times diabetic urethritis; in its subjective symptoms of severe itching like the pruritus of the genitals and anus which often precede it with sometimes glycosuric uretliritis; in its objective signs of acetone breath, sugar in the lu-ine, lividity, excoriation and exfolia- tion of the epithelium in the discharge which contains decomposing ^ Genito-urinary and Venereal Diseases, 3d ed., p. 500. 9(> COyfPlJCATIOXS AND SEQUELS OF ACUTE URETHRITIS sine<];ma and niicrooriranisms. witli toiulency to ulcer, j>;angrene and verruca; in its benefit throuiih relief of sugar in the urine and local cleanliness and finallx' in its termination in recovery or a severe gan- grenous sequel or in its relapses with every return of sugar in the urine. In doubtful cases, having no sugar in the urine, hematological exami- nation will reveal its accumulation in the blood where sugar is patho- logicall\' present before it appears and after it disappears from the urine. PaplHoniatous or warty differs from gonococcal bah no posthitis in the notice by the patient of warts ]ircceding the condition, of almost total absence of pain and inflainmation. Objectively the condition is purely a mechanical irritation of the parts into a catarrhal inflamma- tion. Retraction of the foreskin at once reveals the diagnosis, as will posthoscopx'. Edema is usually absent unless the inflammatory change has been profound. The discharge is mucoserous or mucopuru- lent and contains no organisms of syphilitic, chancroidal or gonococcal infection unless in the last instance the papillomata complicate a chronic urethral lesion. Cancerous differs from gonococcal haJanoposthitis in that it is pre- ceded liy the typical induration and ulceration of epithelioma and followed by the usual infiltration and fixation of the mass and the lymph vessels and lymph glands in relation to it. Inflammation is relatively little excepting in the ulcer itself. The discharge is sanious, fertile in the products of the ulcer but barren in the special organisms already mentioned. A section is the final diagnostic aid. Cardiovascular differs from gonococcal balanopost Iritis in that it is secondary to disease of the heart, vessels and kidneys, being accom- panied by pronounced edema of the lower extremities and sexual organs, which produces a manifest phimosis. Extreme cases of this condition are at times seen. Inflammation of the foreskin is relatively little in most cases. The discharge would necessarily be mucus, serum or mucoseruin and devoid of any infectious organisms. Exami- nation of the heart, bloodvessels, liver, lungs, kidneys and urine immediately clears the diagnosis (Fig. 17). Chronic Balanitis, Posthitis and Balanoposthitis are invohed like phimosis with frequent attacks of any of the foregoing forms and their causes until at last a persistent or a relapsing inflammation is established. The symptoms are those of infiltration, excoriation, fissure and discharge. The features of the various forms just described need not be repeated. When the foreskin is irreducible examination with the meatoscope or the urethroscope reveals these lesions. Treatment of Gonococcal Acute and Chronic Balanitis, Posthitis and Balanoposthitis. — These lesions are in their significance commonly minor, rarely major. Prevention and abortion rely on the treatment of phimosis and allied conditions, which in both the congenital and acquired forms are very apt to have a balanoposthitis — acute or chronic with relapses or chronic with persistence and progress of symptoms. As the best preventive, circumcision is indicated whenever there has been an acute nongonococcal attack or chronic lesions. PREPUTIAL FOLLICULITIS 97 Curative Treatment. — Relief of these complications must be deter- mined by the indications. Curative treatment develops in accordance with the acute or chronic symptoms of itching, i)ain, ardor urinse, rubbing of the foreskin and discharge free at the opening in irretractible cases or held within the folds of retractible foreskins associated with excoriations and ulcera- tions. Antisepsis of the discharge, rest in bed with the penis sup- ported, diluents and antacids in drink and food are the management and hot irrigations, hot penile baths and sitting baths against the edema and discharge are the hydrotherapy. In retractible cases medicinal measures are hot antiseptic and astringent penile baths for twenty minutes twice a day, preferably of potassium permanga- nate 1 in 4000 to 1 in 1000, aided by hand injections of the same every two hours with the long rubber tip subpreputial syringe. Painting or washing the glans and foreskin with nitrate of silver, 1 in 2.50 to 1 in 125, is almost magic especially for the ulcers and excoriations. Drying and antiseptic powders and the standard penile dressing (Figs. 10 and 11) are the last step. In chronic cases the applications are usually somewhat stronger. In irretractible cases the only means are irriga- tion of the foreskin by the author's method and hand injection. When retraction is again possible return to the other methods is indicated. Relapse is prevented by the toilet of the foreskin during the urethritis. Author's Subpreputial Irrigation. — This means of treatment requires a reservoir, tubing, the Valentine or other cut-off and shield, a female catheter with a hub fitting the shield, both as shown in Fig. 18, as equipment. The patient is prepared with the standard draping (Fig. 15) reclining on the operating table or standing exposed as in Fig. 1.3 before a sink or other office fixture. The technic passes the catheter under the foreskin while gauze is dropped over penis and catheter to catch all splash and lead it into the Wolbarst basin between the thighs. The flow is opened at high head of pressure to balloon out the foreskin and about one gallon of irrigation is used, of 1 in 4000 to 1 in 1000 hot potassium permanganate solution, twice a day. Cure requires relief of the infection without preputial folliculitis or other complication and without tendency to chronicity. Aftertreat- ment is circumcision which ciu-es the underlying congenital deformity and the natural tenderness of the parts seen in phimotic subjects. The operation is usually done after all gonococcal disease is absent and especially if the thickenings of chronic phimosis are present. PREPUTIAL FOLLICULITIS. Definition.- — This acute complication may be described as gono- coccal infection of the follicles of the prepuce, which are really glands with ducts much like those within the urethra itself and for the most part evacuating at or near the margin of the foreskin where the true and modified skin meet. 7 98 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS Varieties. — Acute, subacute and chronic arc the chnical types, of which the last is discussed later. Cases without abscess and with abscess of the foreskin itself and abscess of the follicles near the fre- num are forms as to severity. Such abscesses are rather minute, though unmistakable and are not to be confused with periurethral abscesses of large jiroportions and described under their own heading. Etiology .^A long, tight foreskin is the predisposing local cause, with a tendency to frequent attacks of sbnple balanoposthitis through retention and decomposition of smegma. This condition results in relaxation and patency of the ducts and invites the penetration of the gonococcus as the exciting cause during the balanoposthitis which always occurs in such a foreskin. Pathology. — As in all other gonococcal invasion the essence of the process is penetration of the organism along the duct and into the gland followed by exfoliation, proliferation of the lining, pus forma- tion containing gonococci, modified secretion and detritus. The temporary lesions are these and seen only in mild cases of true follicu- litis without abscess, but the permanent lesions are destruction of the gland by the abscess, which leaves chronic sinus or even urethro- preputial fistula. Symptoms. — So slight a lesion has no invasion distinguishable from the gonococcal acute urethritis which it complicates. In fact, in irretractible foreskins it is often not recognized until the declining stage reveals the sinus or fistula. In a retractible foreskin, the sub- jective establishment is manifested by discomfort, pain and discharge, or by relapses of balanoposthitis bringing the folliculitis to the front. Objective signs are redness, edema and enlargement of the gland and its duct froQi which pus containing gonococci dribbles or may be expressed. The refined sensitiveness of minute abscess is always present. The termination is commonly by spontaneous external evacuation if no abscess occurs, or rupture upon the surface of the foreskin or near the frenum or Aery rarely into the urethra. Com- plete healing may then occur or a chronic infiltration, sinus or fistula result. The clinical significance of these little lesions is that they may be the carriers of infection into wedlock or even of autoinfection under a simple exciting cause. Diagnosis. — In the history of acute preputial folliculitis during a gonococcal m-ethritis the follicles of the prepuce are invaded and little abscesses appear, with their characteristic symptoms of pain, redness, swelling and finally evacuation. The pus may be expressed in little plugs without or with incision of the abscess and a small pocket remains. Chronic Preputial Folliculitis shows numerous acute attacks in its history with the result of a persistent focus or pocket which is always open and relapsing and has the symptoms of a chronic discharge, sinus and node of unhealed abscess if there is no occlusion of the sinus, but if its outlet becomes stopped then an acute folliculitis with all the foregoing features originates. The laboratory is interested in smears and culture taken from these abscesses and in the free pus of the fore- PARAURETHRAL FOLLKJULiriS 99 skin for the gonococcus. Treatment of the urethritis may aid in tfie disappearance of this compHcation especially if attcr)tion to tin; cavity of the foreskin is given before true abscesses appear. Otherwioc minor surgical attention settles the diagnosis. PARAURETHRAL FOLLICULITIS. Defmition.^ — Paraurethral or juxtameatal folliculitis is a complica- ting gonococcal condition recognized as infection of the little glands at or near the meatus leading to suppuration, abscess, sinus or fistula, lying along the urethra and evacuating in or near the hp of the meatus on the surface of the glans and not on the lining of the urethra. Fig. 19. — Gonococcal paraurethral folliciilitis with abscess. The abscess has not yet ruptured and obstructs the meatus. No sinus is therefore apparent. (Taylor.*) Varieties. — Acute, subacute and chronic are the clinical lesions while unilateral and bilateral as to situs and large and small as to extent are recognized, as well as cases without and with abscess. Etiology. — The causes of paraurethral folliculitis duplicate those of the preputial follicles and need no further discussion. Pathology. — Unusually large follicles situated along the margin of the meatus emptying upon the glans are the basis of the process while infection with the gonococcus followed by the usual processes excited by it is the essence of the disease. The ducts open laterally upon one lip in unilateral cases, both lips in bilateral forms and at either upper and. lower commissure in mesial cases, almost always externally but occasionally externally and internally, thus forming balanourethral fistulse. The length of such passages is from 1 to 2 cm. Temporary lesions are seen only when there is no abscess, ^\hile permanent lesions with destruction of the follicle, slight stricture of the meatus, chi'onic sinus and fistula are common. The associated lesions are regularly those of the gonococcal acute uretliritis wdiich they complicate. 1 Loc. cit. 100 COMPLICATJOXS AND SEQUELS OF ACUTE URETHRITIS Sjnnptoms. — In so niimito a IosIdii tluMV is commonly no discernible perioil of invasion, the i)atients complaining only of the snbjective establishment of the abscess or of a discharge from a particular point of the meatus, lateral or central, during the declining period of the gonococcal, infection or only of the persistent crusting later on. The objccti\e signs are a red. swollen edematous li[) in recent cases or normal in old lesions "with patulous duct, "pinhole" to the naked eye or magnifying glass, discharging pus spontaneously or permitting its expression. A ])robe will enter 1 or 2 cm. into a blind sinus or a balano- urcthral fistula. Crust o^•er the meatus when removed will reveal these conditions which are the sole origin of the crust in many cases, as distinguished from urethritis. The termination is in mild cases recovery. Glands with short, simple ducts also tend toward recovery or a chronic discharge without abscess. Those with long, tortuous ducts more often have abscess, frequent relai)ses with exacerbations followed by sinus or fistula. The clinical imi)ortance of these lesions is that without dis- comfort they may persist for years and become the source of infection in marriage or of autoinfection through some slight cause. Hence, the little droj) of pus within them should always be examined for the gonococcus. Diagnosis. — Added to the history in acute paraurethral folliculitis of a se\'ere m-ethritis is that of a ra]:»idly developing swelling exactly at the meatus on one or both sides with the symptoms at first of pain, edema and obstruction and then discharge of a drop of pus, frequently recm-rent. Expression of the pus from the small abscess cavity is usually easy with the fingers alone, but frequently this method develops pus from the urethra also. Chronic Paraurethral Folliculitis shows an origin in acute compli- cated attacks in its history or several attacks of urethritis resulting in the abscess and then the chronic sinus with a mass of infiltration tissue about it and with the symptoms of pain and discharge like an acute abscess when the ojiening closes or of chronic droj) if it remains open. The prol>e and the meatoscope com})lete the diagnosis. A hairpin or other loop may be passed into the urethra beyond the abscess and used to express its contents absolutely for laboratory demonstration of the gonococcus in smear and culture. Under treatment as the urethritis subsides the drop of ])us from the follicle ])ersists aufl does not cease imtil local applications or incision and drainage oliliterate the pocket and complete the diagnosis. Treatment of Gonococcal Acute and Chronic Preputial and Para- urethral Folliculitis. Almost in^'ariably minor and not major im])or- tance attaches to these lesions. Pre^■ention is only the toilet of the foreskin in irrigations, powders, baths and the like from the onset of the urethritis and the only abortive means are hot antiseptic local applications at the first sign of folliculitis but are usually of no avail. \^ Curative ircatiucnt is much alike in both these lesions which differ only as to their sites respectively in the foreskin and the meatus and is sjTiiptomatic according as the abscess is acute and blind or is evacuated PERI U RET JIB. A L FOLLIC IJLA R A liSC'ESS ] 01 or chronic with i)ockct or sinus causing j)ain, (h'sc(jrnfort, enhirg(;rncnt, perforation, discharge, pocket, sinus aurl associated balanop(jsthitis. Electrotherapy in the form of the high-frequency current of Oudin is valuable when the wire may })e readily introduced into the follidf. The spark gap should be one-eighth inch or less and the switch half open. The current should blanch and not char in a few seconds and the electrode should not bring away tissue with it. The medicinal measures are chiefly against the balanoposthitis as prescribed. Incision, evacuation and sterilization of recent cases is the best surgical treat- ment, while old cases may require curetting and stimulation, occasion- ally ablation. Aftertreatment provides against relapse or recurrence by proper attention to the balanoposthitis. Cure requires healing of the abscess cavity so as not to become a source of chronic infectiousness. PERIURETHRAL FOLLICULAR ABSCESS. Definition. — To abscesses of variable but rather large size, situated along the urethra from glans to penoscrotal angle, the term peri- urethral is applied and should distinguish them from the much smaller and less significant abscesses in small follicles near the freniun just dismissed as preputial folliculitis. Varieties. — Forms are distinguished as to situs, frenal, penile and penoscrotal, unilateral, bilateral and discrete, bilateral and confluent and finally bilateral by extension and as to severity without and with sinus and fistula formation. Bilateral abscesses may arise individually on either side of the frenum T\"hich is the commonest seat and remain discrete or become confluent into a common cavity or after arising on one side may erode into the other and thus simulate the former kind. Etiology. — A long, tight foreskin with tendency to sodden mucosa, to frequent simple balanoposthitis, to decomposition of smegma, and to relaxation of all ducts is the predisposing cause and the penetration of the gonococcus is the exciting cause, so far as the frenal tjq^e is con- cerned. The penile and penoscrotal types arise from similar infection of the larger urethral follicles. They are regularly associated with any period of severe gonococcal urethritis, that is, the full establishment, decline or termination, and during ckronic urethritis, as subsequently discussed, they are by no means uncommon under any additional excit- ing factor. Pathology. — Tj'pical gonococcal abscess formation follows occlusion of the duct of the follicle about the frenimi or within the urethra w"ith probably unilateral frenal situation the most common. The other situations are spoken of under ^'arieties. The essence of the process is invasion of the gland and duct, exfoliation, penetration of the organism, infiltration, pus and detritus, occlusion of the duct, destruction of the gland and finally involvement of its amiexa in extensive abscess. Manifestly temporary lesions are not seen as the destruction is marked. 102 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS The porinanont lesions are a fibrous nodule in the simplest cases, but nuK-h more eommonly a sinus evaeuating into the sulcus of the corona or into the urethra or a fistula connecting the cavity of the foreskin or the surface of the skin with the in-ethra. The associated lesions are regularly those of the intense gonococcal urethritis which precedes or is accomi)anied by these abscesses. The persistence of the sinuses and the tistuhe with little discomfort to the patient but with danger of autoinoculation or mfection of an innocent party is the clinical importance of these cases. The smear, culture and blood-tests for gonococcal disease should always be carefully made. Symptoms. — The majority of these abscesses arise with local sul)- jecti\'e in^•asion during the declining stage of the uretlu'itis and by their pain, enlargement and obstruction attract the patient's attentiob, even before their full establishment, which increases these symptoms. The systemic subject i^'e and objective signs are not common but when present may be those of any pus-focus, chill or chilliness, fever, malaise, prostration and the blood-count. The local objective conditions are at the onset a distinct red spot, like a pimple, near the frenum or a nodule along the anterior urethra in front of the scrotimi, rapid enlarge- ment into a spheroid or ovoid abscess, infolded in the foreskin with edema of moderate or large extent immediately around it, and sometimes obstruction of the urinary stream. In the termination complete reso- lution is the exception, but the rule is an infiltration, sinus or fistula as described under pathology and having the same clinical importance for the patient and his future wife already spoken of under preputial and paraurethral folliculitis. Diagnosis. — In its history acute periurethral abscess is found in severe or otherwise complicated acute or relapsing chronic urethritis and has severe symptoms of swelling of the urethra downward around the corpus spongiosum at any point and to any reasonable size, at first without and then with evacuation of pus, which recurs intermittently. Downward enlargement is enforced by the corpora cavernosa penis above. Pressure on the swelling in the early period develops no pus but in the later period shows a spurt of pus especially if the urethra has been previously washed clean. Urethroscopy may develop the mouth of the abscess as occluded or open. Chronic Periurethral Follicular Abscess presupposes an acute attack in its history with one or more abscesses which have never recovered and its symptoms suppuration which is indolent and persistent or active and variable according to occlusion of the opening of the abscess into the urethra. Urethroscopy will reveal the infiltration of the mucosa and the sinus and permit with the ureteral catheter or probe exploration of the same and sometimes recovery of pus. The laboratory specimen for smear and culture of the gonococcus is essential. Treatment of the urethritis will cause minor abscesses to disappear but the more severe ones may continue after the urethra is well and require individual management through the urethroscope which still further proved their nature. PERIURETHRAL FOLLICULAR ABSCESS 103 Treatment of Acute and Chronic Gonococcal Periurethral Follicular Abscess. — Its significance is usually minor, but may in chronic cases become major through absorption and infectiousness, and prevention suggests gentle means and no violence to avoid extending the infection into the glandules of the mucosa. Mild concentration of fluids, mini- mal force in irrigation by the Janet or Chetwood methods or preferably by the syringe-and-catheter method are required. Abortion in the real sense cannot be done as the onset is masked in the other symptoms of the urethritis. Curative Treatment.— Curative treatment is developed by the patho- logic and symptomatic indications according as the cases are acute or chronic and without or with a sinus. The symptoms without sinus for relief are pain, enlargement, edema and obstruction and with sinus they are relapses with discharge or a constant discharge. The manage- ment embraces the typical hygiene, rest in bed with the penis supported, careful diet and drink and regular bowels. Massage is contraindicated in acute cases exactly as instrumentation is but in chronic cases often aids with the sound in situ to evacuate the indolent contents of the abscesses or sinuses and to stimulate resorption. Hydrotherapy is of more avail in acute than chronic cases to reduce edema and swelling and relieve mild obstruction and consists of hot penile and sitting baths which if well done may prevent formation and rupture of the abscess. Electrotherapy is contraindicated in the acute forms but in the late periods is of value against the infection and relapses. The glass elec- trodes of the x-ray tube vacuum attached to the negative pole of a high- speed multiple plate static machine are correct to employ against the organisms while cataphoresis with a metal electrode attached to the positive pole of the galvanic machine with a current of 3 to 5 milli- amperes is used against the chronic discharge without infection. Serotherapy in the declining or sinus stage may be attempted for increasing resistance and immunity. The serum may be used earlier than the bacterin but without producing a negative phase which would add to the progress of the disease. The autogenous bacterins or the heterogeneous bacterins will produce active immunity as compared with the serum and its passive immunity. The methods are discussed in the section on Serotherapy in Chapter IX on General Principles of Treatment on page 512. On the whole this treatment is not very satisfactory. Medicinal measures are against absorption, if present, by catharsis, diaphoresis and urinary antiseptics and diluents by systemic adminis- tration. If there is no sinus the local measures are cessation of hand injection, hot penile and sitting baths and hot irrigations when the decline appears by the methods already described for the sjTinge-and- catheter inethod under acute anterior urethritis. Nonoperative sur- gery consists in wet dressings of astringents, antiseptics and sedatives such as bichloride of mercury, potassimn permanganate, alum acetate, lead and opium wash and lead water — often with improvement in many symptoms. Catherization may be gently used to overcome obstruction. 104 COMPLICATIOXS AXD SEQUELS OF ACUTE URErilRiriS Oporati\o moans arc oautii)us aj^ainst premature and innnature treat- ment, as OAertreatment is likely. The abscess is incised through the meatus if accessible or through the urethroscope for free evacuation of pus and instillation of the cavity with argyrol, nitrate of silver or iodin. If the sinus opens externally it should be left alone until several months after the urethritis is thoroughly healed and all resori)tion ])ossible has occurred. Then a straight soinid is passed into the urethra and the sinus or fistula opened carefully along its course, previously stained with methylene blue, down to the mucosa and rarely through it. Ligature at this ])oint will sometimes close the sinus or the whole mass may be dissected free to the nuuosa and ligated and moved and the defect sutured. Dilatation with soft sounds during the subacute or succulent stage and with straight steel sounds during the late chronic or infiltrating stage is indicated for urethral obstruction, but e\'er without a reaction such as pain, bleeding or temporary increase in the symptoms, because such foretell true stricture formation. In the acute period a soft catheter is used to draw oii' the water. Afterfrcafnicnt centers on tlie sinus, pocket or fistula always after the urethritis is cured and the infiltration resorbed as much as possible. The foregoing surgical lines are indicated. Stricture requires dilatation by mechanical or electrical methods as detailed in Chapter VII on the Treatment of Stricture on page 375. In all cases gentle measures applied at long sittings and rather rare intervals are the preference. Cure requires relief of the abscess and its infectiousness and if possible restoration of the mucosa, with the least amount of deformity, therefore surgical methods should be judiciously performed. LYMPHANGITIS AND LYMPHADENITIS. Anatomy. — The lymphatics of the penis are according to Quain^ a dense network on the skin of glans and prepuce and beneath the mucosa of the urethra, and pass chiefly into the inguinal glands. A deep system issues from the cavernous and spongy body, passes with the deep veins under the pubic arch and joins the h'mphatic plexuses of the pelvis. Significance. — These two complications are one, as neither can exist without the other in certain degree. Acute infection of lymph- vessels and l\'mphglands is in gonococcal acute urethritis without mixed pyogenic infection rather rare on the one hand, but on the other hand if balanoposthitis with phimosis or paraphimosis is present such l^Tnphatic involvement becomes much more common. Free suppuration and abscess is not a common eventuality in the glands. Ssrmptoms. — Subjective and objective sATnptoms are pain and tender- ness along the lymphatic trunks and over the glands and in the tissue if cellulitis is imminent. Often red streaks pass up the penis marking the dorsolateral position of the trunks or there may be a general redness 1 Quain's Anatomy, 1896, iii, Part 4, p. 243. LYMPHANGITIS AND LYMPHADENITIS 105 due to the cellulitis. The glands are often enlarged, tender and tense and may resolve or go on to suppuration marked }>y fhictuation and adhesion, infiltration and edema of the skin ov^er the gland. Diagnosis. — The anatomical features have been sufficiently detailed in Chapter II on Complications of Acute Urethritis, on page 1(J4. Acute lymphangitis and lymphadenitis in the history are those of acute processes, with pain along the penis and in the groin on one or both sides. Examination often reveals red, liot, cord-like, tender streaks passing lengthwise of the organ and traceable into the glands of the groins which in their turn also become enlarged, hot, tender and sometimes adherent to the skin, tense, very painful and finally fluctuating if abscess appears. Laboratory investigation demonstrates the gonococcus or other organism in the initial infection and may by aspiration with a fine needle recover the same from the affected glands. Treatment directed to the origin of the infection may by prompt and appropriate results give still further proof of the underlying infection. Chronic Lymphangeitis and Lymphadenitis. — Chronic l}Tnphangeitis and lymphadenitis are seen occasionally. The former with relation to urethritis seems rare, although the latter may occur in the strict sense. What is seen much more commonly is a number of acute attacks followed by infiltration of the glands and sometimes of the channels. Treatment of Gonococcal Acute and Chronic Lymphangeitis and Lymphadenitis. — Their significance is major only when very severe with inguinal abscess, and prevention is attention to the foreskin to avoid excoriations and ulcerations of balanoposthitis by early and efficient treatment, because such breaks in the surface become the foci of absorption into the hniphatics. If such portals of infection are open prevention is difficult against vicious forms of invasion so that the complication is rarely present in the absence of lesions on the surface and of abscesses within the urethra. The only abortion is the wet dressing with hot penile baths of antiseptics — alimi acetate or bichloride of mercury 1 in 5000 changed every two hours, but it usually fails. Curative Treatment. — The management in acute cases requires good hygiene, complete rest until the redness and tension are decreasing and suitable diet and drink to allay the irritation. Preputial irrigations for cleansing and antisepsis and hot penile and sitting baths as sedatives and antiphlogistics begin the physical measures. Heliotherapy with the therapeutic lamp must produce great redness of the skin, but no pain when applied several times a day for from ten to thirty minutes by the patient himself up to the limit of his comfort. Medicinal measmes introduce the care of the urethritis and balano- posthitis as underlying sources of _ the IjTnphatic involvement as described under the heading of anatomy in the clinical paragraphs on this subject. The preputial irrigations and hand injections are continued and perhaps increased combmed with wet dressings exactly as noted in balanoposthitis. In the chronic cases the glands are more apt to be involved but the treatment of chronic phimosis and balano- 106 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS posthitis teiuls to reduce the amount of absorption by heaUug the foci. Operative surgery incises and drains tlie abscess of tiie inguinal glands or if the suppuration is extensive removes them entirely. Dressings of the wounds are on common surgical lines. A single gland in the earliest stage of supi)uration may be drained of its contained pus by aspiration followed by the injection of 10 ])er cent, iodoform in sterilized glycerin only up to filling anil not distention of the cavity. Circumcision must not be forgotten as prevention of subsequent attacks and of extension of chronic cases to suppuration. Aftcrtrcaimcut avoids a relapse by the toilet of the foreskin during the remainder of the urethritis in irrigation, hand injection, lavage and dressings. Proper treatment of the urethritis may check complications of pus foci along the urethra, leading to a relapse. Circumcision is, as stated, the i)roper step in all cases. Cure requires no active infiltrations or foci in the foreskin, urethra, lymphatic vessels or glands, and full bacteriologic proof of no infec- tiousness. GLANDULAR COMPLICATIONS. Varieties and Importance. — Any and all glands of the anterior urethra may be involved in gonococcal infection as a complication of the urethral inx'asion. This i)ath()logical fact therefore concerns the tubo- alveolar subepithelial, the simple depression, the submucous glands and finally Cowpcr's glands. In all the ducts may be patent, resulting in suppuration, with free discharge upon the surface or closed, causing retention of exudate and abscess formation, which may rupture externally upon the skin or internally into the urethra, leaving behind a cavity, sinus or fistula, of size and importance according to the gland affected and the extent of the secondary conditions. Cowper's glands are most important in this respect. The great number of small urethral glands and the acknowledged frequency of their invasion and the relative absence of subjective symptoms, except in retention cases, make these complications among the most important, insidious and dangerous of the disease through tendenc}' to harbor chronic infection. LITTRITIS AND FOLLICUUTIS. Varieties. — The small mucous glands have often infection of two varieties, without retention of pus, called littritis and with retention of pus, termed folliculitis. The cause is intense infection, lowered local and systemic resistance and traumatism of faulty instrumentation or other local treatment, such as instillation, irrigation or application. Pathology. — The pathology of littritis is briefly a migration of the gonococcus into the gland, and its same penetrating destructive infec- tion as on the urethral surface, with pus usually in slugs through its temporary thickening within the cavity of the gland. The wall of the gland becomes thickened, so that on objective examination they may be felt as little shot-like nodes or granules scattered along the urethra. LITTRITIS AND FOLLICULITIS 107 A higher grade of littritis, that is to say, folHcuhtis, adds only reten- tion of the pus in abscesses with thick walls and final rupture into the urethra. The pathology of folliculitis continues the latter process beyond the wall of the glands and is therefore a periglandular and peri- urethral process, with retention, abscess and rupture either into the urethra or upon the skin. The termination of these glandular com- plications is usually destruction of the function of the gland and even anatomical obliteration of its cavity. More frequently chronic catarrhal inflammation follows with or without persistence of the gonococci. Pus-bearing and urine-bearing sinuses and fistulte upon the skin are seen. Fig. 20. — Gonococcal glandular periurethritis or folliculitis. (Legueu.^) Symptoms. — Subjective sjinptoms of littritis are usually not noticed, w^hile those of folliculitis may be swelling and deformity of the urethra, usually along the floor, presenting in variable size, externally to that of a cherry, and in different degree internally, to cause partial obstruc- tion to urination. The objective symptoms of littritis may be absent or the nodules along the floor and sides of the urethra whose palpation is easy and commonly followed by expressed pus; while those of fol- liculitis establish the abscess or its secondary purulent or urinary sinus or fistula. The termination is suflEiciently described under pathology in the preceding paragraphs. Diagnosis. — As already discussed on pages 106-108, acute littritis and folliculitis are extensions of each other, the folliculitis being more severe than the littritis. In general the persistence of a gonococcal anterior urethritis through a longer subacute stage than usual suggests the presence of littritis. The history is mild in littritis, more severe in follicuhtis, especially in the declining period, when much more dis- charge in heavj^ shreds is present. Symptoms include a little pain and swelling noticed subjectively and nodules with little shot-like masses 1 Traite Chirurgical d'Urologie, 1910. lOS COMPLICATIONS AND SEQl'I^LS OF ACUTE URETHRITIS along tlie urethra ohji-ctivoly, especially if an instrument is in the urethra against which the i)ali)atic)n is nuule. Urethroscopy will find in(li\iilual f(»llicli> in \arious degrees of intianunation and recovery. Chronic Littritis and Folliculitis arise from the acute lesions during a severe or se\"eral ri'])eated attacks recognized hy the foregoing diag- nostic details. The history shows shred and drop never absent from the in-ethra or lu-ine and the symptoms are those of acute attacks simu- lating the original acute disease or of the chronic conditions of discharge, pasted meatus and shreds. Nodes of infiltration, with ex])ression of pus, are ajjparent and the multiple glass test will show whether the folliculitis is of the anterior, posterior or anteroposterior distribution, fully ^•erified by the urethroscope. Shreds should be reco\'ered and sent to the laboratory for identification of origin and bacteriology. Laboratory findings demonstrate the gonococcus in the slugs and shreds in the urine as passed and in sterile irrigating fluid after massage of the lU'ethra. Treatment directed in general toward the gonococcal infection removes all discharge except the slugs of pus whose charac- teristics aid in the diagiLosis. Urethroscopic applications of astringents, caustics, electricit}' and lancet renioNc indixidual foci. Treatment of Gonococcal Acute and Chronic Littritis and Folliculitis. — Their significance as sources of infection is practically major in poten- tiality and prevention in the acute stages notes dilute solutions and conservative methods only in the declining period of the urethritis, which tends to avoid driA'ing the infection into the follicles by the injmy of trainnatic dilatation with a stream under pressure. There is no abortive treatment, because the symptoms are hidden by those of the urethritis and the nature of the lesion is an insurmountable obstacle. Curative Treatmeni. — The indications require respect. Curative treatment in the acute stages which usually are those of an intense tu-ethritis with only the usual management of hygiene, require rest in bed until the symptoms begin to decrease and great attention to diet and drink. When folliculitis is apparent in the form of nodules or tender points all irrigation and hand injections should be temporarily suspended. In the physical measures, with a sound in the urethra only during the chronic stages, massage may be gently employed to stimulate evacuation and resorption while hot penile and sitting baths reduce the edema and the obstruction. Electrothera])y is of A^alue only in the late declining and chronic periods in the form of cata- phoresis against indolent nonbacterial discharge and in the form of high potential vacuum electrode attached to the negative pole of the standard multiple plate high-speed static machine. Medicinal measures are directed against the fever and absorption if present through systemic administration in marked cases. Serumthera])y is excellent in some individuals, as described in Chapter IX on page 512, the serum tending to establish passive immunity and bacterins to excite active immunity. Locally, in the acute stages, all. intraurethral treatment is stopped until the decline is well established, when it is COWPERITIS 109 resumed, at first with gentle means and later with slow augmentation determined by reaction. The expectant mctliod is by all rne;iris 7)re- ferred as irrigations under high pressure only increase the pathological lesions. When chronic manifestations appear the urethroscope is indicated for applications of caustics and the high-fre(}uency current of Oudin, and .r-ray vacuum glass electrodes, with static electricity, as already shown to destroy lurking infection and finally incision with the knife as required-. Nonoperative surgical treatment in the acute stages are w,et dress- ings to allay suffering, swelling, edema and obstruction, which may be relieved by cautious catheterization with the soft-rubber instrument. Later on soft sounds or hot or cold straight steel sounds, with gentle massage and instillations of slowly ascending solutions of nitrate of silver, from 1 in 20,000 to 1 in 100, with the soft-rubber catheter or with the Bangs syringe sound, also with massage, are of great benefit. The author's irrigating sound in affording a retrojection as well as gentle dilatation should be used. Operative means reach the blind abscess by incision through the urethroscope while sinuses and fistulse are opened upon a sound and dissected out or tied off exactly as detailed in periurethral abscess while contractures of the canal are dilated gently and gradually or divided according to indications. Aftertreatment. — Aftertreatment is concerned with relief of the urethritis from which relapse may appear in the follicles, and with dilatation of stenoses with soft instruments during the early develop- ment and steel sounds when the mucosa is dry. A study of shreds in the urine is the guide of cure along with the author's multiple glass test. Cure. — The little pockets should be free of infection even if not with- out their drop and the larger abscesses should follow the same course. Folliculitis is therefore one of the problems in urethritis and is on the border-line between minor and major complications. The most careful bacteriology is required to prove the cure. Some cases have a positive gonococcal complement fixation test. COWPERITIS. Varieties. — As in the infections of most glands with ducts the out- lets of Cowper's glands may or may not become occluded and thus arise the two forms, cowperitis without retention and cowperitis with retention. Occurrence. — Like the small mucous glands of the urethra, Cowper's glands may be the subject of acute complicating involvement of treach- erous, persistently infectious character. The occurrence is not common compared with littritis and folliculitis, but the clinical significance on account of the long, tortuous ducts and compound body of the glands is after their involvement far-reaching. The onset of the irinfection is after acute urethritis has involved the entire anterior urethra in full establishment; that is, about three or four weeks after the initial 110 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS invasion. I'siially one, occasionally both glands simultaneously, are attacked with an insidious invasion exactly like the lu'ethritis itself with at first relatively few suhjeetive syni])toms. The varieties are Fig. 21. — rrotcctivc dressing for rectal examination. A rubber finger cot is placed on the index finger and over it is slipped several layers of gauze, about six inches square, ■with a hole at the center rather tight for passage of the finger. The gauze receives any fecal or infectious matter from within or wdtho\it the amis. Fig. 22. — Is rectal examination, with the index finger of the gloved hand lubricated and passed into the rectum, with the fingers folded into the palm and the elbow sup- ported by the hip for force in penetration, leaving the hand flaccid for palpation. COWPERITIS ]]] two, determined by the patency or occlusion of tlic duct— namely, without retention and with retention. Pathology. — The lesions duplicate those found in and described for folliculitis in all details of the forms with and without retention, except that in the case of Cowper's glands organs of anatomical instead of histological proportions are involved. Symptoms, — Cowperitis without Retention. — This form occurs the more commonly and is marked by freedom of the ducts to discharge the pus, actively under .muscular action or passively under the examin- ing finger. The symptoms are increasing swelling, pain and inter- FiG. 23. — Is palpation of Cowper's glands; with the right index finger in the rectum the gland is pushed down against and between two fingers of the left hand, which permits thorough digital investigation. mittent discharge, followed by decrease in the pain and enlargement temporarily until refilling of the gland occurs. The termination is least frequently complete resolution, but more commonly permanent damage or chronic disease of the gland. Coivperitis tvith Retention. — ^This type occurs rather infrequently and is really abscess of Cowper's glands, characterized by closiu-e of the ducts, retention of the pus, destruction of the gland, extension of the process into the siu-rounding tissues and final ruptme, either upon the skin or into the urethra. At no time is active or passive evacua- tion of the pus possible and the gland is always damaged beyond future function and often beyond anatomical identity. The abscess is essentially acute, while the outcome in pocket, sinus, pm-ulent or 112 COMPLICATIOXS AXD SEQUELS OF ACUTE URETIiniTIS urinary fistula is chronic. The symptoms are pain of heavy then acute progressing type in the perineum, accomj^anied by enhirgement of the ghind, witli later heat, redness, tenderness, fixation and thinning of the skin and tenninally with ru]>ture and evacuation, externally u])on the skin or internally into the canal, which is followed by pocket, sinus or fistula formation. Diagnosis. — It is imj^ortant to distinguish the two forms. Acidc coivperitis ivitJioiit rdotfion a]>i)ears during a long,' severe urethritis, as to its history, with a tendency toward other glandnlar involvements such as folliculitis, and prostatitis. Posterior urethritis is a feature although Cowper's glands are at the bulb of the urethra and therefore in the anterior urethra, but the infection is extensive. The symptoms are severe pain in the perineum, with enlargement and abscess, intraurethral rupture through its own duct and persistent evacuation. Examination before evacuation is that of abscess and after evacuation that of a sac Avhich empties under pressure. Rectal examination against a soft bougie in the anterior urethra will develop the position of the gland and its connection with the luvthra. After cleansing the urethra a laboratory specimen may be obtained by pressure on the gland or through a urethroscope one may be secured with a swab or before evacuation aspiration with a fine needle is possible through the perineum. Treatment through relief of the ure- thritis may also subside the cowperitis and add to the evidence. IN'Ias- sage of the gland and in persistent cases incision and drainage fix the identity of the condition. Actiie cmvperitis with reicniion is strictly abscess and essentially augments all the difficulties and symptoms. In addition to the fore- going facts we ha\'e rupture intraurethrally or extraurethrally at almost auA^ point with sinus formation in which a probe may touch an instrument in the urethra. Surgical exploration settles the matter and distinguishes it from other abscesses in the perineum. Chronic Cowperitis Without and With Retention is common on account of comj)lexity of the gland and length and tortuosity of the duct. The history is that of acute invasion without recovery or with seeming recovery associated with relapses and the symptoms are those of more or less constant indolent discharge in the type without retention asso- ciated with discomfort or consciousness of the gland or those of acute or subacute relapsing abscess. The infiltrated mass of gland and duct is apparent with sudden expression of much pus in each form. The urethroscope is of final diagnostic aid. Treatment of Gonococcal Acute and Chronic Cowperitis. — Their sig- nificance is major in cowperitis on account of complexity of the glands, severity of many cases and foci of chronic infection which the glands often become, and prophylaxis is as against other complications, care in the treatment of the gonococcal acute urethritis in regard to the stages of this process and to observation of the earliest signs of the glandular inAolvement. Abortion is impossible because the glands have long ducts and complicated acini, so that when infection has once penetrated it cannot be eliminated in this manner. COWPERITIS "113 Curative treatment during the acute period consists in the approved management of hygiene, rest in bed up to full subsidence and proper diet and drink, with due sexual rest. In the chronic form nothing irritating must be done, including sexual activity. The physical measures in the acute stage are dangerous. In the chronic stage massage is of benefit in evacuating the gland and in promoting resolution. ITot rectal irrigations, sitting baths and body baths in hydrotherapy are quieting in the acute stage and tend to relieve the kidneys. The psychrophore is a sedative while leeches in extreme cases decrease the congestion. Light applied from a 60- candle power lamp in a small parabolic reflector for half an hour to an hour up to the tolerance of the patient for heat and actinic effects will relieve the pain and quiet the inflammation. The electrotherapy is forbidden by acute inflammation but accept- able in dechning and chronic periods either with or without occlusion. It stimulates the evacuation of pus, the destruction of infection and the restoration of the infiltration. When infection has nearly or fully disappeared, galvanic cataphoresis with a small electrode wound with cotton soaked in weak solutions of zinc chloride or copper sulphate and attached to the positive pole or in one-tenth to one-fourth strength of the tincture of iodin and connected with the negative pole may be used in 3 to 5 milliamperes of current for five to ten minutes every three to five days. There should be no reaction and only benefit. If infection is present then the .T-ray vacuum glass electrodes attached to the negative pole of a standard high-speed multiple plate static machine is used, with intensity of current of a spark gap one-haK to one and a half inches for five or ten minutes every three to five days, likewise always with benefit and without excitation. Its strong actinic and germicidal effects are thus localized upon the glands. Experi- mentally the actinic effects penetrate to a depth of from 2 to 6 mm., depending on the intensity of 'current employed. Medical measures are in the acute period little or none. Locally ail hand injections and irrigations should be stopped and only external applications by the physical means adopted, including wet dressings of lead and opium wash for the pain and of lead water, acetate of aluminum and weak bichloride of mercury for their antisepsis. In the chronic stages the irrigations of the urethra and instillations as described for anterior and posterior chronic urethritis may heal the urethra overlying the gland, but are without effect on the cavity of the gland, likewise applications through the uretliroscope. Systemic- ally the measures previously described against the absorptive condi- tions are again used. Nonoperative surgical means are contraindicated in the acute and cautiously begun and judiciously progressed in the chronic period. The author's irrigating sound is of advantage in cowperitis without occlusion and combined gentle dilatation, wdth retro jection of the urethra and irrigation of the bladder against possible infection. Abscess contraindicates sounds until incision and drainage relieve 114 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS the toii?ion. Retention of urine in acute cases and in relapses of chronic forms is catheterized \vith a small soft-rubber catheter with great gentleness. Operative measures through the urethroscope on cowperitis with- out occlusion stinuilate the mucosa overlying the gland while the occluded gland must be incised and drained whether acute or chronic. Cyst formation in the latter forms is seen. The technic requires the following instruments: The author's irrigating sound, one scalpel, Fig. 24. — Abscess of Cowper's gland. Left side, postoperative condition, showing posi- tion and direction of the incision. (Hayden.') one scissors, several small hemostats, ligatures, small sharp and blunt retractors, probe, director, small gauze drains, dressings and a good T-binder — almost duplicating those for external urethrotomy with a guide. The preparation of the patient and the field is the accepted methods, while in chronic cases the anesthesia is local but in acute forms general. The posture is the exaggerated lithotomy w^hile the landmarks of the m-ethra are shown by the sound and of the gland by the finger in the rectum. The superficial field is the perineum between the anus and the scrotum in which the incision is made over the pronu'nence of the swelling down to the surface of the gland in the deep field, which is incised with scalpel and scissors to the full length of the skin incision and gently probed for pockets and burrows which are broken into the main cavity with the blunt point of an artery clamp. The cavity is gently wiped clean and packed without pressure on the urethra. The author's sound irrigates the bladder against infection and is then withdrawn and the T-binder is applied over the dressing. 1 Venereal Diseases, 1916. COMPLICATIONS OF GONOCOCCAL ACUTE URETHRITIS 115 Immediate aflertreatment is dressinpj at regular ii)t(;rvals as noedefl, with renewal of drains on the third, fifth or sev(;nth day, and balsam of Peru stimulating dressings. All packings arul drainage are stopped as soon as possible and the dressing is made light simply to keep the skin open and avoid a sinus. The remote aftercare is the passing of sounds for the infiltration, massage and electricity for resorption and suitable applications through instillating sounds and the urethro- scope for the bulbar urethritis. Cure. — In the sense of restoring Cowper's glands to fully normal condition is very rare indeed in either the form without occlusion or that with occlusion of the duct. The large size of the gland and its complicated acini leave it a focus of disease even after the gonococci have disappeared, which is the chief standard of success. When this fails the complication is immediately major on account of the infection which remains years behind after symptoms have ceased. Cure in the sense of evacuating the pus and obliterating the gland is much more easy whether in the period of obstruction and abscess or in the occasional later period of cyst formation. 2. Urinary Forms. Inasmuch as anterior urethritis does not reach the urinary organs above the pendulous part of the penis, there is no urinary group of complications arising during its course. This class of complication makes its first appearance during posterior urethritis, when that part of the canal in direct outlet of the bladder becomes involved. Their description will therefore be found under the subject of Complications of Posterior Urethritis on page 162. B. Systemic Group. The general characters of the anterior urethra and its glands make septic absorption from it and systemic complications rare and difficult, but less so the posterior acute and anteroposterior acute lesions. Systemic complications are most common in chronic urethritis, under which heading they are more appropriately discussed. Anterior chronic urethritis may during any exacerbation or under any exciting cause develop an acute complication. It is for this reason not easy to draw a fixed line of distinction between complica- tions of acute and chronic disease. Both forms are so correlated and interwoven that both acute and chronic complications may be asso- ciated with or sequel to either acute or chronic uretliritis. n. COMPLICATIONS OF POSTERIOR GONOCOCCAL ACUTE URETHRITIS. General Clinical Features. — The complications of posterior acute urethritis have the same clinical peculiarities, independently of cause, just as do those of the anterior m-etlira. In discussing the latter IIG COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS subject gonococcal infection avus taken as tlie standard and will be again in connection with tlie ]M'esent matter, because its tN^^e is the most nmnistakable. Varieties. — The general classes are local, aft'ecting the urinary -and sexual organs only, and s>'steniic, reaching the body at large in particu- lar systems or in general. The local or urogenital complications in anatomical order are the sexual: prostatitis, vesiculitis, funiculitis, epididymitis and orchitis; and the urinary: cystitis, retention of urine, ureteritis, pyelitis and pyelonephritis. The systemic or extraurogenital group embraces cutaneous, diges- tive, circulatory (including inetastatic abscesses), respiratory, special sensory and locomotor (including bone, articular, muscular and teno- synovial) complications, and are discussed in Chapter III on page 201. There are no urinary or systemic complications of anterior acute urethritis, as stated in the introductory paragraphs of this section. These two groups are therefore properly considered under posterior urethral lesions. A. Urogenital Group. Varieties. — Two groups are recognized: sexual and urinary. Of these all not only may be acute complications during posterior gono- coccal acute lu-ethritis, also may be acute complications during exacer- bations or dining the ordinary course of posterior gonococcal chronic urethritis. The sexual group comprises prostatitis, seminal vesiculitis, funiculitis, epididymitis and orchitis. The last three are so closely related as to be considered usually under the one subject of epididy- mitis. The urinary group includes urethrocystitis, cystitis, retention of urine, ureteritis, pyelitis and pyelonephritis. 1 . Sexval Forms. For the sake of convenience the anatomical order will be followed and the comparati^'e frequency of occurrence will be noted under each example. PROSTATITIS. Occurrence and Etiology. — Infection of the prostate through its position and connection by ducts with the posterior urethra occurs as a very common complication of posterior acute urethritis or during an acute exacerbation of chronic disease or as an acute condition in the course of chronic urethritis, as will be later discussed. The exciting cause is direct extension in continuity of mucosa of severe infection with or without associated pus organisms. All-important predispos- ing factors are catarrhal prostatitis of venereal excess and masturba- tion, irritation l)y alcoholism and condiments and traumatism by faulty treatment and agitation by railroad, automobile, bicycle and horseback-riding. Varieties are acute, subacute and chronic, of which the last will be discussed as cognate with chronic urethritis in a later chapter. PROSTATITIS 117 Gonococcal Acute Prostatitis.— Varieties. — Acute coinplicating pros- tatitis shows two forms accordin^^ to the portion of the gland involved, namely, follicular or glandular prostatitis, in which acini and ducts alone are involved, and parenchymatous or phlegmonous j)rostatitis (abscess of the prostate), in which the gland-tissue as a whole in one or more parts is destroyed. Pathology. — Acute follicular iirodatili'i is that of mild congestion, with full recovery or that severe suppuration involving the ducts and the acini usually without retention so that the pus is evacuated spon- taneously into the urethra. The acini and ducts may recover fully or be permanently damaged and obliterated or become the seats of chronic foci of infection. Subacute follicular 'prostatitis has the same lesions as the acute type but in much milder degree, owing to the fact that it commonly arises through causes other than severe infection, such as exposure, vicious habits and faulty treatment. Chronic follicular prostatitis is usually the outcome of the more severe suppurative forms, but occasionally the subacute type also becomes chronic. Each follows the tendency of its own preliminary form in that the follicles chronically diseased continue either suppurative or catarrhal, as the case may have been at the outset. Suppurating follicles, however, may eventually lose their pus but retain their mucous discharge. This subject is further treated in the Chapter on Complications of Chronic Gonococcal Urethritis. Acute Parenchymatous Prostatitis. — ^The abscess is mild, severe or intense in degree according to the activity, extent and complications of the lesions. It is caused by follicular infection, penetrated, extended and involved in the stroma as well as in the glandular elements of the prostate, with resulting abscess. In site, the abscess may be superficial or deep, in any lobe or lobes or in the gland as a whole, and may vary in number from single to multiple, with a tendency to coalesce into one common cavity, and may differ in size from that of peas to eggs containing from a few to 250 c.c. of pus. The contents may be pure pus or a mixture of detritus, pus and blood without odor or very foul from the presence of Bacillus coli communis. In termination the phlegmon evacuates according to its site and the periprostatic infection: (1) internally into the urethra, bladder, vesicorectal space, rectum and peritoneum, and (2) externally, usually upon the skin of the perineum. The complicating lesions of prostatic abscess are due to penetration into or association in the periprostatic spaces of the initial infection, with burrowing of the pus determined largely by the original sites: (1) backward into the rectum by abscesses originally near its cavity; (2) downward into the perineum, sheath of the penis or scrotmn ; (3) laterally into the ischiorectal fossae and thigh, and (4) upward upon the loins and back. Pockets, sinuses and seminal, urinary or fecal fistulas are often the sequels of such complications. Symptoms. — The symptoms of acute follicular i^rostatitis vary with the degree of the infection, being less in the superficial follicular and subacute cases and greater in the deeper follicular and parenchymatous lis coMPLiCArinxs axd sequels of acute urethritis and acute forms. They are local ami systemic, subjective and objec- tive in distinction. The local subjective symptoms are (1) sensory: pain and weight in the perineiun, rectum and bladder in the deep pelvis or referred down the thighs and into the loins nnich as uterine jiain in the female, and ('2) vesical: dysuria, i)ollakiuria, tenesnms through congestion and irritation, and retention of urine by edema or spasm; (3) sexual: chordee and painful, blootly, seminal emissions, and (4) rectal: pain in defecation, altered stools and obstipation, through mechanical i>ressurc and tenesmus tln-ougli reflex action or peri])rostatic invasion. The local objective symptoms are urinary and rectal. 1. Urinari/ Signs. — All test-glasses of urine are filled with i)us, but the last often with slugs of prostatic detritus and blood. The seven-glass test of the author may be done with caution in the less severe cases. It ^^"ill show large amounts of pus in the first three glasses. Only the fourth or bladder glass secured with the catheter will be fiee of abnormal constituents unless the bladder and other urinary organs are infected. If gentle massage of the prostate is made the fifth or massage glass will be loaded with the expressed contents of those follicles ^^■hic•h haxe not been occluded. The sixth and se\'enth glasses are again negative if both seminal vesicles have escaped involvement. The technic of the scAcn-glass test is described in the Chapter on Pos- terior Chronic Urethritis on page 291. In the more se\'ere cases the four-glass test is of much value. The prostatic products in the third or posterior urethral glass and in the fom-th or prostatic massage glass make the diagnosis. Passage of catheters in these intense cases for a bladder specimen is contraindicated. 2. Rectal Sicpis. — Through the rectum : The prostate is hot, enlarged, tense, fluctuating at various points or in the A\hole body of the gland and tender, obstructing the rectum more or less completely and the periprostatic tissues may be boggy or infiltrated. Vesical and rectal tenesmus follow examination. Instrumental urethral examination is contraindicated except to relieve retention. The subjecti\'e and objective systemic sj'mptoms are chill or chilliness, fever from 100° to 105° F., prostration, depression, nausea, vomiting, blood-count * tj^Dical of active pus processes and willing confinement to bed for many days. Severe lesions cause extreme suftering, almost more than any other destructi\e pus condition in any organ, ^^'hen the pus is actually present all symptoms are greatly augmented. The termination is in mild cases always slow, but usually complete recovery. In the more se^■ere cases follicles may be destroyed and obliterated or go on to chronic catarrhal or sujipuratiAc infiammation, which may last for years or life. The ducts of such follicles are patulous in the field of the urethroscope and often discharge clouds and slugs of pus while under observation. Subacute FoUiciiIar Pni.statitis. — This is very similar in kind but much less in degree and concerns primary and secondary cases. The primary cases are caused by the improper use of irrigations, injections, PROSTATITIS 110 catheters, sounds, urethroscopes, cystoscopes and lilliotrites and the secondary cases arise during a i)osterior urethritis or after excesses in alcohol, food, coitus, ma-iturbation and exercise. The termination is usually complete recovery after withdrawal of the cause, particularly improper medication and instrumentation. Acute Parenchymatovs Prostatitis. — This very important disease follows mild, severe and intense courses in accordance with the number, size and destructiveness of the abscesses and the complications. Pain in the prostate is severe, augmenting with the progress of the pus, throbbing and heavy in character, often referred along the penis and urethra and backward into the lumbar regions. Obstruction of the rectum is marked. The urinary symptoms are severe, scalding polla- kiuria, dysuria, even drop by drop and retention by edema. The urethra is obstructed to the catheter even to 10 or 12 French and naturally deviates away from the point of greatest enlargement. The rectal symptoms are obstipation, stools compressed to "ribbons" or scybala and the gland greatly enlarged into the rectum as a general abscess or as multiple soft foci or a urethral submucous abscess, difficult to distinguish positively. The sexual symptoms are commonly wanting, owing to the pain which inhibits the spinal reflexes; but if present they are scalding, bloody, purulent emissions. The systemic symptoms are those of intense pus focus an}T\'here in the body, with active absorption. Typhoid fever is not uncommonly wrongly suspected as present in these cases on account of their active septicemic condition and prostration and may be disproved only by the absence of the Widal reaction in the blood and the t^q^hoid bacilli in the blood and excreta. The symptoms are therefore severe and often recurring chills rather than mere chilliness, fever of sudden appearance and wide variations, rapid high-tension pulse, profuse perspiration, depression and a septic exhausted appearance. The termination is usually spontaneous or operative evacuation, with prompt positive decrease of all sjonptoms. Natural pointing of the pus is in the line of least resistance, and as described under Pathology may be devious and unexpected, leaving behind chronic pockets, sinuses and urinary, seminal or fecal fistulae. Death from septicemia is rather common in neglected cases. In general, infection of the prostate is a serious and long-continued condition, owing to the complexity and delicacy of the gland itself as shown in its embryological foundations and owing to its direct connec- tion with the posterior urethra which is in itself so often the site of chronic infection. Diagnosis. — ^It is essential to determine the form of prostatitis present. Acute and subacute follicular prostatitis present intense invasion of the urethra, in their histories, with rapid extension into the posterior portion and with signs of vesical irritation, active and persistent. Subacute forms are the milder. Local sjTnptoms are sensory, vesical, sexual and rectal, subjectively, with a tendency to focalize in the prostate, and objectively the multiple glass tests (without use of 120 COMPLICATIOXS AND SEQUELS OF ACUTE URETHRITIS catheter in the bladder) show the posterior urethral glass and the massage glass full of jnis and prostatic elements through muscular action of the neck of the bladder and the urethra and by the compres- sion of the massage. Through the rectum all signs of infection, infil- tration and obstruction are present. Systemic symptoms are those of infection, fever, chill, prostration and blood count. For the laboratory a specimen ma>' be obtained after gentle irrigation of the anterior urethra by massage followed by cA'acuation of the bladder, and will contain the gonococcus for smear and culture associated with many prostatic elements. This complication sometimes gives a positive complement fixation test early. Treatment by securing subsidence of the anteroposterior urethritis benefits the prostatitis indirectly, but direct treatment of the gland with massage, rectal irrigations and sometimes electrical applications proves the lesion. Acute iKireiichyinaioiis prostatitis duplicates and augments all the foregoing symptoms, and develops a large focus of pus in one or both lobes or the gland as a whole with characteristic symptoms. In all forms of acute prostatitis urethroscopy and other forms of instrumen- tation arc contraindicated. Gonococcal Chronic Prostatitis.- — Differences in degree mark chronic catarrhal from chronic siippiu'ative forms as their general character is much the same. The history marks the catarrhal cases as originating in diatheses, in indiscretions as to diet, drinking and sexual intercourse and in frequent attacks of lu-ethritis which leave the sunpler inflam- mation behind them without true suppurative prostatitis. The gono- coccal prostatites, however, have a record of one or more definite mvasions of the organ, with follicular (less severe) or parenchymatous (more pronounced) manifestations. The subjective symptoms are therefore in definite or marked sensory, sexual, vesical and rectal disturbance. Leaking from the urethra during defecation contains mucus or pus according to the catarrhal or pyogenic lesions. The objecti\e signs comprise the findings in the seven-glass test folknved by laboratory examination and the conditions of the prostate on bimanual or unimanual examination. Catarrhal prostatitis gives universal softness, follicular prostatitis contains spots of softening, with purulent discharge and parenchymatous prostatitis has one or more large points of softening, due to abscess. The periurethral method consisting in passing a soft woven lisle thread or silk catheter into the bladder and examining the prostate around it should be employed only by those of great skill and caution in obsciu'e cases. As to the objective signs, Schlagintweit^ states the following phe- nomenon: During massage of the prostate the patient holds below the meatus a tumbler filled with water, in order to catch the outflow of the secretion. Drops massaged out of the lower portions of the prostate in the immediate neighborhood of the anus fall from a height from 5 to 10 c.c. to the surface of the water, where they dissipate themselves in 1 Nitze-Oberlaender's Centralblatt, 1901, p. 173. PROSTATITIS 121 so far as they consist in normal thin secretion of the gland. The rc^suJt is a slight opalescence imparted to the water exactly hke that seen in tli(; urine after massage of the prostate. Those drops of the fluid expressed which contain pus sink to the bottom of the glass as thick flocculent masses. The drops, however, which are brought away from the upper part of the prostate, which have subsequently been shown to arise from the seminal vesicles, cling in formed condition to the upper level of the water and gradually elongate themselves, in accordance with their thickness and weight, into longer or shorter mollusk-like floating saccules or vessels. Oberlaender and Kollmann^ say that the surest and safest diagnostic proof of prostatitis is the microscopic findings in the secretion expressed. Normal prostatic secretion consists chiefly of masses of lecithin kernels and scattered epithelial cells. The secretion of prostatitis contains in accordance with the severity of the inflammation admixture of pus with the normal fluid or consists of pure pus. Seminal crj^stals and amyloid bodies are not constant factors. Spermatozoa are found only when the seminal vesicles and the ejaculatory ducts are victims of the inflamma- tion. The microscopic findings are shown in the normal secretion and of mild and severe inflammation of the glands. The laboratory analysis obtained by irrigation of the urethra, massage of the prostate and centrifugation of urine embraces bacteriology for the gonococcus and other organisms in sterile specimens and the gonococcal fixation test. The treatment usually involves easy distinction of the fact of prosta- titis and of one form from another. According to Young^ the relation of leukocytes, pus cells, epithelia, spermatozoa and bacteria in expressed prostatitic fluid is the deciding factor. This contribution by Young is fully discussed on page 318, under the subject of chronic prostatitis as a complication of posterior chronic urethritis. Treatment of Gonococcal Acute and Chronic Prostatitis. — ^^Yith due regard to significance, this complication is distinctly major because it usually involves the gland deeply, may lead to absorption and rhemna- tism, and not infrequently to an important operation. The varieties of follicular and parenchymatous prostatitis are considered together because, like the symptoms, the treatment is usually one of differences in degree only and not in kind. The prophylaxis is only concerned with the same measures of pre- vention available in all other complications of gonococcal disease, such as caution, care, conservatism and judgment in the treatment of the anteroposterior urethritis. Most important is the instrmnentation of the urethra during the disease. In doubt it had best be omitted. Like- wise the physical methods especially massage and electrotherapy if begun too early and carried on improperly may induce a follicular or parenchymatous involvement otherwise avoidable. Abortion in the 1 Die chronische Gonorrhoe der mannlichen Harnrhohre, Zweite Auflage, 1910. 2 Johns Hopkins Hospital Reports, No. xiii. 122 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS strict sense cannot l)t' accomplisliocl because the symptoms of the prostatitis merge imlefinitely with those of the urethritis. Curaiivc Trcattiwnt. — All measures are founded on inter])retatiou of indications and ])roper choice and ai)])lication of the \arious means at ccunnuukl. The essentials of management are described in ('liai)ter IX, page 4S3, on General Principles of Treatment. Of ])hysical measures in acute follicular prostatitis massage is contra- indicated, but in the subacute stages is valuable and in the chronic stages is ad\-isable for emptying the acini of pus and thus giving them ^estorati^•e impidse. In parenchymatous prostatitis massage is a danger — by extending the abscess through trauma. A chronic abscess with sinus, while awaiting oi)eration, may be tem])orarily benefited by Fig. 25. — Rectal examination of the prostate. The patient is in the knee or knee- chest posture on the table. The elbow of the examiner rests on the side of hip and the body gently presses the hand deeply into the perineum while the finger is relaxed and free of strain to make the exploration of the prostate gland, seminal vesicles and lower bowel. judicious evacuation and absorption from it thus limited. Massage is best performed with the bladder full and the patient stooping over a chair or ta})le. The well lubricated glove index finger is inserted into the rectum w^hile the forearm is supported by the hip for penetration (Fig. 25% The ducts of the gland radiate more or less in orderly manner from the colliculus and the prostatic fossettes. All pressure should therefore be exerted from the lateral borders toward the urethra and the author begins at the lateral border and at the base of the gland and then steadily passes his finger toward the urethra along the upper border, then on the same side a centimeter in front of the first zone, and then a similar distance in front of the second zone until the apex of the gland is reached. Thus one lateral half is completely evacuated and the second lateral half of the gland is treated in exactly the same PROSTATITIS 123 manner. Thus the anatomical structure is carefully respected arifl the normal physiology reasoiial)ly imitated. The hydrotherapy, locally, during the acute period forbids all urethral and vesical irrigation unless acute retention of urine shall have made the gentle passing of a small soft rub})er catheter necessary. While the catheter is in situ the bladder should be protected against infection by irrigation. Rectal lavage with hot water through the double current tube and with hot or cold water through the psychro- phore and the ice-bag to the perineum with protection of the testicles against the cold and to the suprapubic region are comforting. Very hot sitting baths and leeches directly decongest the deep pelvic cir- culation. All these measures quiet the hyperemia and disturbance and thus reduce the pain, irritability, reflex symptoms of the acute and subacute periods but are of little value in the chronic stages. General hydrotherapy is of little importance in the acute period but otherwise in the subacute and especially in the chronic stages. Bodily baths and Turkish baths aid in elimination of the septic absorption so often seen in the recovery after operation. The application of light through its heat and in actinic power in acute onset will decrease the pain and in the chronic stages aid in resorption. It requires prolonged application by the patient or attendant several times a day and will aid the other methods, but is of itself not sufficient. Its convenience of use makes it more attractive than hydrotherapy. The electrotherapy is obviously impossible in the acute period, but is applicable during the late subacute and chronic stages. Its local means are chiefly rectal by the high vacuum glass electrode, attached to the negative pole of a standard multiple plate, high-speed, static, electrical machine for its powerful actinic and mild .r-ray effects. In persistent infection the spark gap is from one-half to one and a half inches for the intensity of the current, five to ten minutes are the duration, and every other day at first and then longer intervals are the frequency. When the infection is cured the static wave current is applied through the metal electrodes, attached to the positive pole of the same static machine, with a spark gap of from one inch to six inches for intensity, according to the resistance of the patient, with twenty minutes as the limit of duration, and with alternate days as the early and longer intervals as the later frequency. Easy count of the interruptions by the spark gap is the standard. Thus are gained alternate physiological tissue contraction and relaxation in a way that is not possible with the finger in massage. Electrolysis through galvanism is the only way in which this modality may be applied to the deep urethra with the copper or silver tip electrodes. Intensity is from 3 to 5 milliamperes, five to ten minutes are the dura- tion and every other day is the early frequency followed by more extended intervals. The positive pole is attached to the electrode and the current induces a deposit of the metal in the tissues. The current should be turned off before the electrode is removed, and if there seems to be spasm or adhesion the polarity should be reversed, either 124 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS or both difficulties are corrected by loosening of the electrode. Cata- phoresis cannot be carried on in the deep urethra hocauso an electrode wound with cotton cannot be introduced there, lliuh-frcciucncy cur- rent of Oudin is applied to iniHvidual follicles in the chronic i)eriod through tlte urethroscope as dctailctl under that subject. The systemic electrotherapy is available for stimulating elimination, digestion, circulation and the nervous system as discussed under the l)aragra])hs de\otc(l to systemic a])i)lication in the electrical treatment of acute urethritis on page 2S1. Medicinal measures are of little avail in the acute or in the chronic stages by systemic administration. Sedatives are required for the pain in the form of o]Mum suppositories, codein by mouth and hypodermic injections of morphin for the urinary disturbance through dilution and neutrality of the urine by drinking water and any of the standard prescriptions already stated, and for the sexual irritation by instruction to keep the bladder and the rectum empty. The })ollakiuria always keei)s the bladder empty in the acute stages, but in the chronic i)eriods such directions are necessary. The rectal distress is aided by the foregoing measures. The serotherapy may be tried in the acute and avails in some cases, but fails in many, and is not in gonococcal disease the magical relief which it is in diphtheria, for example. In general, the serum tends to promote passive immunity in acute conditions and the bacterin to establish active immunity. The latter preparation may be autogenous or heterogeneous and is of more service in the chronic absorptive conditions, but by no means invariably so. Persistent use with other means secures success, and the negative phase must be avoided as detailed in Chapter IX on General Principles of Treatment in the section on Serumtherapy on page 512. The mixed bacterin of Van Cott is often very serviceable in cases having the mixed infection and acti^'e al)soiption. The local administrations are omitted during acute follicular pros- tatitis as all invasion of the posterior urethra must be abandoned until the declining period is well established. Irrigation of the bladder after catheterization for acute retention and retrojection of the urethra, with the antiseptic contents of the bladder as part of this process, is an exception of this rule. Instillations, at first with the soft-rubber catheter and later with the Bangs syringe sound or the Keyes-Ultzmann syringe, Avith very dilute and then slowly ascending standard solutions, are valuable, but often reach only the surface of the mucosa and not the depths of the follicles. They may be called "blanket applications" in covering a large area without definite localization or penetration. Later in the chronic stage, applications of astringents and antiseptics to individual follicles through the urethroscope are good, as discussed under this subject. In the acute and chronic parenchymatous prostatitis local metlica- tion is practically fruitless, because the abscess is deep under the mucosa beyond their reach. Nonoperative surgical measures are advisable and serviceable. PROSTATITIS 125 Acute Follicular Prostatitis.- — For retention of urine, catheterization is foremost, with a soft -rubber catheter, which should be tied in order to avoid frequent invasion of tlie viscus. In th(; later chronic p(;riod instillations and retrojections, as already discussed, are noted. The author's irrigating sound is of special service when dilatation becomes indicated, because it combines retrojection with it at one passage of the instrument. Similarly the Bangs instillatiiig sound may be used for focal medication and for mild massage, with the instrument in place, but only in chronic follicular cases. The Kolhnann irrigating and nonirrigating dilators are also available, but only with the greatest possible gentleness and in the latest period of the disease always without any reactions. Parenchymatous Prostatitis. — ^All these methods are of avail only in the postoperative stage, when the chronic urethritis associated with the prostatitis requires treatment of the mucosa. Operative Procedures. — ^These are chiefly urethroscopic measures and open operation. Chronic Follicular Prostatitis. — ^The operative steps in this lesion are chiefly applications through the urethroscope of astringents and caus- tics to the mucosa, the high-frequency current of Oudin and evacua- tion by incision with the long scalpel of individual acini. Instillations through long needles attached to a hyjDodermic barrel may be tried. The chief field of operation is in acute parenchymatous prostatitis having one or more distinct abscesses or an old abscess either with chronic discharge or frequent relapses of acute attacks with repeated rupture into the urethra or even externally. The technic of operation is simple for cases with pus present to the examining finger by the enlargement, tension or fluctuation, or with pus indicated by severe absorption closely simulating typhoid fever, with which they are sometimes confounded during the first few days. Equipment is the same as in external urethrotomy w^ith a guide, and the preparation of the patient is that usual for any major operation and of the field by any recognized method, of which none is better than tincture of iodin, provided the scrotum is not thickly coated. iVnes- thesia is by choice general on account of the uncertainties of the deep dissection, but may be spinal in occasional cases, and rarely local because the inflammation makes the instillation so painful. Posture is exaggerated lithotomy and general landmarks are the rectmn behind, base of scrotum in front, with its raphe, the tuberosities of the ischia and the urethra made prominent by the author's irrigating sound. The incision should leave the urethra intact and be made over the prominence of the swelling in unilateral cases and over each swelling in bilateral, discrete cases, exactly as in bilateral cowperitis and over the abscess as a whole in bilateral confluent cases. Its form may be straight and oblique, horizontal or cu^^^ilinear, as in perineal prosta- tectomy. The horizontalincision is to be preferred when possible because it most conserves the muscular structiu-es of the perineum, gapes longest for drainage and is in general parallel with the prostatic 126 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS ducts. Tlie superficial field is the perineal skin, fat and fascia and avoids the muscles as far as possible hy blunt dissection to the lower surface of the gland, which is the deej) fiekl. If pus is not apparent to the fiJiger an aspirating needle will locate it, upon which as a guide the straight l)la(le sharp point bistoury is entered and the prostate divided to the limit of the skin incision. The finger in the wound now explores the cavity of the gland for other foci and gently breaks them into the main pocket. The rouniled tip of a velvet eye catheter is passed into the wound for irrigation and stitched to the skin for drainage combined with one or more cigarette drains which with external dressing and a good T-binder still all hemorrhage. No suture of the wound should be necessary. If no pus is located free incision is warranted as a relief of hyperemia and absorption. Pus will ai)pear in such a wound (piite regularly after a day or two. The disa])pro\ed methods are puncture of the abscess, with trocar and cannula, through either the perineum or the rectum, because neither route nor instrument gives adequate drainage, and the rectum becomes infected with the gonococcus and the abscess, with the flora of the bowel, notably the Bacillus coli communis. Immediate Ajtertreatment. — Irrigation of the bladder is adx'isable through the author's tunneled and grooved sound, used as a guide before its removal, and observation and change of the dressing for imdue drainage or oozing, and remote aftercare is removal of the drainage tube in from three to five days and of the cigarette drains in from five to ten days when the patient begins to get up. Standard nursing and diet are the rule. When the wound has practically healed, cautious attention to the posterior urethritis should be begun and ])rose- cuted with great judgment in order not to offend the recovering gland again. Cure. — Cure is not possible for entire restitution in the pathological sense, but relief from all symptoms and restoration to nearly normal physiology is usual in the symptomatic aspect. Return of the urethral mucosa to absolute normal probably rarely occurs. Perhaps most important of all is relief from infectiousness in })otii the follicular and the pa^ench^Tnatous forms, thus constituting bacteriological cure — a most important sociologic matter, because the prostate is copiously and directly related with the production of the semen. SEMINAL VESICULITIS OR SPERMATOCYSTITIS. Occurrence. — Infection or affection of the seminal vesicles as a complication of any urethral condition is a rare occurrence except in posterior suppurative and especially posterior gonococcal urethritis, of which the latter is taken as the type. Etiology. — It may appear during acute disease or during an exacer- bation of chronic disease or simply in the course of the latter, induced by an exciting cause. Seminal vesiculitis has as exciting causes direct extention of infection by the gonococcus from a posterior urethritis SEMINAL VESICULITIS on SPERMAl'OC'YSTiriS 127 through the ejaculatory ducts as they emerge through the collicuhis seminahs nearly at the midpoint of the prostatic urethra. The pre- disposing causes are lowered local resistance through other forms of urethritis, notably catarrhal and diathetic lesions, through congestion of masturbation and venereal and dietetic excess, and tlirough infiaiii- mation augmented by traumatism from catheters, sounds, urethro- scopes, instillations, irrigations and the like. The most potent con- tributing cause is coitus or masturbation during a posterior gonococcal chronic urethritis. Varieties. — Seminal vesiculitis is recognized under the following forms, primary and secondary as to occurrence; unilateral and bilateral as to situation; acute, subacute and chronic as to course; catarrhal, suppurative, gonococcal and tuberculous and with and without occlusion of the ducts, as to pathology. Chronic seminal vesiculitis belongs to the general subject of chronic disease in later chapters on page 318. The primary seminal vesiculitis is of very rare occurrence, except in tuberculosis, with which this work is not directly concerned except mention and differentiation. On the other hand the secondary seminal vesiculitis is very common, associated with and complicating posterior gonococcal urethritis. The catarrhal form and the suppurative form are more commonly the terminal stage of the gonococcal condition than essential lesions. As in all other glandular complications of gono- coccal origin the ducts may be occluded or not leading respectively to abscess formation or severe infection, with constant drainage of pus into the urethra. Any form of sperm atocystitis may be unilateral or bilateral, with a tendency toward double involvement, wdth one vesicle the more actively diseased. Pathology. — Acute Sperviatocystitis. — Acute spermatocystitis with- out retention is in essence a gonococcal invasion of the seminal bladder, with a stage of invasion, establishment and termination, exactly as in urethritis. The cavity of the vesicle after the congestive lesions of the invasion are over is filled wdth pus containing desqua- mated epithelium, blood, pus cells and other detritus. At some points the process is deeper than elsewhere. After temporary distention the contents are evacuated into the urethra and the process renews itself. The whole process may be temporary or in part permanent, respectively with full or partial recovery. The pathology of acute spermatocystitis with retention is that of a localized abscess, more or less destroying the seed sac as a whole and extending frequently into the surrounding tissues and pointmg in almost any direction, downw^ard through the perineum to the skin, forward into the urinary bladder, backward into the rectum and upward into the peritoneal cavity as a rare occurrence. The pathology of chronic spermatocystitis depends on the initial variety. If there has been no retention the chronic inflammatory changes in the gland and its duct continue with persistent or relapsing discharge. The gland is often converted into an indolent pocket, in 128 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS Avliirli the discliarge insistently forms and from whicli it is evacuated. Sometimes the ghmd is atrojjliied to a eicatrieial or infiltrated recess with little or no discharge. If retention has occurred, the condition subsqeuent to abscess any- where in the body is seen, varying from total destruction of the gland to cyst formation and including listuhv into various annexa, as de- scribed under symptoms. It is in the early periods of the chronic dis- ease that infectiousness continues and may last for years. It is probable that finally it always disappears through Nature's processes. Symiitoms. Si/)iiptoin^' of Acute Seminal ]'c.sicNUtis Withoid Reten- tion. — This is the much less severe, but the more common form, and its subjective symptoms vary with the activity of the case and, though relatively indefinite in mild cases often masked by the con- comitant i)rostatitis or epididymitis, may be in themselves very active. They show, like all infections, stages of invasion, establishment and termniation and local and systemic features. The local subjective SNinptoms of im-asion are insidious, as a rule, attracting little or no attention in addition to the symptoms of the condition with which it is comi)licated: that is, posterior acute or chronic urethritis, prostatitis, funiculitis, epididymitis or epidid\inoorchitis. Frequently the lesion is showTi only by slight increase in s^inptoms already existing, particu- larly when the primary condition is also acute. The establishment shows sensory, urinary, urethral, rectal and sexual features. The sensory symptom is pain, dull or severe, thro])bing or heavy, referred variously to the deep pelvis, neck of the bladder, root or head of the penis, testes, perineum, anus, loins, and even kidneys. The pain is increased by muscular activity and pressure of a full bladder or loaded rectimi and usually decreased by rest. The urinary s^'mptoms are pollakiuria, dysuria, tenesmus and vesical spasm. The painful frequency of urination is great by day and night, and the act is painful and straining with altered stream, particularly when the prostate is much involved. For the latter reason also tenesmus and vesical spasm may be almost uncontrollable. The urethral symptoms are usually a decrease in the discharge, exactly as occurs in epididymitis, unless the prostate is very actively inflamed. The posterior urethral discharge, however, resumes its former character when the seed sacs are in the declining stage of inflammation, and if bloody shows in terminal streaks or drops. As the spermatocystitis progresses and evacuates itself the discharge increases and appears in shreds, strings and slugs, at times uniformly blood-streaked. Sharp colicky pain may accompany the discharge of the distended vesicles, through a veritable colic of obstruction. Reliquet' claims that it may be confused with ureteral and renal colic. Its origin is disturbance of the spermatic vesicle like that of the urinary bladder during inflam- mation. The rectal symptoms are constipation from pressure and strain and fear of pain during defecation and tenesmus and spasm ' Coliques Spermatiques, 1880. SEMINAL VESICULITIS OR SPERM ATOCYSTIT IS 129 from nervous irritation. The sexual symptoms are frequent erections and seminal emissions, accompanied by blood and the colic just spoken of, which is a more common cause of the colic than draiuaKe of the i)us. The local objective symptoms of acute sperm atocystitis without retention had best be obtahied on a full bladder. Definite knowledge of the anatomical position of the parts is necessary. Above the pros- tate, near the angle of each lateral lobe, lie the common ejaculatory ducts formed by the confluence of the vas deferens with its ampulla nearest the middle line with the duct of the seminal vesicle, most laterally close to the pelvic wall. In the angle between the ampulla and the seminal vesicle is the ureter, usually out of reach in health unless the examining finger is unusually long and the })ladder highly distended. From without inward the structures are therefore high up, the seminal vesicle, ureter and ampulla and low down the duct of the vesicle and the outlet of the ampulla uniting into the common ejaculatory duct. In order to reach the vesicle the finger should be passed to the angle of the prostate and then as far upward and out- ward to the pelvic M^all as possible. This manipulation will never fail. One or both vesicles and invariably the one more than the other will be found hot and tender, tense and elastic or fluctuating. Even gentle touch often causes sudden flow of the contents into the urethra, which the patient announces. Urinalysis shows all glasses filled with pus. The author's seven-glass test is important. The first three glasses from a full bladder are accepted as reasonably indicative of the urethral contents; gentle massage of the vesicles wiU be foHowed by great increase in the pus of the sixth and seventh glasses, containing rather clearly the separated pus of each seminal vesicle. The fifth glass contains the prostatic secretion. A catheter carefully passed eliminates the bladder in the fourth glass. Thus most pus will be in the first and second urethral glasses and in the sixth and seventh or seminal vesicle glasses and least pus in the third glass in the average case, unless the prostate is greatly compromised Phosphaturia from the constant leakage of semen into the urethra is sometimes seen, especially in the first glass and massage seminal vesicle glasses, thus distinguishing it as a local and not a renal phos- phaturia. These facts should make a diagnosis, but the exploratory needle may be used — not advisedly, except in very skilled hands. The routes are two: through the rectum, which is to be condemned on accomit of the danger of infection and fistula and through the perineiun, which is the safer, under the following technic : The skin may be nicked with a scalpel in the perinemii about one inch (3 cm.) anterolaterally from the anus, and then with the finger in the rectum as a guide, the needle is entered and directed upward, outward and slightly for^'ard, passing the prostate along the finger, which should be on the lower part of the vesicle. A specimen thus obtained should be microscopically examined. The microscopic diagnosis displays pus, detritus, spermatozoa, gono- cocci and its allies, and should never be omitted. Its feature is paucity 9 130 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS of prostatic elements, provided the prostate is little or not affected and the vesicles predominately or solely involved. The systemic, subjective and objective symptoms of acute spermato- cystitis without retention are similar to those in prostatitis: chill or chilliness, fever from 100° to 105° F., malaise, nausea and vomitinji;, depression, prostration and loss of sleep. A feature of this complica- tion is a tendency toward absorption, leading especially to arthritic and allied conditions, so that one might clinically say that there are two tj'pes: cases with absorption and cases without absorption. The fever is, moreover, apt to be of the so-called urinary or urethral type, easily provoked by examination of the vesicles, suddenly showing great height, delirium, anuria and prostration. It is therefore important to proceed with the greatest possible gentleness in the objective examination. The s^Tuptomatology of subacute spcrmaiocystiiis without retention duplicates the foregoing description in kind but much less in degree. The sjTuptom-complex of acute seminal vesiculitis with retention, othenvise called abscess of the seminal vesicles, augments all the fore- going conditions and adds the presence of the abscess itself, which may involve the seed sac alone or the surrounding structures also, leading to more or less total destruction of the organ and penetration of the pus as set forth under the subject of pathology. Each such sequel has its own obvious train of symptoms, due to the pocket, sinus or fistula left behind, either seminal, urinary or fecal. Abscess of the seminal vesicle is always the source of the absorptive conditions pre- viously spoken of. It has another peculiar feature in that pressure of the abscess may obstruct the ureter and cause distinct s>Tnptoms of colic. This is more apt to be the cause of renal colic than is the drainage of the seminal vesicle contents spoken of by Reliquet.^ The termination of all forms of acute seminal vesiculitis begins usually in one or two weeks after full establishment. Recovery and resolution occur in mild cases, much damage rather than little damage is seen in severe cases and total destruction in abscesses of the sacs. Both sides are usually involved, of which one may recover and the other not or both be damaged the one more deeply than its fellow. The burrowing of pus in abscesses with perivesicular complications often terminates in chronic pockets, sinuses and fistuloe in the ischiorectal fossa, rectima, bladder and perineum. Semen is an element in the fistula no matter where it empties and should therefore always be looked for in suspected cases, associated with urinary or fecal connec- tions. Rupture of the abscess into the peritoneum and septicemia have been noted in fatal cases. INlyositis, tenosynovitis and iirthritis and other signs of absorption may also occur, and do occur rather more frequently with seminal vesiculitis than with any other gonoocccal manifestation. Ureteral pain, owing to the relations between the ureter and the ampulla of the vas and the vesicle on each side of it and arising ' Loc. cit. SEMINAL VESICULITIS OR SPERMATOCYSTITI S 131 in the pressure and obstruction of the distention and perivesicular infiltration, is often a later sequel in severe cases. Complications.— The complications of acute seminal vesiculitis are rather the lesions with which it is commonly associated — namely, funiculitis, epididymitis, orchitis usually making one and the same clinical picture and prostatitis generally the condition to which it is secondary. Intense funiculitis may cause peritoneal symptoms along its course from the base of the bladder upward, forward and outward to the deep abdominal ring, and if it were not for the obvious local infection appendicitis might be suspected. Diagnosis. — ^The two general forms of this lesion must be remembered and distinguished. Acute seminal vesiculitis without retention implies a vicious antero- posterior infection of the urethra, in its history, with intense involve- ment of the posterior portion of the tube and often combined with prostatic and testicular lesions, even overshadowing symptoms from the seed sacs themselves. The local subjective symptoms are absent or merge with those of the other sexual glands, such as the prostate, or are otherwise sensory, urinary, sexual and rectal showing intense irritation. Objectively are found enlargement of one or both sacs and signs of infection with infiltration, swelling, pus formation and peri- vesicular invasion. Systemic symptoms are those of severe infection at any other point of the body. Although at first seminal vesiculitis seems to give less absorption than prostatitis, in the end it leads much more frequently to arthritis and similar remote complications. Irriga- tion of the urethra followed by massage of the vesicles, with careful avoidance of the prostate, develops characteristic contents for the laboratory. By repeating this test at different sittings a specimen from each sac may be obtained with reasonable distinction between the two. Microscopic features display pus, detritus, spermatozoa, gonococci and its allies. Its feature is paucity of prostatic elements, provided the prostate is not massaged in securing the specimen and is itself much less involved. Treatment of the urethritis, as in other complications, tends to benefit this, but the local measures of massage and similar procedures have a direct influence. Direct treatment of the vesicles should not be undertaken until the subacute stage has long been established. Acute seminal vesiculitis ivith retention is a fully established abscess of the seed sac and offers all the intense forms and kinds of s^anptoms just described, but much increased. Rectal examination presents a tense or fluctuating mass and widespread perivesiculitis. If external ruptm^e has occurred, exploration of the sinus with the probe along the rectal finger is advised and final in its proof. Surgical evacuation of the abscess, as yet unruptured or after rupture, will reach the cavity of the destroyed sac and dispel any doubt of the lesion. Differential Diagnosis. — Differential diagnosis respects tuberculosis and neoplasm in the following general terms: Tuberculous differs from (jonococcal spermatocystitis in the history of other foci, as in the lungs, joints, kidneys or urine, in the s\Tnp- 132 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS tDiiis of" ]>us, loss coinmon, ol' hlood iiioro frtHjiU'iit in tlu> oarly stages, and wasting nianitVst in tlio later stages; in nioiv pain of nagging char- acter and in the i)resence of nodes and nodnles which are tender not only in the vesicle but in the prostate, ampulla of the vas, the ^•as in the groin "and scrotum and epidid\inis on one or both sides, in its painful seminal emissions and in signs of tuberculosis in the bladder and ])osterior urethra on cystoscoi)y and urethroscojiy. The Ial)ora- tory tliscovers no gonococei on smear and culture but the bacillus of tuberculosis^ verified by animal inoculation. There is no gonococcal complement fixation reaction, but often the tuberculin reaction. l*us in the sj)ecimen is often less prominent and blood more prominent. Treatment by the standard methods of management and suj)])ort against tuberculosis are of avail. Serotherapy with tuberculin and other bacterins is often of advantage, while open invasion of the vesicles is undertaken Avith caution because the wound often becomes infected widely and sinuses which never heal may result. XeojjJasiic differs from f/onococcal spermafoci/stitis in having a very dubious history of no infection with the gonococcus and no tubercu- losis in the kidneys or elsewhere in the body;, in its unilateral situation ; in its early indefinite or absent symptoms of dragging and discomfort, of irregular bleeding with or without seminal emission or coitus, and of tendency to painful erections; in its nodes, at first discrete then with progressing infiltration, with little or no pus but more blood on pres- sure, and finally with involvement of the whole region. The author's seven-glass test will secure a specimen from the diseased vesicle in glass seven, from which the diagnosis may be possible, provided tumor cells appear in the exudate. The bloody character of the tubercle bacillus tends to show that the disease is not tuberculosis. Cystoscopy is negati\'e early, but later the bladder is deformed by the prominence of the tumor and engorgement of the bloodvessels, and may ulcerate by direct contiguity. Urethroscopy in the invasion is negative, but blood may be discharged from the vesicle-on pressure, with little pus at first, then much, associated with detritus from one side. The labora- tory rules out the tubercle bacillus and the gonococcus, the tuberculin reaction and the gonococcal complement fixation test. Specimens contain pus, blood, detritus, epithelia and sometimes shreds of tissue establishing the diagnosis. Treatment if done early removes the affected vesicle and proves the diagnosis, anatomically considered; if done late the specimen taken does likewise. Calculous differs from (/onococcal spermatovesiculitis in haA^ing little or no history or one similar to that of the complication without reten- tion; in its symptoms of spermatic colic on the effort to evacuate the vesicle during orgasm, emission or massage, due to the temporary plugging of the duct or moving of the calculus about in its pocket; in its pain milder but comparable to that of bladder calculus, situated in or referred to the testicle or penis, the rectum or perineum and the sacral or lumbar region; in its dull discomfort, instead of pain due to irritation by the stone and evoked by a full rectum or bladder aufl their SEMINAL VESICULiriS OR HPERMATOCYHTJTJH 133 evacuation and by massage. Rectal examination detects the stone and secures a specimen of the pus. Urethroscopy is negative unless the duct is inflamed or pus presents in the field on pressure. The seven-glass test of the author will show one vesicle (lis(;as("(l and the other normal. 'VYm laboratory j)roves the absence of tubercle bacillus and the gonococcus, the tuberculin reaction and the gonococcal fixa- tion test, but shows pus and blood cells, mucus and detritus from the affected organ. Treatment with hot sitz baths and rectal irrigations and medicinal sedatives relieve the symptoms as in any other form, while exposure of the vesicle and removal of the stone finishes the diagnosis. Chronic Seminal Vesiculitis. — Chronic seminal vesiculitis repeats the story cf severe and complicated attacks in the history of gono- coccal urethritis or in that of a single intense attack without cure but with relapses of discharge. The actuality of or tendency to absorptive signs is almost essential. In chronic sijermatocystitis without retention insistent discomfort and consciousness of the perineal zone without real pain is the chief com- plaint, adding variable frequency of urination, much discharge of pus in clumps, slugs and strings and expression of semen and pus during defecation. Almost uncontrolled sexual excitement and seminal emissions mixed with pus and blood are not uncommon. Objectively, the vesicle on one or both sides show^s enlargement with prominence, thickening with sclerosis or thickening with bogginess and a free flow of pus and detritus — all by rectal examination. The seven- glass test reveals the anterior urethra without much involvement, the posterior urethra with many slugs and strings of pus, the bladder con- tents normal, the prostatic glass without or with elements from this gland and either or both seminal vesicular glasses equally or variously filled with the products of focal inflammation. The difference between these two glasses diagnosticates the more involved vesicle and whether or not the prostate is much involved as is frequently the case. Sys- temically there is less intense disturbance but more absorption than in acute lesions, so that arthritic, myositic, tenosynovial and cardiac lesions are by no means uncommon. " In chronic sijermatocystitis with retention all the foregoing subjective and objective conditions are found with the fact of a true abscess in or about one or both vesicles added, which follows either the chronic persistent course with little or no change or the chronic progressive course with relapses. Absorption furnishes the greatest syndrome which may sunulate almost any other disease, such as anemia, myelitis, neuritis and neurasthenia. Cautious analysis of each case is essential. Urethroscopy of the deep uretln-a in both types of the lesion reveals pus from the prostatic ducts if this gland is compromised, and pus from the seminal ducts wdiich may have nearly normal or greatly inflamed mouths in a colliculus covered with edema and granulations. Much invoh'ement of the posterior urethra is common. The finger in the rectum readily expresses pus for a specimen, which in the labora- 134 COMPLICATIOA'S AND SEQUELS OF ACUTE URETIIRiriS tory on smear and culture reveals the ii;onococcus, with its allies combined with sijcrmatozoa and epithelia. The seven-glass test also furnishes desirable specimens and the gonococcal complement fixation test is the final i)c)siti\e point. Treatment by massage of the vesicles by their exj)osure in the ojjcn operation completes the diagnosis. Treatment. — Gonococcal seminal vesiculitis has recently assumed great importance in all its aspects. Its significance is major because spermatocystitis is the most potent single factor in the absorj)tion causing arthritis and similar systemic invasion. rroi)hylaxis so far as })ossible avoids the causes enumerated in the clinical re\iew on page 127, such as ill health, attacks of catarrhal and diathetic urethritis, frequent congestion in venereal and dietetic excesses or in traumatism of instrumentation and medication. Direc- tions as to sexual abstinence from direct and indirect excitement or mastm'bation or intercourse during a chronic urethritis are important and emphatically so in judicious treatment of posterior acute or chronic urethritis. As the symptoms emerge imperceptibly from those of the posterior urethritis abortion is not practicable. Curafire Treatni ent.—Heliei of infection of the sperm sacs must be guided by the featiu-es of each case. Thomas and Pancoast^ say — "Thus the following considerations arise: (1) Is the ejaculatory duct strictured or obstructed? (2) is the vas deferens strictured? (3) is the inflammatory collection in the seminal vesicle loculated?" and quote Belfield- and Aschofi"'^ to show that strictures do occur. Seminal vesiculitis with occlusion therefore forbids success to massage and vasopunctiu'e or vasostomy and indicates vesiculotomy. Subjective and objective symptoms are sensory, urinary, lu'ethral, rectal and sexual in their elements, locally, as presented in the clinical data on page 130. They have the general type of irritation in the acute lesions and of the production of pus with discharge or of the production of pus with retention in the chronic cases according to the patency or occlusion of the duct. Systemically absor])tion is seen chiefly in the chronic form with relapses, due to temporary occlusion of the duct and retention of the pus, as relapsing abscess and less commonly when the duct is not obstructed and drainage is more or less incessant and indolent. Both forms, however, are often active foci of low-grade systemic involvement. Management should tend to maintain resistance and bodily health and to provide antisepsis by suitable hygiene and other protection. Rest in bed is imperative during the acute disease or active exacerba- tions of the chronic disease and sexually through abstinence from intercourse and other excitement and the abolition of seminal emissions by suitable sedatives. In chronic cases this reflex cannot l)e controlled except through avoidance of irritating food, drinks and the fondling 1 Loc. cit. 2 Jour. Am. Med. Assn., March 15, 1900, p. 800; November 22, 1913, p. 1867; Surg., Gynec. and Obst., May, 1913, p. .569; November, 1916. 3 Loc. cit., p. 24. SEMINAL VESfCULiriS OR, SPERMArOCVSTITIS 135 of women, but intercourse must be forbidden — all on account of the hyperemia which in these subjects is l)ad. Exercise is abolished during active symptoms and is begun with walking in chronic cases and with avoidance of agitation and vibration incident to cycling, running, automobiling, railroad-riding and the like. Diet and drink are of the fever and nephritis types in acute cases, and always of light, non- irritating varieties in chronic lesions. Alcohol in any form or amount had best be abandoned. In physical measures, overstimulation or even traumatism in acute cases forbids massage, but the failure of competent drainage and even retention of pus require it in chronic spermatocystitis without or with occlusion of the duct. The preferred method requires a full bladder, insertion of the gloved and well-lubricated index finger into the rec- tum, supported by the hip for penetration (Fig. 22). The vesicle lies farthest out of the three structures, which from without inward and above the prostate are the seminal vesicle, ureter and ampulla of the vas. The finger reaches the highest part of the vesicle, and with steady, firm, gentle pressure passes along it from above downward and from without inward toward the urethra and prostate, where the ejaculatory ducts empty. The ampulla of the vas is felt for and massaged in the same way because it is almost always diseased like- wise. Several minutes are given to the massage of each side and the treatment is repeated once in five to seven days or oftener if well borne, which implies no reaction in the testes, prostate or seminal vesicles themselves. Such massage duplicates the action of sexual intercourse in emptying the seed sacs of semen and of pus in this dis- ease at regular intervals, but differs from coitus in its freedom from congestion and excitement. The hydrotherapy, locally, requires all measures to be stopped in acute disease, to which rule irrigation of the bladder and retrojection of the urethra in cases of acute retention of urine are exceptions exactly as specified under prostatitis. Rectal irrigations through the double current tubes or through the prostatic cooler are fully worth while in the active cases, and sitting baths and leeches may be added as potent decongestants. General baths augment elimination and may inhibit absorption and benefit rheumatic tendency. Turkish baths are best of all. Light is a convenient excliange for the heat of hydrotherapy and for its known actinic and penetrating effects. It is attractive because so easily applied by the patient himself with the 60-candle power therapeutic lamp several times a day for from thirty to sixty minutes at each sitting. The electrotherapy, locally, is contraindicated in acute cases, but is reserved for declining and chronic disease according to the case. Diagnosis of the exact lesion is all important. Persisting infection calls for the high-degree vacuum glass electrodes (Fig. 69), inserted into the rectum and applied to the affected vesicles in turn and steadied in a suitable holder against slipping. Urethral treatment is of less service. Attachment to the negative pole of the standard multiple- 136 COMPLICAriOXS AXD SEQl'ELS OF ACUTE mETHRITIS plato liiixh-speeil static inacliinc is made. The sj)ark gap is from one-halt' to one and a half inches for intensity, five to ten niinntes fix the duration and alternate days are the frequency. There must be no pain or reaction after these treatments and the intervals and the sittinjis arc made longer as the case ])rogresses. In absent infection the static wave current is applied through the metal electrodes, connected Avith the positive side of the same static machine. A spark gap from one inch to six inches sets the intensity within the toU'vance of the patient, twenty minutes limit the dura- tion and alternate days give the early and longer intervals the later fre(iuenc\' and the accepted interruptions should he readily counted. Electrolysis, by which a copi)er, zinc, aluminum or silver electrode insulated with shaft to protect the anterior urethra is passed into the deep urethra and attached to the positive galvanic i)ole, is of moderate value for the urethritis. The indiii'erent electrode is ajjplied to the abdomen. The current is measured to from 3 to 5 milliamperes and the duration five to ten minutes and the frequency every three to five days. There must be no reaction. Adliesion or spasm about the electrode retiuires reversuig the i)olarity until the instrument is free before withdrawing. The systemic electrotherapy duplicates that described under acute urethritis, and referred to under prostatitis, as of benefit to elimina- tion through the skin and kidneys, nutrition through the digestion and circulation and sedation through the nervous system. ^Medicinal measures in the acute spermatocystitis suggest sedation of circulation, sensation, reflex irritation and functional disturbance by systemic administration exactly as in urethritis itself. Support against absorption and depreciation of health with the secondary rhemnatic tendencies is aimed at in the chronic forms. The various drugs and formulas aA^ailable are the same as those given in previous pages for acute and chronic urethritis and for other complications in their acute and chronic manifestation. The serimitherapy may aid but is without value in some patients. The seriun in acute cases may establish passive immunity, while the bacterins either hi the autogenous, heterogeneous or Van Cott's^ mixed form will possibly induce active immunity, as described in section on this subject on page 520. Persevering administration without ex- citing extreme negative i)hase, and with the aid of other means of treatment, is important, but gonococcal laboratory products are not as successful as, for example, diphtheria antitoxin. The local administration invariably presents no treatment of the urethritis until the vesiculitis is well along on its decline. As in hydro- therajn', irrigations, injections, instillations and ai)plications are all stopped during the acute symptoms. ]{etrojections in the presence of acute retention may be allowed with dilute fluid. Retention of the catheter is preferable to frequent passing of it for this purpose. In the ' Loc. cit. SEMINAL VESICULITIS Oil SPEUMATOCYSTITIS 137 chronic stage, after the seminal vesicle has been dealt with surgically, all the methods and drugs applicable to posterior chronic urethritis may be chosen with caution, judgment and gentleness. In nonoperative surgery of acute periods, only during retention of urine an indwelling catheter may l)e used for relief for a jew days, with lavage of the bladder several times daily, or if not severe a small soft-rubber catheter may be passed and irrigation performed with retro- jection. In the late aftertreatment, after the operati(jn, the posterior urethritis requires attention, but its treatment must have no reactif>n but only progressive benefit, and should be discontinued at the slight- est disturbance. Dilatation gently performed with the author's irri- gating sound, with flushing of the bladder and retrojection, or in the same manner the Bangs instillating sound and the Kollmann dilators may be used. Gentle massage of the posterior urethra with a soft catheter or flexible dilator in place is sometimes helpful when the case is nearly well and still has indolent symptoms. Operative surgery provides the same rules for urethroscopic applica- tions and fulgurations after the operation on the vesicles themselves has ceased and the sac recovered. As in prostatitis, these measures are of avail only for the remaining posterior urethritis. They are wdth effect only on the surface and immediate underlying region. There are four approved operations available: vasopuncture, vasostomy, and the vesiculotomy of Fuller and of Squier, and one disapproved technic — aspiration of the vesicle through the perineum. Thomas and Pancoast^ describe the first two procedures as follows : Vasopuncture and Vasostomy. — Chronic spermatocystitis, with or without drainage, is the proper selection of case for benefit without the dangers of radical operation, according to Thomas and Pancoast.^ The instruments and supplies are scalpel, scissors, forceps, hemostats, ligatures, small sharp and blunt retractors, needle holder, needles, sutures, drains and dressings, with a large suspensory bandage, also hypodermic syringe, with the following drugs of which Thomas' prefers collargol, 10 per cent. The other preparations are 20 per cent, protein silver, made in the Hare Chemical Laboratory of the University of Pennsylvania; argyrol, 10 per cent.; protargol, 0.5 to 1 per cent.; nitrate of silver, 1 to 2 per cent. Anesthesia is by local infiltration with cocain, 1 in 500 watery solution, or its analogues, and the posture is supine, with the one landmark of the spine of the pubis and the cord passing outside and below it, which places the mcision over the cord from one to one and a half inches long passing through skin and superficial fascia as the superficial field down to the pillars of the super- ficial abdominal ring, with the cord emerging as the deep field, whose layers are separated to reach the vas deferens usually behind and above the other structures. A rubber-covered clamp, after Crile's method, or a stitch is passed across the vas distally to prevent pene- tration of the drug into the epididymis and secondary chemical reac- 1 Loc. cit. ' Loc. cit. 3 Personal communication to the author, April 25, 1916. 13S COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS tion. ^'asopllnctllre is pert\)rmocl by exposing the vas in the inguinal canal, and then injecting through a fine needle passed into its canal various medications, and Aasostoniy consists in Iea\ing the vas open for nunuTous rei)eated medications. During such applications in either of these procedures the distal portion ])assing to the testicle should be very gently closed with a rubber-guar^led clamp after the method of Crile, Avhich will not injure it if carefully performed. The dithculties of these procedures are traumatism to the vas by repeated use of the needle and irritation of the mucosa by even dilute solutions; certainly no concentrated medications could be considered. The con- dition of the duct for outlet of such fluid must also be known, other- wise traumatism of the vas and vesicle by distention would be assured. This detail is exactly like that of injury to the pelvis and kidney by overdistention of the ureter with fluid opaque to the .c-rays. The suture material is the finest plain catgut introduced transversely dia- metrically across the vas at about the midpoint of the oblique path of the needle puncture. By making sure to pick u}) only the outermost coat of the vas there is little danger of harm to the hunen, although it will be temporarily compressed. This stitch seems to be the only effectual method of preventing backflow of the silver solution along the path of the puncture and backward into the epidid^iiiis. In ^•asopuncture the needle of the syringe is gently passed into the hmien of the vas deferens and from 3 to 5 c.c. of the solution gently injected, and then the vas is dropped back into place and the Crile clamp remoA-ed and wound closed with standard suture, with or with- out a small rubber tissue drain, for twenty-four hours against oozing. Primary union without incident is the rule and great pain in the epi- didymis and vesicle is the exception. One efficient injection relieves if this method is adequate at all in a given case. In vasostomy the vas is either slit longitudinally or transversely divided and brought into the wound for repeated medication during from one to four weeks. The re])air of such an opening into the vas is the problem of this technic. Aftertreatment. — The immediate aftercare provides primary union without drainage except for twenty-four hours and standard nurs- ing and diet and symptomatic medication for vasopuncture, while secondary union is the rule for vasostomy. Remote aftertreatment respects the occasional chemical vesiculitis and epididymitis along the lines already described for them. Comments include the absence of danger to the seminal apparatus. Cautions avoid inflammation of the mucosa lining it by the use of only 3 to 5 c.c. gently injected and the end-results are a s\Tnptomatic cure shown by relief of sjanptoms and signs, by the absence of inflammatory products in the urethra in the author's seven-glass test and perhaps by the presence or absence of spermatozoa. On the last point, Thomas, in a personal letter to the author, has no conclusions and likewise concerning histopatho- logic restoration. The author feels that the difficulties of the pro- cedures are those of traumatism to the vas by repeated use of the needle and of irritation of the mucosa by even dilute solutions. SEMINAL VESICULITIS OR SPERMATOCYSTITIS 139 Fuller s^ Vesiculotomy. — Much credit is due J^'uller, oi New York, for developing the surgical treatment of si)ermatocystitis. Selection of case respects all subacute and chronic conditions especially those with systemic symptoms and sequels, such as rheumatism unrelieved by other means. The instruments are few and usually only scalpel, scissors, long-grooved director, needle-holder, needles, sutures, rubber- tube and cigarette drains and gauze packing. Artery clamps and ligatures are rarely needed as the operation has minimal hemorrhage and retractors may be omitted because the wound gapes widely of itself. The preparation of the patient and the field are the standard used in all major work with special attention to an empty bowel and bladder and the anesthesia is by choice general although spinal might be possibly used for the posture, which is the knee-chest supported by attendants or the strap and bar holders of the ordinary table. Super- FiG. 26. — Line of incision. (Fuller.) ficial landmarks are the tuberosities of the ischia, the borders of the sacrum, the anus and the perineal body while the deep landmarks as encountered are the central perineal tendon, rectum, ischiorectal fossa, urethra and posterior surface of the prostate. The incision is transverse from tuberosity to tuberosity well below the anus and joined at each end by a 6-inch lateral, oblique, liberating division along the borders of the sacrum. All three cuts interest the skin, superficial fat and fascia exposing the superficial field, as Step I, Fig. 26. Perineal dissection is Step II. Natife-al retraction of the wound releases the rectum for separation from the prostate prefer- ably with the back and not with the edge of the knife in order to spare the muscles of the perineum and the vessels of the rectum which retract upward with the bowel while the perineal body with the pros- tate retracts downward, both through normal elasticity of the tissues. The central raphe and tendon of the perineum are divided as in Fig. 1 Jour. Am. Med. Assn., May 4, 1901; Am. Jour. Derm., vol. x, Xo. 3; Med. Rec, January 23, 1915; Tr. Am. Urol. Assn., vol. vi, p. 274; Tr. Am. Urol. Assn., iii, p. 44. 140 COMPLICATIOXS: AXD SEQUELS OF ACUTE URETHRITIS 27. Tho Hiiijor must be in the rectum as a uuide for this technic. Rectal isolation is Stej) III involvins;- its separation from the prostate, seminal vesicles and bladder in the deep fields. The left finger is in the rectum while the ri.yht works with the j^alm toward the pros- tate and the tip curved to avoid injury to the bowel, which should not be entered. Hands rcsistinu' the lin,m>r arc cut throuiih. When issectiiiii. I Fuller.) the rectum is thus freed the dissection is extended laterally to reach the seminal ^•esicles (Fig. 2.S). Insertion of director is Step IV along the a])ex of the forefinger of one hand resting on the seminal vesicle, while the opposite hand passes the instrument and holds it in place while the guiding finger is withdrawn (Fig. 29). Incision of the vesicle is Step V. The knife, guided along the director to the sac Fig. 2S. — Separation from the rectal wall. (Fuller.) and its belly i)ressed against it by the guide, makes an incision the entire length of the spermatocyst through the jiosterior wall at least and in severe cases through the anterior wall also. Additional reliev- ing incisions are placed in the same way in infiltrated cases (Fig. 30). Packing with gauze, as Stej) VI, is done along the finger as a guide, side to side: that is, the right finger directs it to the right vesicle while SEMINAL VESfC'd/JT/S Oh' HI'KliM Al'OdYSTITI H 141 the left hand does the packing, and vice versa, (Fif^. 'M). Tiifx- position with the depth of each vesicle and ])osteri()r to the f^au/.e drain enicrg- ing near the lateral angles of the wound across the perineum (Fig. o^j. Fig. 29. — Placing the grooved director. (Fuller.) The liberating incisions are now closed with silkworm-gut sutures and the gauze and tube drains are secured with safety pins and the latter with adhesive plaster against slipping. A suitable T-bandage or diaper is placed over a standard dressing, which completes the operation (Fig. 33). Fig. 30.— Passing the knife. (Fuller.) Aftertreatment. — Immediate aftertreatment evacuates the bladder and if spasm occurs use an indwelling catheter for a day or two with suitable lavage and the remote aftercare leaves the drains //? situ for several davs as long as thev remain clean and changes the 142 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS dressings as often as discharge soils them. Irrigation of the wound is usually not necessary. Standard nursing and diet and symptomatic Fig. 31.— Placing the packing. (Fuller.) Fig. 32. — Drainage tube and packing. (Fuller.) Fig. 33. — The completed operation. (Fuller.) treatment suffice. Attention to the urethritis is entirely abandoned until the patient recovers from the operation and then a thorough diagnosis and conserv'ative treatment shoidd be followed. SEMINAL VESICULITIS OR SPERMArOCVSTITIS 143 Squier's^ Vesiculotomy. — This technic is an advanpe on Fuller's, in permitting the work to be done under the eye. The type of case is the one having predominant purulence, relapsing epididymitis, chronic Fig. 34. — Perineal skin incision. (Squier.j Fig. 35. — Skin flap retracted, showing fossae on either sides of median perineal tendon which have been opened by blunt dissection. (Squier.) 1 Cleveland Med. Jour., December, 1913. Boston Med. and Surg. Jour., June 11, 1914; New York Med. Jour., February 20, 1915. 144 CO}rPLICATI().\S AM) SEQUELS OF ACUTE URETHRTTIS persistent or clironic relaj)sinti si)erinjit()cystitis, pain and rheumatism. The ])re])aratii)n t)f the ])atient and the field, the choiee of anesthesia and the reeognition of superficial and deep hmdmarks are the same as iu any otlier ])erineal operation and the ])osture is hy clioice tlie exas:;.uerated hthotomy. '1 lie incision is the inverted l extending from tuherosity to tuberosity of the ischium. Retraction of the con\ex Ha]) downward exposes the sui)erficial field containing the central teiidon of the perineum and the ischial fossre on each side, marking Stej) 1, h'ig. .'U. ()j)cning the fossa' l)luntl\" with scissors or clamj) comprises Step IT, shown in Fig. oo; while digital dissection into them after di\ision of the central tendon but before di\-ision of the tendinous union between ]M'ostate and rectum is Ste]i III, Fig. 30, Fig. 36. — Median tendon divided, further blunt dissection of lateral fossa;. (Squicr.) Fig. 37. — Hooking finficr around upijcr limit of muscular attachments between urethra and rectum. (Squier.) and further penetration reaches the deep field of the operation. Iso- lation of urethrorectal muscles with the finge^r hooked around them and by division upon the finger along the tendinous part avoids injury of the urethra, spares the rectum and reaches the apex of the prostate in Step IV, Fig. 37. Isolation of rectum from the prostate, seminal vesicles and bladder in front and their retraction with a .strip of half hard metal H inches wide that may be bent as desired at any length for the depth of any wound in various patients is Step \, Fig. 38, and involves recognition of the vesicles by touch and sight. Pros- tatic traction b>' sutures plassed near the bladder in either angle and by pulling toward the operator and upward toward the scrotum (Fig. 39) reaches the fascia of Dcsnonvillicr bulged by the distended vesicles or matted with infiltration as Step M, in F'ig. 40. Vesicular SEMINAL VESICULITIS OR SPERM ATOCYSTITIS 145 enucleation by dissection of the fascia from the sacs, much as the peritoneum is freed from the bowel, partially by blunt dissection and partially by snipping until the layer of cleavage is found, and all adhesions and inflammatory compression relieved, makes Step ^U, Fig. 38. — Proper line of division of urethrarectal attachment close to the urethra. (Squier.) Fig. 39. — Traction su- tures applied, at junction of base of prostate and bladder; posterior retrac- tor in place. (Squier.) Fig. 40. — Traction upon sutures exposing vesicles covered by fascia of Des- nonviUier. (Squier.) Fig. 41. Drainage is now performed by free, single or multiple inci- sions of the vesicle, ampulla of the vas and any diverticula and a small rubber tube is sutured into appropriate pockets completing Step VIII, Figs. 42 and 43. Closure is performed by suturing the Fig. 41.— Method of di- vision of Desnonvillier fascia so as not to enter the vesicles. (Squier.) Fig. 42. — Wide exci- sion of covering of fascia exposes vesicles beneath lines of incisions and punc- tures into vesicles. (Squier.) Fig. 43. — Methods of anchoring the drainage tubes. (Squier.) rectum to the urethra to restore as nearly as possible their forrner relations and then the skin is united in the standard manner leaving the drainage tubes at each angle (Fig. 44). A standard dressmg 10 146 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS with a T-binder or diaper is applied, niakino; the final Step IX. The cautions require as little cutting and as little traumatism as possible in the region of the deep ])erineal nuiscles, vessels and nerves. The terminal branches of the pubic ner^•es occupy the anterior portion of the perineal triangle and their injury would lessen or abolish erection. In general they are in relation with and run toward the crura of the penis. Afiertrcafmcnt. — The aftertreatment is the same as that for any other perineal operation both inunediately and remotely and duplicates that specified for Fuller's vesiculotomy. Fig. 44. — Closure of wound, showing position of tubes and gauze drains. (Squier.) Cure in the pathological sense of restoring the seminal vesicles to their former anatomical and physiological state is well-nigh impos- sible except in the mildest cases, but the s\Tnptomatic relief followed by virtual physiological health is very often seen. Bacteriological cure is in large measure the most important because the vesicles may remain for many years a source of infection in intercourse and of absorption within the individual so that failure in this regard has a sociologic standpoint of great importance. V esiculedomy is still suh jvdice much as were the various tubal and ovarian operations about a generation ago when laparotomy was still a new technic. The chief reason of doubt is that it is very apt to be followed by sterility on the side affected because although the testicle remains, semen no longer reaches the urethra througli damage of the outlet and surrounding tissues. In typical cases, however, the vesicle may be removed with little or no damage to the ampulla and the vas, provided there is not much perivesiculitis. EPIDIDYMITIS, EPIDIDYMObRCHITIS AND FUNICUUTIS. Clinical Importance. — Infection of the testis and its duct, that is, the epididjTnis and the vas deferens, is a complication of gonococcal disease of grave clinical importance, because it may unsex the patient in either or both sides. In occurrence it is one of the two most com- EPIDIDYMITIS, EPIDIDYMOORCHITIS AND FUNIC (JUT IS 147 mon complications; the first is infection of the small urethral mucous glands and the second is invasion of the vas, epididymis and testicle. The laity denominate it "swollen testicle," or "big ball," independ- ently of the varieties medically distinguished. Classifications. — Varieties are recognized according to cause, occur- rence, location and course. According to cause, the lesion is gono- coccal or nongonococcal, of which the latter is rare and the former almost universal and, therefore, accepted as the type for description and comparison. As to occurrence the infection is primary or second- ary, of which the latter is almost the unvaried rule, in that it is a sequel of posterior acute or chronic urethritis, prostatitis, seminal vesiculitis and the like and in that it rarely if ever is itself antecedent to urethral or periurethral conditions, excepting alone tu})erculosis, which does not concern this work. As to location, it is unilateral or bilateral and involves: (1) the epididymis alone, which is the com- monest form, either as a whole or in the globus major or globus minor predominately; or (2) involves the epididymis and the testicle, which is the less common form, as a rule the orchitis being later than the epididymitis and the reverse order is hardly ever seen; or (3) involves the vas deferens as a whole or in portions, especially near the testicle and base of the bladder in the ampulla. Associated condi- tions which add subvarieties are vaginalitis or acute hydrocele and seminal vesiculitis. Extension into the tunica vaginalis from an epi- didymitis is in mild or marked degree rather common, but extension of an orchitis into a periorchitis is never seen as the process is limited by the fibrous tunica albugiiiea. Taylor^ says that the more common variety is epididymitis with adjacent deferentitis and vaginalitis and the less common is epididymoorchitis with vaginalitis. A peculiar variety makes the epididymitis antecedent to the sjinptoms of ure- thritis and is explained by a latent focus of virulent infection in the posterior urethra, excited by alcoholic or sexual debauch and rapidly extending down the vas into the epididymis and testicle and inhibit- ing through its activity the onset of urethral sjonptoms exactly as it checks them temporarily when the reverse order of pathogenesis is seen. In each case it is to be noted that the urethral symptoms appear or reappear when the subsidence of the epididymitis is present. Etiology. — As usual the causes are systemic and local, predisposing and exciting. The systemic causes are chiefly predisposing, hardly ever excitmg and are identical with the factors underlying all forms of urethritis, as previously stated on page 19. Low resistance to infectious diseases in general is undoubtedly the preeminent systemic cause. The local predisposing causes respect really the antecedent condi- tions, particularly posterior acute urethritis, prostatitis and seminal vesiculitis. For discussion in the Chapter on the Complications of Chronic Urethritis, page 150, is reserved acute epidid\Tnitis arising 1 Genito-urinary and Venereal Diseases, 3d ed., p. 114. 148 COMPLICATIOXS AND SEQUELS OF ACUTE URETHRITIS diirini; an exacerhatioii of })c)stcrior chronic invthritis, chronic ])ros- tatitis and chronic seminal vesiculitis. In these, years after apparent recovery, local injury of the testicle by blows and falls, muscular strain or pressure, may cause an acute invohement of the testicle. Likewise by the same factors an old epidid> initis apparently recovered may light up in a fresh attack. The local exciting factors are transmissit)n of the organisms and lowered local resistance. The organisms are most commonly the gonococcus alone and much less frecjuently with pyogenic and other normally hannless bacteria of the urethra which descend the vas with great ra])idity. Local resistance is diminished by excesses hi diet, alcohol, intercourse and muscular action, especially such as shake the organs: cycling, automobiling, horseback-riding, railroading, running and the like. Resistance is also affected by traumatism in strains, falls, blows and the congestion of travel, by irritation of faulty instrumentation, injection, irrigation and instillation and of drugs internally administered, such as the balsams, or locally applied, such as the astringents. Cases are seen without assignable local exciting factor. One under the writer's observation had prostatitis and bilateral seminal vesiculitis, funiculitis and epididymoorchitis within three weeks of his infection without treatment locally or systemically, and without other assignable excitant. The resistance of this patient to the disease must have been practically nil. The local predisposing and exciting causes of nongonococcal acute epididymitis are as follows: The urethra is normally inhabited by many nonvirulent organisms, which are harmless when quiescent in health, but harmful when carried into posterior urethra and inocu- lated into the raw mucous membrane by improper instrumentation and treatment and when engrafted on a catarrhal lU'ethritis of any origin whatever. They may then' invade the epididymis, as after stricture operations, such as dilatation, divulsion, internal and external ure- throtomy and prostatic operations such as suprapubic and perineal prostatectomy and prostatotomy and even occasionally prostatic massage. Pathology. — The manifestations are the same in primary cases and secondary cases, so far as the affected organ is, strictly speaking, con- cerned. The essence of the process is invasion of the \'as, epididymis and testicle usually by the gonococcus and much less freciuently by other organisms. The epidid,\Tnis is invaded as a whole or chiefly in the globus minor, where it is a single tube or, in globus major, where it is many tubes, and the testis is involved in the seminiferous tubules and the vas throughout the whole or various portions of its length, notably in the ampulla near the seminal vesicle and in its origin near the globus minor. As in every mucosa elsewhere the lesions are edema and infiltration, exfoliation and destruction of epithelia and pus- formation. Even the fibrous framework of the testis, epididymis and vas may be involved. The exudate is the contents, consisting of semen, detritus, pus and organisms, chiefly gonococci. Rapid progress is EPIDIDYMITIS, EPIDIDYMOORCIUTIS AND FUNIC'ULITIS 149 probably due to the confinement of the i)ns })y the anatomical arrange- ment, so that the symptoms are so intense that one cannot distinguish the orchitis from the epididymitis; but on the other hand resolution of the exudate is the rule and abscess-formation the exception. The temporary lesions predominate and are characterized by the foregoing description, but i)ermanent lesions are by no means uncom- mon. They are infiltration, thickening and occlusion of the epididymis, especially in the globus minor, where the single tube of the vas is already established and less commonly in the globus major where the semi- niferous tubules drain the testicle but are not yet confluent into one channel. Similar results may occur anywhere in the vas itself. Rela- tive sterility as a common occurrence with even atrophy of the testis as a rare sequel occurs especially when the globus minor and vas are occluded, but the multiple tubes of the globus major make this result less common therein as some of these tubules escape relatively or entirely. The associated lesions are products of the epididymitis itself, chiefly acute hydrocele with the usual features of exudative inflammation, or are parts of the same general infection, particularly seminal vesiculitis, prostatitis and posterior urethritis, each discussed under its own subject. Seminal vesiculitis occurs in at least two-thirds or three-fourths of the cases, either as the antecedent or as the associate of the epididy- mitis. Broennum^ secured gonococci from the vesicles in 80 per cent, of his cases examined. Monod and Terrillon^ sum up the pathology as follows: During the acute complication the seminiferous tubules become greatly swollen, their walls edematous and infiltrated and their epithelium loses its cilia. The tubules may contain pus and semen mixed and the connective tissue stroma in which they lie becomes edematous and infiltrated. Abscess is a rare formation because the exudate gradually resolves and is absorbed. Adjacent parts often involve the process and the testis is not frequently included. Acute hydrocele through inflammation of the tunica vaginalis is usual, as emphasized by Jacobson^ and Malassez and Terrillon'' found that an injection of 1 per cent, to 1.2 per cent, solution nitrate of sih^er in the deferens will almost always set up deferentitis and epididjonitis. The solution is thrown into the inguinal canal with a syringe as near as possible to the deferens. Symptoms. — The clinical characters of epididjonitis are described in the stages of invasion, establishment and termination and in sub- jective and objective, local and systemic manifestations. The stage of incubation and invasion is so merged with the ante- cedents, usually posterior urethritis, as to be masked by their s^Tnptoms. The onset is in primary cases between the third and sixth week of posterior acute urethritis with the fourth week as the average in uni- 1 Hospital'^tidende, 1907, No. 46. 2 Traite des maladies du testicle et de ses annexes, Paris, 18S9. 3 The Diseases of the Male Organs of Regeneration, 1893, p. 255. * Arch, de physiol. norm, et pathol., 1880, vii, 738. 150 COMPLICATIOXS AXD SEQUELS OF ACl'TE URETHRITIS lateral cases. In bilateral cases, the second testis following the first by about three weeks or very rarely may accompany it. [Secondary cases may appear at any time in the ordinary courses or durinu' an exacerbation of posterior chronic urethritis, ])rostatitis or seminal vesiculitis. The symptoms of invasion are usually most rapid and tend to merge at once with the establishment, so that it is difficult to set the i^eriods ai)art and to distinguish the involvement of the testis from that of the ei)idi(lymis. The local subjective sxinptoms are usually ])romi)t within twrnty-four hours, but sometimes slower within two or three days of discomfort and incapacity for ambidation of the patient. There are present, neuralgia, pain and tenderness, weight, heat and discomfort. The local objective signs are slight enlargement, boggi- ness and tenderness. Systemic symptoms are absent or trilling unless ])ro(luced by the antecedent conditions. The local subjecti^'e symptoms of establishment are pain and sensitiveness, enlargement and weight, pollakiiu'ia, heat, congestion and edema in the scrotum. Of these the last three are more distinctly physical signs. The pain and sensitiveness advance from dulness to sharp intensity, located at first in the \'as and descending with the process into the epididymis and testicle. It may therefore first be noted deep in the pelvis in its intraabdominal portion at the base in the bladder and seminal vesicle or in the extraabdominal ])ortion along the inguinal canal. It may be referred to the renal zone, perhai)s through pressure on the ureter by the inflamed ampulla and seminal vesicle or through reflex influence. It is usually constant Avithout remissions or with paroxysms at night, and sometimes accompanied by scalding bloody seminal emissions and always by hypersensitiveness, which is the promi- nent s\inptom. The pain and tenderness are increased by mction and decreased by rest and when the testicle follows the epididymis and the vas as a whole is involved, they are likewise greatly increased. Symp- toms of local peritonitis aroused from the intraabdominal portion of the vas add their characteristic symptoms and increase those of the epididymitis. The early sense of weight is quickly followed by enlarge- ment at first of the epididymis, then of the testicle, rendering support grateful to alleviate pain along the cord from the dragging. Pollaki- uria is often distinct from the conditions antecedent and from the secondary congestion on the floor of the bladder and about the ureter. Discharge regularly decreases, sometimes disappears, so far as the patient's obserAation is concerned. The systemic subjecti\'e symptoms of the establishment are not marked, as a rule, excepting in seA'cre cases or in virtue of the whole process of infection, in which the epididymitis shares. They are, as a rule, chill or chilliness, fever from 100° to 103° F., hot skin, coated tongue, thirst, anorexia, nausea, vomiting and constipation, depression, irritability, ner\"ousness, headache and insomnia. The local objective symptoms of establishment are tenderness, enlargement, heat, congestion and edema, hydrocele and discharge. Palpation shows extreme tenderness along the vas in its ampulla EPIDIDYMITIS, EPIDIDYMOORCIIITIS AND FUNKJULITIS 151 through the rectum, along its course through the inguinal canal and down the scrotum to the glo})us minor, also in the epididymis as a whole or its tail or head in particular and finally in the testicle. If the latter organ has escaped, it is relatively not tender. As a rule, the acme of the tenderness is either in the globus minor or major of the epididymis. The enlargement may be moderate or great, tense, harrl and tender, involving the epididymis only chiefly in its head, tail or body, or the epididymis with the testicle and the vas near its origin. The largest swelling occurs when all three are affected and hydrocele is added. The surface of the enlargement is smooth and tortuous and not hard, angular and knotty as in tuberculosis of these parts. When the epididymis as a whole is involved, it forms a large swelling above, behind and below the testicle, respectively, through the enlargement of its globus major, body and globus minor, so that frequently the sulcus normally between the two is obliterated. When the testicle is involved, one mass of fist size occurs, while the epididymis alone is like a large thumb lying upon the gland. The heat, redness and edema of the scrotum are rather moderate if the epididymis alone is attacked, but somewhat more apparent when the testis, vas and tunica vaginalis are involved. Extreme cases show dull redness and lividity. Acute hydrocele or vaginalitis marks involve- ment of the tunica vaginalis testis in the process. The effusion may be fluid, moderate in quantity and difficult to recognize, or the reverse with very great swelling, or fibrous and scanty with adhesions. Marked cases of hydrocele usually appear with every symptom greatly increased : the pain is unendurable and referred to the thighs, perineum, sper- matic cord, deep pelvis and even loins. The redness and edema are extensive and the subjective signs of infection unmistakable. The entire process may be regarded as at its height at this time. Frank discharge from the urethra is greatly diminished and practically abolished during the height of the process, but there -is always suffi- cient exudate in the canal to permit smears and to show in the urinary test-glasses. The systemic objective symptoms serve only to verify those com- plained of by the patient. The blood count corresponds with that of pus-processes. The urethral discharge is regularly scanty. The stage of termination begins in five or ten daj'^s in cases without successful treatment, but in half this time in well-managed cases and persists from ten to fourteen days in the average case, less in milder, longer in severer examples. The subsidence of sjinptoms is rather rapid and more or less in the following order : Pain, tenderness, conges- tion and edema, hydrocele with its adhesions and the enlargement. The local and systemic subjective signs are very early in changing, the pain rapidly lessens, the fever falls, nervousness and indigestion dis- appear and the urinary distm'bances decrease. The local and systemic objective symptoms behave in much the same way. The discharge previously diminished slowly returns, but is usually changed in con- sistency and quantity, being slightly thinner and more copious, as a 152 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS rule, owing to the improvement in the antecedent urethral condition progressing during the subsidence of tlie epi(iidymitis. Palpation is no longer the source of agony. The congestion, heat and edema of the scrotum vanisli anil signs of ahsor])tion of the hydro- cele occur^ Enlargement diminishes, so that the epididymis is distinct from the testis beyond the now normal furrow. Return of the testicle itself to its normal state under the finger is earliest and most prompt, if there are no sequels. Rapid hivolution of the ei)ididymis is rare, but in the average case requires weeks, sometimes months. Permanent enlargement as a whole or in the head or tail is frequently seen; as previously stated, chiefly in the globus minor where the seminiferous tubules have already' become one duct as the origin of the vas deferens, which for its first few centimeters may also sufter. Chronic Epididymitis. — Relapsing, subacute and chronic infection of epidid\inis and \as are common, lasting for years. Sterility is the result of obstruction from the nodes and of destruction by the chronic suppuration. Destruction and atrophy of the testicle either from suppiu'ation or disuse through strictured Aas are by no means unknown. Acute epididATiiitis tends toward resolution if it has no sequels, but with sequels the outcome is different. The usual important results are the lesions of the vas and epidid\Tnis, already spoken of, damage to the testicle as a secreting organ, and the unusual sequels are abscess, cysts and atrophy of it, chronic hydrocele, gangrene of the scrotum, neuritis, neuralgia and finally septicemia and death. Relapsing acute epididymitis during the subacute or subsiding stage is another form of termination. Its frequent attacks upon the delicate lining of the parts render it likely to cause abscess of the testicle or epidid\Tnis. The outcome of gonococcal acute epididjinitis relates to life and the organs involved. As to life, the result is good, as fatalities rarely occur. Septicemia is rare and is probably more the outcome of the general infection present than of the epididjinitis itself. As to the organs involved, the outlook depends on management and treatment of the cause and of the lesion, on cooperation bj'' the patient and on the tendency toward relapses. Without removal of the cause and proper care of the epididATnis and testicle progress of the disease in the present and relapses in the future are invited. Without intelligent cooperation and a normal resistance to disease on the part of the patient, the end result is far less favorable. In the testicle absolute pathologic restora- tion probably never occiu-s in that certain tubules must remain per- manently damaged from the nature of the infection, but such damage may be so slight as not to interfere with its function and hence cases of clinical restoration are the rule. In the epididymis absolute recovery seems likewise very rare, owing to the penetration of the disease into the fibrous wall of the canal, whence proceed thickenings which always remain but clinical recovery, however, is common. Only infiltrations with occlusion are important. As previously stated, foci of disease in the globus major are less occluding than in the globus minor. Ster- EPIDIDYMITIS, EPlDfDYMOORCIIITfS AND FUNIC HUT IS ]o3 ility by occlusion may affect one testicle only witl)r)iit jiinitin^^ iiii|>rc<,'- nating power in the other gland, })ut sterility on both sifl(;s remlers the victim childless but does not affect sexual desire or gratification. In domestic relations, therefore, a childless marriage may arise from these facts, which must be settled before the wife is held responsible and perhaps subjected to operative treatment. Diagnosis. — After a urethritis of rapidly extending anteropfjsterior type, great severity and usually other complications, such as prostatitis, seminal vesiculitis and then extension into the groin as a funiculitis, in its history, the invasion of the testis begins. The element of funi- culitis is invariably present. Direct and indirect trauma, exertion or excesses may be admitted. Symptoms are pain, tenderness, enlarge- ment, weight, congestion, edema, all due to the testicular and other complications, pollakiuria proceeding from the posterior urethritis and urethrocystitis, temporary cessation of the urethral discharge from transfer of the active process to another organ and finally chill, fever and similar signs of septic absorption. Physical examination reveals tenderness, enlargement, heat, congestion, edema, hydrocele and discharge as the final index of the cause. Laboratory work is devoted to smear and culture of the urethral discharge for the gono- coccus, which while decreased is still frant in amount. Treatment of the urethritis indirectly benefits the testicular condition and when the recovery period is present and urethroscopy of the posterior urethra safe, conditions there leading to the epididymitis may easily be recog- nized. Differential Diagnosis of Gonococcal Acute Epididymitis.^ — Under this subject are considered undescended and anomalous testis, erysipelas of the scrotum, traumatic orchitis, traumatic hydrocele, tuberculous epidid}Tiiitis, syphilitic epididymitis, neoplastic epididymitis and hernia. Acute epididymitis in undescended and anomalous testis is often difficult to settle. The gland must be accessible in the inguinal canal or the superficial ring in nondescent. The epididjuiis may be attached above, before or below the testicle through anatomical defect, torsion of the cord or adhesions within the tunica vaginalis. All may be determined by the careful finger. The history will show^ an old or recent urethral infection and an acute painful course and the laboratory by smear or culture isolate the gonococcus. Rest in bed with its prompt results is an aid. Erysipelas of the scrotum differs from gonococcal acute epididymitis in its severe general involvement, rapid advance over the scrotiun, fiery redness, marginate brawny infiltration, absence of testicidar symptoms and signs of urethral discharge, bacteriology and comple- ment fixation test. Traumatic orchitis and traumatic hydrocele differ from gonococcal acute epididymitis in the history of definite injiu-y, vers' sudden onset, absence of funiculitis and of urethral findings and blood test. The light test is negative, but tension or fluctuation suggests fluid and 154 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS Fig. 45. — Hydrocele of the cord. The sac was nonadherent and was readily removed whole. (Author's case.) Fig. 4G. — Acute tuberculous epididymoorchitis. Extensive involvement of the epididymis and testis is shown. (Author's case.) EPIDIDYMITIS, EPIDIDYMOORCIIITIH AND FUNICULITIS 155 aspiration brings blood. If the traumatic hydrocele is not a true hematocele then the light test is i)ositive aiul tlie necflh; evacuates the serum of true hydrocele. A B Fig. 47. — Tuberculosis of the deep urethra. A is the deep urethra of a recent acute tuberculosis of the epididymis in a young man ; from one of three dilated prostatic ducts caseous pus exudes; B is advanced tuberculosis of the prostate in a patient having tuberculosis of the right kidney and its ureter. (McCarthy. i) Tuberculous differs from gonococcal acute epididymitis in being a chronic process. The history reveals tuberculosis elsewhere in the body in many cases, insidious onset, little pain or systemic subjective symptoms, excepting those of the antecedent foci elsewhere. Some cases show the emaciation, rapid pulse, anemia and afternoon tempera- ture of all tuberculosis. Examination shows a knotty, nodular, fre- A B Fig. 48. — ^Tuberculosis of the deep urethra. A represents extensive lesions of the prostatic urethra in a case of tuberculous epididymitis, on account of which operation was refused and climatic treatment adopted with marked benefit; B, advanced tuber- culous foci of the deep urethra in a patient with nocturnal and diurnal frequency of pyuria and occluded left ureter due to tuberculosis of the kidney. Focal necrosis with caseous destruction of the prostate on the left and greatly dilated prostatic diicts on the right of the colliculus. (McCarthy .2) quently adherent epididymis and foci in the semmal vesicles, prostate, lungs and the like. Bacteriology of the m-ethral discharge is negative for gonococci, but if a sinus exists in the testicle, it may be positive 1 Surg., Gynec. and Obst., March, 1916, pp. 330 and 331. 2 Ibid. 156 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS for tubercle bacilli. The gonococcal coin])leinent test is negative. Tubercle bacilli may be found in the urine in the mixed specimen of the bladder or in separated specimens after ureteral catheterization. The tuberculin test and tuberculous management are aids. Si/philitic differ^' from (/oitucoccal acute cpididipititi^' also in being chronic. The history of s\i3hilis in primary and secondary manifes- tations ma>- be given, as the orchitis is usuall>- tertiary. Physical examination elicits the testis as first and most and the epididymis as second and least involved. Other lesions of the tertiary or secondary stage, as the case ma>- be, are also usually present. The swelling is uniform without tenderness, adhesions or hydrocele. Laboratory investigation gives a i)ositive complement fixation test fen* sy])hilis but negative for gonorriiea. Sometimes the Treponema pallidum may be obtained by asi)iration of the testicle and anemia is usually present in neglected syphilis. There are no urethral pus, gonococci or other organisms except the normal urethral group. Marvelous results of intensive treatment with neosalvarsan, sah'arsan, mercury and the iodides coml)ined Avitli hygienic management settle the ([uestion. Fig. 49. — Teratoma testis, adult type. Patient well and without secondaries nearly three years after operation. (Author's case.) Neoplastic differs fro)u gonococcal acute epididymitis in its history of slow onset followed by perhaps regular rapid growth in a few weeks or months, absence of pain early, which appears, however, later. Anemia and emaciation and depreciation may be early and marked. Lym- phatic involvement is early and characteristic. Teratoma of the testicle is the most common and rapid form. Physical examination shows a stony, hard testis and in an advanced case the lymphatic channels and glands invaded. There is no special tenderness. The testis is usually attacked first, then the epididymis. The laboratory findings are no urethral pus, no gonococci cr other organisms except the normal urethral flora, no complement fixation test for cither gonor- rhea or syphilis. The blood may show the changes characteristic of malignant disease. Hernia differs from gonococcal acute epididymitis in its history of anatomical defect, or acquired and slow onset, after direct or muscular EPIDTDYMITTS, EPTDTDYMOORCIITriS AND FUNJCULITIH 157 violence or during chronic cough, consti})ation, strain and the like. The pain is of dragging not of intense incai)acitating character and without fever, chill or other sign of infection. Physical examination reveals a mass in the inguinal canal or scrotum, insensitive, always somewhat distinguishable from the testicle and ei>ididymis, with impulse on coughing and without redness or edema of the skin. Kedu- cible hernia permits restoration of the mass into the abdomen; irredu- cible breech shows partial or absent return of the contents of the sac; inflamed or incarcerated hernia presents inflammation at the site of previously irreducible rupture, while strangulation adds the terrible elements of intestinal obstruction. Even in the last two, the diagnosis is easy and the mass separable from the testicle in no small number of cases. "Differential Diagnosis of Gonococcal Chronic Epididymitis." — The same basis as in the acute exists — history, physical and laboratory examina- tions for distinction between chronic epididymitis and tuberculosis, syphilis and neoplasm of the testicle and hernia. The remarks given under the acute lesion concerning the diagnosis of undescended, anomalous and adherent testes need no repetition here. Tuberculous differs from chronic epididymitis in the history of other tuberculous foci, slow onset, absence of urethritis and perhaps latent progress in the testicle, rather than early subsidence and later per- sistence from an acute process. The physical examination may reveal the other foci and the systemic depreciation. Nodulation, adhesion of the testicle to the skin, chronic hydrocele and local abscess and sinus may be present. Laboratory and bacteriologic examination reveals no gonococci in the urethral discharge and not infrequently tubercle bacilli in the urine and semen, for which the guinea-pig test must often be employed. The various tuberculin tests are also available with caution as to deductions. Syphilis and neoplasm of the testicle and hernia are sufficiently dis- tinguished from chronic epididymitis under its antecedent acute form, so that further review would be redundant. Treatment. — Gonococcal epididymitis, epididymoorchitis and funi- culitis in their significance as complications damage the vas, epididy- mis and testes more or less profoundly or permanently and unilaterally or bilaterally so that relative sterility may result. The injmy may be partial and what is sociologically important, infectiousness through the semen may persist for a long time. Prophylaxis. — Careful instructions as to care are essential during posterior acute and chronic urethritis. There must be no excesses by the patient in diet, drink or sexuality. Thorough comprehension of lesions and adaptation of treatment are necessary on the part of the physician to prevent extension of the infection from the urethra to the sexual glands. The principle of immediate cessation of all local treatment, such as irrigation, at the earliest sign of tenderness or neuralgia of either testis is too little understood and followed. Special avoidance of the predisposing and exciting causes given in the clinical 158 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS section on page 147 is important. All attempts at abortion fail if infection is incident. Fnrtlier ])ro<]:ress cannot be checked if tlie fore- going prevention has failed becanse the symptoms arise indistinguish- ably from those of the ])osterior uretliritis. ■ 1 III / Fig. 50. — Belle\'Tie bridge for epididymitis. The wide adhesive plaster, tongue- depressor supports and gauze pad are shown in the upper half. The lower surface of the bridge ready to place appears in the lower half. (Author's model.) Fig. 51. — Hayden's "bridge" for an acutely inflamed testicle. (Hayden.i) The reader is referred to pages 495 to 497 of Chapter IX on General Principles of Treatment for data of management. ' Loc. cit. EPIDIDYMITIS, EPIDIDYMOORCIIITIS AND FUNICULITIS 159 Curative Treatment. — All m(;asures at definite relief are referable to the features of each case. The physical measures are of little benefit until the severity of the attack is over and then their service is indirect. Massage of testis and epididymis is impossible but of associated prostatitis and seminal vesiculitis is in the late declining stage advisable in aiding the cessation of one source of the lesions in the testes and their outlets. The uniform pressure of a rubber band- age belongs under this heading. It is made of dentists' rubber dam cut in a strip about two and a half inches wide and eighteen inches long, with a short piece of adhesive plaster attached to the middle of one end. The bandage is wound reasonably tight about the affected testicle and secured by the adhesive plaster, which must be short enough not to interfere with elasticity in accommodation of possible increased swelling. Hydrotherapy is the ice-bag locally applied to the testis supported by the bridge and protected by gauze or flannel and to the affected mguinal canal for the funiculitis. Hot poultices of lobelia and tobacco are said to be soothing and sedative. Irriga- tion of the rectum for the prostatitis and seminal vesiculitis, asso- ciated, indirectly benefit the testicle, and in the later stages hot sitting baths decongest the entire region. Systemically body baths and Turkish baths aid in elimination of absorptive conditions. The application of light during long periods several times a day by the patient with one of the approved therapeutic lamps soothes, decon- gests, resorbs and fm-ther acts in actinic influence, especially in the later neuralgic pains and vascular spasm. The electrotherapy is important even during the acute stage. In the declining and termi- nal stages, however, the following modalities are indicated: The modality^ is the local application on the epididymis, testis and vas deferens of a surface vacuum electrode attached to the negative pole of the multiple-plate, high-speed, static electrical machine with the positive pole grounded. The intensity is a spark gap of a half -inch to one inch giving 0.5 to 1 milliamperes of current which in duration must remove all pain at a given sitting — usually in from fifteen to thirty minutes or more. Frequency is daily for from seven to ten days, producing an action relieving vascular spasm and inducing resorption and drainage through the natural vascular and IjTxiphatic channel and having a result, as a rule, of the disappearance of the enlargement in about ten days. The medicinal measures are sedatives for the pain, urinary anti- septics for the pus and urinary diluents and antacids for the polla- kiuria, circulatory sedatives for the hyperemia and supportives for the toxic influence, if present, and alteratives, such as the iodide of potash, for resorption — all by systemic administration according to indication. Of questionable value during acute stages is serotherapy, except in the occasional patient benefited by the antigonococcal serum for the estab- lishment of passive immunity. In the chronic periods, however, a few 1 Modality is a term used by electrotherapeutists to denote the type of current used. 160 co^rPLICATroNS .i.vd sequels of acute urethritis patients are greatly restoretl by autogenous or lietert)gencous bacterin, especially of the mixed type, such as Van Cott's, when absorption is present, chiefly from the associated jn-ostatitis and seminal vesiculitis. The local administration of any urethral treatment should be dis- continued during the acute period but ointments, such as ichthyol, in 10 to 25 peT cent, strength and guaiacol in 25 to 50 per cent, strength are of great service. Uectal irrigations with the double current tube or the prostatic cooler treat the ])eriin-ethral structures with benefit to the testis. Only after the ei)itlidymitis is nearly well should any in-ethral treatment be even cautiously begun and most conservatively continued. Chronic ej^ididymitis may be made acute and relapsing by imjiroper in^■asion of the jjosterior urethra. Therefore, instillations, retrojections, catheter-and-syringe irrigations and ai)])licati()ns in the order named and beginning with very mild Huids are the only posterior urethral treatments proper. Xonoperative Surgical Measures. — If acute retention of urine is present, catheterization is called for and if repetition is necessary the indwelling catheter is preferred for a day or two with protective lavage of the bladder and decongesting hip-baths. The best dressing of the testis is the rubber bandage described above. Adhesive plaster strapping is also recommended with the disadvantage of inelastic resist- ance to possibly ad\'ancing enlargement. After the epididymitis is cured all the other nonoperative measures devoted to the posterior urethra become available, as just mentioned. If stricture is a basis of the lesion the author's irrigating sound is of special value in combining gentle dilatation with retrojection, but injections by the patient are hazardous even after the epidid}-mitis has declined. The operative surgical measures are five: (1) Epididymotomy for pus in acute stages; (2) Hagner's transplantation of the vas in chronic obstruction ; (3) prostatotomy for pus as an associative lesion; (4) seminal vesiculotomy for pus as a concomitant focus; and (5) urethrotomy for stricture as an antecedent condition. Of these five procedures prostatotomy is fully discussed under paren- chjinatous prostatitis (page 125), seminal vesiculotomy under sperma- tocystitis (page 139), with occlusion and urethrotomy under stricture (page 395), and will therefore need no further note here. Eindidymotomy (Hagner's^ operation) is available in acute epididy- mitis for evacuation of the pus when there is much accumulation and excessive swelling in selection of case. The operation is not difficidt and requires as instruments and supplies scalpel, tenotome, scissors, forceps, hemostats, small sharp and blunt retractors, liga- tiu-es, needle-holder, needles, sutures, drains and dressings with large suspensory' bandage. The preparation of the patient and field are standard and the anesthesia is by preference general on account of the sensitiveness of the testis during the manipulation but may be local by infiltration of the inguinal branch of the genitocrural nerve 1 Tr. Am. Assn. of Genito-Urinary Surg., 1907, v, ii, p. 262. Ibid., p. 37. Am. Surg., May, 1908. Med. Rec, December 4, 1909. Ibid., August 10, 1907. EPIDIDYMITIS, EPIDIDYMOORCHITIS AND FUNICUUTIS 101 as it emerges from the superficial abdominal ring. The posture is supine and the prominence of the swelling along the epididymis at the interval between it and the testis is the one landmark, determining the site, extent and depth of the incision, which passes through the skin and dartos as the superficial field down to the tunica vaginalis testis and after hemostasis reaches the obvious point of accumulation after free division of the tunica to the limits of the skin oj^ening. The testis is then delivered upon warm towels and examined. Mul- tiple punctures with the tenotome are made penetrating the infiltrated fibrous capsule and entering the thickened connective tissue beneath as the deep field. As the knife pierces such thickenings marked decrease in resistance is felt and free pus may escape from any of the openings, which should be enlarged and gently probed toward the pocket, which is safer than further use of the knife, and then gently * massaged until empty. Irrigation of each pocket in the epididymis and of the whole cavity of the tunica is then done with 1 in 1000 bichloride of mercury watery solution followed by normal salt solution. Light suture of the tunica with catgut after restoration of the testis to its bed and drainage with a cigarette packing through the suture line in the tunica down to the epididymis followed by standard closure of the skin with silk and a generous dressing within the large suspen- sory bandage or a T-binder closes the operation. Immediate Aftertreatment. — Packings secure drainage and avoid ad- hesions as far as possible and remote aftercare is devoted to antecedent and associated conditions within and about the urethra. Drainage usually ceases on the fifth to the tenth day and the frequency of dress- ings is correspondingly decreased. Accepted diet and medication are, of course, the rule. Epididymovasostomy (Martin's^ operation). — The following essen- tials are noted in the careful selection of case for reasonable chance of success. Sterility due to causes other than obliteration of the tail of the epididjonis is a contraindication and the patency of the vas deferens from the epididymis to the prostatic urethra must be demonstrated by preliminary injection of pigment passed in the urine or received in massaged specimens. A vaso- puncture as just described is, therefore, required. Martin^ says further: "Before the operation is undertaken strictures, posturethral lesions and chronic inflammation of the seminal vesicles and vas should be cured." He also states that a microscopist should be on duty to show the presence of spermatozoa as a means of prognosis and of determining whether the anastomosis shall be into the epi- didymis or testis. The instruments and supplies are scalpel, eye scis- sors and forceps, hemostats, ligatures, small sharp and blunt retrac- tors, eye-needle holder and needles, fine silver wire or silk sutures, drains and dressings with large suspensory bandage. The prepara- 1 Tr. Am. Assn. Genito-Urinary Surg., 1907, ii, 32. Martin, Carnett, Le^a and Pennington, Univ. Penna. Med. Bull., 1902-3, xv, 2. * Loc. cit. 162 COMPLICATIONS AXD SEQUELS OF ACUTE URETHRITIS tion of the jxitient and fiold are of rocognizoil ty])e and anesthesia, local by infiltration of the genitocrural ner\'e or general in nervous patients. The landmark is the posterior border of the testis and the epididymis for the incision which crosses the skin and su])erficial fascia of the dartos as the superHeial field and thus reaches the outer side of the sexual gland and spares the si)erinatic artery and the arters' of the \'as, Avhich are pushed aside in the deep field. The vas is opened at the level of the globus major for about one and a half inches and then an ellipse is cut out of the head of the ejjididymis in general corresi)ondence with such incision. Martin^ believes it is better to cut the vas oblicpiely, split it upward for a (piarter-inch and sew this widely stretched lumen to the opening made either into the epidid^Tnis, or if spermatozoa are not found there, into the testicle. Immediate microscopical examination should be done to decide this point. Four sutures of silver wire or fine silk make this union, one at the upper and lower limits of the woimd and one at each side. After this the skin wound is stitched in the usual manner without drain, unless a small rubber tissue wick is used for twenty-four hours. The immediate aftercare aims to secure primary union by maintaining an evenly arranged dressing under gentle pressure and the remote after- treatment does not neglect examination for spermatozoa which may appear early or late. The posterior urethi'a, as stated in the paragraph on selection of case on page IGl, should be as far as possible cured before and not after the operation. The comments are .caution as to traimiatism of the veins which leads to thrombosis, pain and delay in recovery, as to traiunatism of the arteries which may produce loss of the testis, and as to demonstration of living spermatozoa and patency of the vas before selecting the point of anastomosis or completing the operation. The dangers to life or the testis are nil, if none of the above accidents happens and the end results in properly chosen cases are a return of \Wmg spermatozoa within a few days or weeks or months. Cvre. — Pathologically, in the absolute sense cure is rare and in only mild cases, but in partial degree, is common even when occlusion does not occur, although infiltration remains. There is failure when occlu- sion is present and the testis does not functionate except in its systemic influence. Symptom atically there should be no pain, little or no nodule in either the globus major or minor and no absence of semen in the author's seven-glass test, which is of special value in such cases. Bacteriologically there must be no gonococci in the semen secured by the foregoing test or in a condom worn at night to preserve a seminal emission. 2. Urinary Forms. Significance.— All urinary complications are major on account of the importance of the structures imaded and of the difficulties of cure, ' Loc. cit. GONOCOCCAL ACUTE UliKTflROCYST/T/S 103 which often lead to operative interference. The infection of a pos- terior urethritis may pass tlie sphincter of the bladder and invade the urinary organs in regular order from below npwarrl, causing urethro- cystitis, cystitis, ureteritis, pyelitis, i)yeIonei)hritis, separately or variously associated. Ascent of the organisms over the direct con- tinuity of surface is the rule in these cases. Gonococcal manifestations are again accepted and described as the type. Varieties. — Varieties refer to the bladder in urethrocystitis and cystitis, to the ureter in ureteritis and pyelitis, and to the kidney in pyelonephritis and pyonephrosis, as indicated in the clinical section. These may all occur separately or be variously or collectively associated. Etiology. — The catarrhal diathesis producing a favorable soil and low systemic resistance to disease permitting rapid progress are pre- disposing conditions. Direct extension of the organisms, most com- monly the gonococcus in pure or associated infection from the posterior urethra into the bladder and thence upward, is the exciting cause. The gonococcus renews its activity during an exacerbation of a posterior subacute or chronic urethritis, or invades upward through its native virulence during an acute attack. Artificial extension pro- ceeds from sounds, urethroscopes, cystoscopes and catheters, irriga- tion of the urethra under high pressm-e and with strong applications, all producing subacute or acute catarrhal inflammation which imme- diately affects the gonococcus. The author's irrigation sounds are of value as preventives in that the filling of the bladder with a mild antiseptic through the channel of the sound not only sterilizes and washes the bladder free of any pus inadvertently dragged into it but also cleanses the urethra from behind under Nature's own muscular adaptation. These sounds are described in Chapter VII on page 370. Similar in action is local congestion due to exposure to cold, excesses in food, drink and intercourse and the agitation of horseback, bicycle, automobile and railroad riding. Prophylaxis. — Prophylaxis in general applies to the group as a whole, because if the bladder is once invaded extension is apt to occur by way of the blood-current, the hTiiph-current and the mucosa in direct con- tinuity, especially if the ureter mouths are patent. Urinary antiseptics during any sign of irritability are indicated to increase the acidity which is germicidal. The s;^Tnptoms must not be augmented. iVrtificial exten- sion should be guarded against, whose elements are detailed m the clinical section with reference to instruments (page 506). All excesses in food, drink and sexuality should be forbidden. Abortion is rarely possible but suitable treatment will prevent a urethrocystitis from extending to the bladder as a whole and confine a cystitis withm the viscus from reaching the ureters or kidneys. GONOCOCCAL ACUTE URETHROCYSTITIS. Definition. — As the term indicates, urethrocystitis is infection of the posterior urethra and bladder, of which the latter element is limited 164 COMPLICATJOXS AXD SEQUELS OF ACUTE URETHRITIS to the cervical portion in the retropubic and ureterotrigonal qua(h*ants, particuhirly the triiionuni. From tiiis ori,u;in the inilannnatiou may cause a geuerahzed cystitis, which is a subject in itseh'. Varieties. — Forms are seen primary and secondary in origin, acute, subacute and chronic in course; nongonococcal and gonococcal in bacteric^logy. The chronic lesions lielong to their own subject in this work and the nongonococcal may in description be merged with the gonococcal, which gives the most severe type alone or combined with other organisms, notably the pyogenic bacteria and Bacillus coJ'i communis. Pathology. — The details given under Cystitis on i)age 1()7, to which the reader is referred, apply here. The sole exception is the distribution which in this case is in the annexa of the neck in the retropubic and ureterotrigonal segments. Symptoms. — The condition is regularly secondary to antecedent com- plicated or uncomplicated posterior acute or chronic uretiiritis. Primary causes are not seen excepting in tuberculosis and neoplasm and the congenital deformities, which are treated under Cystoscopy on pages 767, 775 and 781 . The disease has stages of infection, establishment and termination, of which the invasion is so insidious and brief that it merges with the establishment, so that when the ])atient complains of symptoms the objective proof of the disease is already fixed. The conditions are subjective and objective, local and systemic. The local subjecti^'e symptoms are frequency, tenesmus, terminal pain, pus and blood and at times retention. The frequency augments and continues the same symptoms of the antecedent posterior urethri- tis. The tenesmus arises from the inflammation over the muscle, giving the sensation of "unfinished business" after urination. The terminal pain and usually the bleeding also are due to the pressure of the sphincter muscle upon the inflamed mucosa, while the pus is either the last dregs in the bladder or actually expressed from the mucosa. Retention arises from extreme edema and may require judicious catheterization. The objective symptoms are best obtained by intelligent use of the author's seven-glass test. The anterior urethral and the control anterior urethral specimens in the first and second glasses, respectively, indicate the lesions of this part of the canal. The third or posterior urethral glass develops the lesions there with the aid of the microscope. The passage of a small rubber catheter brings the pus, mucus and detritus, sedimented at the neck of the bladder, through the urethro- cystitis. These may be followed by relatively clear urine from the bladder. Irrigation of this viscus until it is clean, followed by full distention and suitable massage of the prostate and the seminal vesicles each in its turn, procures the prostatic and the right and left vesicular glasses as the fifth, sixth and seventh specimens and proves the con- dition of these organs. Sedimentation shows a thick layer of pus at the bottom of the glass followed by a thinner blood-stained or })lood- filled layer, next mucopus and finall}' mucus. Chemical analysis GONOCOCCAL ACUTE URETHROCYSTITIS 105 usually shows acid urine, sometimes alkaline from })loo(l, j)uc1(;(j- albumin from the pus and seroalbumin from the blood and luj easts or other renal elements. Jiaeteriologically gonococci may be found in smear and culture, very often associated with other organisms, as stated, and microscopically are seen epithelia from the posterior urethra and neck of the bladder, pus, blood and mucus in strings and slugs. When the lesion is not overactive a cystoscopy will reveal a localized inflammation in the neck of the bladder and the same observation may be made with the cystourethroscope by penetrating the bladder with it and exploring the neck and the ureterotrigonal and retropubic segments as a preliminary of urethroscopy. The stage of termination is completed first in the subjective, then in the objective symptoms. All complaints cease usually before the urine is free of objective bladder elements, especially squamous epi- thelia, which may persist for some time. The urethral discharge, which usually decreases during severe acute urethrocystitis, reappears when the latter subsides, exactly as it does during the acme and subsidence of any other severe complication. A few cases extend to all four zones of the bladder — namely, the urachal, retropubic, ureterotrigonal and the subperitoneal, and then terminate as a general cystitis does or become chronic for life. A still smaller number of urethrocystites may become chronic and without termination, and catarrhal and other diatheses may produce relapsing cases difficult to cure. Gonococcal and Chronic Subacute Urethrocystitis. — The form of subacute urethrocystitis is so mild as to have no subjective symptoms over and above those of the antecedent urethral lesions. Objectively the bladder findings are present, which indicates that when a posterior urethritis is slightly atypical, the urine should be examined for bladder epithelium — a wise rule with every such urethritis. The subject of gonococcal chronic urethrocystitis is reserved for Chapter I\ on Chronic Urethritis, on page 328. Diagnosis. — Rapid ascent of the gonococcal infection through the anterior urethra and into the posterior portion marks the history, with vicious symptoms of involvement of the neck of the bladder, such as great functional, sexual and urinary disturbances. Both these reflexes are stimulated and irritated in high degree. Occasionally there is a history of instrumentation. Symptoms are frequency of urination, tenesmus, terminal pain, pus and blood, and sometimes temporary retention. Systemically the patient shows nervous dis- quietude, chills, fever and prostration with the usual other traui of symptoms incident to infection and absorption. As a rule, such symptoms are less severe than in complications m the prostate, seminal vesicles, testicles and generalized cystitis. Physical examination through the rectum on a full bladder may show great tenderness above the prostate around the neck of the viscus. Only in the declin- ing stage may cystourethroscopy or cystoscopy be advisedly attempted. The three-glass test will show pus in all specimens and much that is thick and blood-stained in the last glass. The seven-glass test of the 106 COMI'LICATIOXS AXD SEQUELS OF ACUTE URETHRITIS author may be carried out with cautiou in uiild or subsiding cases and will show in the fourth or bhulder glass, if dixided into two specimens, most pus in the first drawn off from the trigonum just as the catheter enters the bladder and perhaps comparati\ely clear urine in the second flow. The prostatic and the two seminal vesicular glasses may be normal except for the presence of ])us and other elenuMits from the posterior urethra. In the lal)()ratt)ry on seilimentation, pus at the bottom of the glass is usuall\' followed by layers of bloody muco- pus, mucopus alone, mucus and pus more t)r less separatetl, depending on tlie severity of the lesion. The microscope will show that this detritus consists only of bladder elements and excludes casts and other renal factors. The amount of albumin in the urine is little and due to the pus, in comparison with albmiiin due to nephritis by the process of transudation. Treatment by irrigation of the bladder until cleansed, followed by the instillation of mild stimulating antisep- tics and sometimes even a])jjlication to individual ])oints through the cystoiu'cthroscope, adds the final proof of diagnosis. Attention to the urethritis is also important because it removes the original source of extension of the disease. Treatment. — The correlation of urethrocystitis and cystitis renders essential the tliscussion of their treatment under Cystitis at the end of this topic on page 173. CYSTITIS. Definition. — Inflammation of the bladder is by definition cystitis when it involves the mucosa as a whole, although it may be more severe at some than at other points, notably about the neck in the ure- terotrigonal and retropubic quadrants. Varieties, — Classification respects primary and secondary as to origin, acute, subacute and chronic as to course, mild ami superficial, severe and deep or parenchimatous, intense and ulcerated as to degree, and finally complicated and uncomplicated as to added lesions. Primary cystitis does not concern the purpose of this work, so that the second- ary form with antecedent lesions of the lu'ethra alone will be con- sidered. Etiology. — As a complication or sequel of posterior gonococcal acute urethritis, cystitis may occur, but relatively mfrequently, or it may arise in the course or during an exacerbation of posterior gonococcal chronic urethritis. In either case the antecedent is a very severe and usually complicated manifestation of the disease. The systemic and local, predisposing and exciting causes duplicate those given under urethrocystitis, of which the cystitis may be only a later generalization. The essential exciting cause is the gonococcus producing the inflam- mation taken as the type, rarely in pure, more often in associated culture, especially in the older cases in which it may be unpossible or very difficult to find the gonococcus in direct proportion to the age of the case. The associated organisms are commonly the catarrhal and pyogenic cocci, Bacillus coli communis and Micrococcus urecB. CYSTITIS 167 Pathology. — In the nature of the disease the lesions are judged chiefly from cystoseopic findings and are really added to the pathology of the antecedent urethral conditions. The essence is a gonococcal invasion of the bladder mucosa as a whole, sometimes without, more frequently with other organisms, characterized by congestion, edema, desquama- tion and infiltration, pus and blood and, in severe cases, by ulceration. The tissues involved are in mild cases the epithelial and subepithelial layers, beyond which no extension may occur; but in severe cases, the bladder wall as a whole may become more or less diseased, especially in localized spots, forming ulcers of variable extent and depth. The macroscopic appearance shows the mucous membrane red, raw and thickened, rough and pus-covered, bleeding and ulcerated, while the microscopic features are the same as in other gonococcal conditions — denuded epithelium, infiltration with small round cells into the sub- mucosa, associated, of course, with the congestion, pus, bleeding and ulceration. Temporary lesions occur only in the mild superficial cases and are the least frequent, while much more usual are the severe cases with permanent lesions, such as hypertrophy, trabeculations, saccula- tion, contracture with deformity and scar of ulcers. Persistent, sub- acute or chronic, purulent cystitis may also be the outcome. Compli- catmg lesions are ascending ureteritis, pyelitis, pyelonephritis and ulcerations of imusual depth and the antecedent urethral disease with their complications are the only associated lesions. Symptoms. — Distinction is drawn between subjective and objective, local and systemic manifestations and between the periods of invasion, establishment and termination. In general the sjaidrome is the same as that of urethrocystitis only in more severe degree. The stage of invasion is masked if it occurs strictly during a posterior acute urethri- tis; but may be marked if instrimiental infection of the bladder is responsible. It is characterized chiefly by uncontrollable uneasiness and rapidly progressing pollakiuria and increasing pus in aU, especially the last test-glass. The period of establishment has, as in all mfec- tion in variable degree and relation, these subjective and objective systemic symptoms: chill or chilliness, fever, malaise, prostration, anorexia, nausea, vomiting and constipation, with willing confinement to bed. The cardinal symptoms are pollakiuria, tenesmus, dysuria, pain and blood in the systemic subjective group and tenderness, pyuria and hematuria in the local objective group. The pollakiuria is every few mmutes, by day or night, even up to fifty to sixty times in twenty-four hours in extreme cases and thirty to forty times in early average cases. It is decreased by rest in bed, which carries the urine away from the neck of the bladder, where its presence in the erect posture adds to this worry. The tenesmus is due to the irrita- tion of the muscle by the infiammation, so that when the bladder is empty the reflex effect of fulness is still present. This s^Tnptom is often very hard to bear. The dysuria is usually due to the edema at the neck of the bladder and in rare cases induces temporary retention of urme or it may be due to the antecedent urethritis with complicat- 168 COMFLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS iiig prostatitis. Its degree may only involve the changes in the form, force and trajection of the stream. The pain is due to the severity of the inHanunation, the congestion and jn-essure on the inflamed sm-face by the accumulation of urine and the muscular cttort of evacu- ation, especially of the last drops. The irritation of decomposing urine is also a source of i)ain. The pain occurs, therefore, before, during and after lU'ination, b>' day or by night, is more or less constant with paroxysms, increased by the erect posture and motion, decreased by rest in bed. Blood in the urine may proceed from ruptm'e of capil- laries, by severe turgescence, by muscular action of the bladder or by ulceration. It is usually terminal in its appearance and spasmodic in its source and not great in quantity, as a rule. Tenderness on palpation and percussion over the bladder demonstrate not the viscus which is usually empty but the reflex muscular rigidity over any inflamed organ. The altered urethral discharge is noted as decreased during the acme of the cystitis, and pyrexia as containing much pus and some blood. The three-glass test gives the most pus in the first and third and least in the second glass. The first glass brings away sedmient near the neck of the bladder and is, therefore, usually very thick with pus. The second glass contains the i:>us as it is mixed uniformly with the urine, which while abundant is not so thick as m the first and third glasses. The third glass through the terminal compression of the bladder often contains the most pus and almost always the most stringy mucus. The seven-glass test of the author is available if the case is not a severe one, so as not to contraindicate the use of catheters and to permit the passage of small ones. The first or anterior urethral glass with the second or control anterior urethral glass vary with the degree' of anterior urethritis present. The third or posterior urethral glass will have its characters changed by the pus from the bladder but the microscope will often distinguish the presence of prostatic or other posterior urethral elements. The fourth or catheterized bladder glass will with the first flush bring away much stringy mucus and pus from the floor of the bladder and immediately thereafter the more even mixtm^e of pus and urine and the last few drops will be again thick and stringy. The fifth or prostatic glass, the sixth or right seminal vesicle glass and the seventh or left seminal vesicle glass are obtainable after washing the bladder until it is quite free of pus and then by massaging each of these organs in turn for its own specimen. The value of these last three glasses is in demonstrating the presence of associated lesions in the prostate and the seminal vesicles. Sedimen- tation of the specimen of urine is the same in kind but greater in degree as that described under Urethrocystitis. Analysis shows the reaction acid or alkaline at first and later alkaline, always through mixed infection. Some cases remain acid throughout. The albumin is nucleoalbumin of pus and seroalbumin if blood is a factor. These are difl'erential points. The microscope reveals in a catheterized spechnen abundance of bladder elements, but absence of urethral and CYSTITIS 169 renal elements. Red blood cells are pres(!nt in (quantity according to the hemorrhage present. The stage of termination leads to total recovery, relapses or chronic cystitis. Full cure is seen only in the very mild sui)crficial cases, which leave behind no damage of clinical importance. The average case, however, does show damage and leaves a bladder of low resistance to subsequent infection and relapses of the original infection which may be troublesome for the patient for years or even life. Chronic cystitis is a very common outcome of severe cases with deep damage and ulceration and in patients with relatively poor systemic resistance to all infection. These are the bladders showing contracture, deformity, trabeculation and sacculation and easy prey of tuberculosis later in life. The acute stage of cystitis with intense suffering begins to sub- side in from seven to ten days, while the subacute declining period extends from thirty to sixty days. Even after this caution by the patient is often necessary. Early correct diagnosis, prompt and proper treatment, full and faithful cooperation by the patient are the ground work of cure. Complications. — Infection of the bladder may extend up the ureter, on one or both sides, causing the complications of ureteritis, pyelitis and pyelonephritis. Such extension is most common when urethral obstruction exists, as in organic stricture or prostatic disease upon which acute gonococcal infection has been ingrafted and thereafter has profoundly affected the bladder. Fig. 52. — Gonococcal acute cystitis, showing universal redness, absence of blood- vessels, great edema, loss of normal elasticity and gloss, infiltration of the mucosa into cerebriform convolutions and folds. A string of exfoliated epithelium, mucus and pus stretches across the field. (Marion. *) Diagnosis. — Full clinical explanation of acute cystitis lies m the histories of direct extension from a severe rapidly advancing antero- posterior urethritis, of the predisposing catarrhal diathesis or of artificial extension by various instruments and irrigations, for the secondary cases. Primary causes are seen in the differential diagnosis as tuberculosis, neoplasm, deformity of childbirth and calculus. ' Marion, Heitz-Boyer and Germain, Cj'stoscopie d'Exploration, 1914. 170 COMPLICATIOXS A.\D SEQUELS OF ACUTE URETHRITIS The syinptoins, systoinically, are those eomnion for infoctiou — chills, fever, prostration, iligesti\t' disorder, high pulse, aiul locally pollaki- iiria, tenesmus, dysuria, pain and blood, tenderness on palpation through the bladder or rectum. Objectively in the multiple glass tests the bladder glass has most of the jjus but all glasses have abundance — a fact arising from final exi)ression of its contents. In the seven-glass test of the author during the stage of subsidence, a soft catheter may be gently passed for the bladder glass which will be shown to contain all the pus with the sole exception of that irrigated from the urethra. In the laboratory, sedimentation gives a thick layer at the bottom with thiimer blood stained or blood filled layer next, then pus or mucopus, and finally mucus and after a while comparati\'ely clear urine. The microscope reveals bladder elements, to the exclusion of casts and other renal elements and smear and culture demonstrate the gono- coccus. Albumin is in relatively small quantities, thus distinguishing it from albuminuria of nephritis. Exploration of the bladder with the cystoscope or cystourethroscope is contraindicated until the stage of termination is nearly established. If necessary, in the earlier periods the\' must be used with great caution. Microscopy shows bladder epithelium, urethral epithelimn antl fresh pus in the recent cases, especially with pure infection, but deformed pus and epithelia and abundant phosphates in old cases commonly with mixed infection. It must be borne in mind that turbidity of the urhie may be due to pus, carbonates and phosphates as admiral)lv shown and distinguished in the following table of Ultzmann.^ Table of Urinary Titrbidity Tests. In pyuria by gradually boiling the upper part of the urine in a test- tube the turbiditv 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 ca- tarrhal secretion or by bacteria. Dimness van- ishes with evo- lution of gas: carbonates Dimness van- ishes Avithout evolution of gas: phos- phates Dimness re- mains un- changed: pus Further in the diagnosis, treatment of the urethritis removes the origin f)f the extension and is of direct benefit to the cystitis, but standard methods of treating the bladder with urinary antiseptics internally and with irrigations, instillations and applications locally still further demonstrate the case. I Vorlesungen uber Krankheiten d. Ham., 1892, p. 3. CYSTITIS 171 Diagnosis. — In chronic cystitis an acute attack rluririg a severe urethritis or direct instrumental infection or hematogenous infarct is recorded by the history or frequent attacks, without definite rehef but with a more or less incessant exacerbating coiKlitif>n. Other forms show periods of apparent cure, then a reinfection with(Mit known cause. Thus the salient subjective and objective systemic symptoms are declining or absent. The subjective symptoms are never acute unless an exacerbation is present but signs of absorption and a low-grade septic state may be predominant with low degrees of pollakiuria, tenesmus, dysuria, pain and blood and objectively pyuria, hematuria, the bladder glass filled with vesical pus in the seven-glass test of the author, and the cystoscopic and urethroscopic findings are absolute, because they eliminate the urethra, prostate and seminal vesicles as sources of the pus. The laboratory reports abundant sediment of vesical origin in the specimen, discovers the gonococcus on smear and culture and the positive complement fixation test in the blood. Treat- ment directed to the bladder alone in the form of irrigations, instilla- tions and applications or to the urine through the blood by urinary antiseptics helps settle the question, along with gonococcal or mixed bacterins in some cases. Drainage of the bladder is absolute in diag- nostic and curative results. Diiferential Diagnosis. — Differential diagnosis rests on the use of the cystoscope and is fully discussed in the section on Cystitis in Chapter XIV on The Bladder (page 770), which deals with the distinguishing features of the common varieties — nonsuppurative and suppurative, membranous, ulcerative and necrotic, neoplastic, calcareous, tuber- culous, colon bacillary and finally regional, disseminate and general. Gonococcal cystitis must be distinguished from pym-ia arising in other forms of vesical inflammation, in posterior urethritis below it and in the ureters and kidneys above it in the various degrees of pyelitis, pyelonephritis and pyelonephrosis. Other varieties of cystitis to be considered are suppurative, tubercu- lous, calculous, neoplastic, and diverticular, all whose details are set forth under Cystoscopy on page 761, but whose general features are these following. In their histories antecedent inflammation of the uretlira and its annexed sexual organs is absent so that extension into the bladder in continuity or infection through instriunents is excluded. Suppurative cystitis is with difficulty distinguished from gonococcal except with the microscope and is the one form which may be secondary to a suppurative urethritis. Tuberculosis of the bladder is insidious and prolonged in history and in this respect is closely followed by neoplasm. Stone in the bladder is usually preceded by gravel and other signs of lithiasis. Diverticulum may give periods of comparative rest followed by floods of pus. Siinptoms of suppurative disease almost duplicate those of gonococcal cystitis while tubercidosis is the most painful and hemorrhagic. Neoplasm in general is that of a foreign body followed by ulceration and slough. Calcidus shows the pain and frequency, pressiu-e and hemorrhage of the stone and always of the 172 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS pus which accH)inpanies it. A divert iciihun may cause coustaut cystitis or while fiUiiii;; up may for a few hours permit rehitively clear uriue. Ou examination throujj:h the rectum the tenderness and infil- tration of tuberculosis and neoplasm and the resistance and ballotte- ment may be elicited. Cystoscopy will hivarialily distiuifuish the five conditions from eacli other even at the first sittinji; in details ^iven in Chapter XllI, from pages 761 to 80G. Catheterization of the ureters and a suspected diverticulum will verify the latter. In the laboratory all refinements of examination of pus, detritus, fragments and other specimens will settle the question. Animal inoculation is sometimes necessary in tuberculosis. In the treatment final ])roof is obtainable in some cases of uncertainty as special means directed toward each bring results. Irrigation and antiseptics benefit suppura- tion, while tuberculosis and neoplasm are very intractable, especially the latter. Removal of the calculus and treatment of the suppuration remaining behind cure the bladder. Cystotomy and remo^'aI of the diverticulum alone avails in its advanced forms. Posterior urethritis differs from gonococcal cystitis in that it precedes any bladder involvement in the regular sequence of rapidly ascending anterior urethritis. Although many symptoms of cystitis may occur, the lesion may be absent. Those of posterior urethritis are always much less m degree and usually of shorter duration. Systemic signs are absent or few and slight and local conditions, such as pollakiuria, tenesmus, and dysuria, persist for only a few da^'s. Pain and tenderness in the bladder over the symphysis and through the rectum are usually absent, likewise blood in the urine. The ordinary three-glass test shows pus in all but most in the first and least in the third which reverses the findings in cystitis and the seven-glass test of the author always gi\'es the bladder glass by catheter clear, but such specimen should be taken only in the declining period. In the laboratory the microscope will sho^w only posterior urethral elements with none or very few bladder signs. If complications in the prostate and vesicles are present then specimens from these sources will also be there. Pyelitis, Pyelonephritis and Pyonephrosis Differ from Cystitis. — Unless careful analysis of each case is made pus found in the bladder will be regarded as originating there instead of in the kidney or ureters. In the history, cystitis gives no element of diathesis or low resistance, previous inflammation or other conditions leading to the kidneys in the primary cases. In the secondary or ascending cases which follow a cystitis, this record is reversed. In the symptoms, subjectively, during distention and evacuation the bladder gives pain and distress in its own zone of the body above the symphysis and in the perineal and anal regions, at times with the urethra. Renal pyuria is either painless or refers the symptoms to the renal zone below the ribs near the spine behind and the hypochondria in front or the course of the ureters. Objectively, rectal examination in cystitis elicits pain, tender- ness and sometimes prostatic engorgement, but in renal conditions negative signs. Abdominal palpation in cystitis reveals a tender CYSTITIS 173 thickened })la{l interval helio- therajiy may be applied. The medicinal measures in all known means by systemic adminis- tration are employed to combat absorption and toxemia, to render the urine antiseptic against extension of infection to the kidneys and to stimulate the mucosa to improved action especially during the declin- ing jxriods. The drugs are the same as those recommended for the medicinal measiu'es for urethritis on page 67. The serotherapy is not encouraging, but is more s'o in subacute and chronic than acute lesions. In particular the negative phase must be guarded against and the serum is preferred for passiAc immunity and the bacterin, either autogenous or heterogeneous or mixed, as ^'an Cott's, is given for active immunity. No such remarkable results as in diphtlieria may be ex^Dected but many cases are aided by properly graduated and increasing doses, as mentioned in this subject in Chapter IX on General Principles of Treatment on page 513. All local administration during acute symptoms should be stopped and only in the subacute declining stages may vesical irrigation be begun — most adA'isedly with the soft catheter-s\Tinge method, always after the patient has urinated to cleanse the lU'ctlu-a. Lavage is made in small Cj[uantities, from 30 to 100 c.c. (1 to 3 ounces), at each filling at first, heated to easy tolerance from 95° to 110° F., of nonirritating chemical character, such as normal salt solution, boric acid water 2 to 4 per cent., nitrate of silver 1 in 20,000, potassium permanganate 1 in 20,000 to 10,000, argyrol 3 to 10 per cent, and similar familiar solutions. Washing is continued with the solvents of pus, such as the first two solutions, until the return fluid is clear, showing that the muco.sa is freed of exudate and then antiseptic and the astringent solutions, such as the last three formulas, are used and commonly a fourth or third of the bladfler capacity is left in for more prolonged action. There must be only trivial pain, spasm, tenesmus or other reaction and the retained fluid when e^"acuated is a retrojection for the urethritis and therefore has (l()u])le function. The frecpiency of lavage is at first twice a day, then once a day and next alternate days and finally longer inter^'als determined by the power of the bla.dder to CYSTITIS 175 throw off accumulated pus. Instillation of the flcep urethra and (;ven the neck of the bladder in the later stages of cystitis may he begun with advantage according to indications and results. I'he fluids and strengths duplicate those given under urethritis. With discrimination this treatment is almost abortive of urethrocystitis in the earlier jKjriofl. When the cystitis is far declined urethral irrigations by the surgeon and hand injections by the patient may be with caution instituted to avoid any disturbance or relapse of the cystitis. Again the catheter- syringe method is the choice. The surgical treatment is nonoperative and operative. The non- operative surgical measures apply to the early symptom of acute retention by catheterism at one or a few sittings in mild attacks or by a retention catheter in severe cases to avoid frequent incursion of the viscus, combined with the same gentle irrigation just described. Instru- mentation is very late, only after the cystitis is almost well, and the author's sound is best in combining gentle dilatation of stricture ante- cedent to the posterior urethritis and its complicating cystitis with lavage of the bladder, retention of medicated fluid and retrojection of the same. All the principles are the same as those given for urethral irrigation, instrumentation, and dilatation with mechanical methods on page 365. The operative surgical methods are reserved for failure of all other means and the terminal stages. Through the cystoscope and cysto- urethroscope, as defined in Chapters XII and XIII on pages 653 and 682, applications may be made to the mucosa of sedatives, stimulants, astringents and caustics and even the high-frequency current of Oudin to localized patches of rebellious inflammation and indolent ulcers always within any severe reaction or relapse. Ureteral catheterism will deter- mine involvement of the kidneys and should be carried out with the technic detailed under this subject on page 821. Careful lavage and reasonable sterilization of the bladder are essential preliminaries. The minor operations include only suprapubic aspiration in cases of severe retention, from a stricture impassable to a catheter. Suprapubic aspira- tion is only required in a bladder known to be distended well above the symphysis pubis by inspection, percussion and abdominal and rectal palpation. Strict asepsis and antisepsis as to the skin of patient and surgeon and the instruments and supplies with the patient supine. After local anesthesia and a small trocar and cannula or an aspirating needle with sjTinge is entered just above the symphysis and pointed 10° to 15° downward and backward and carried into the cavity of the bladder practically at the upper border of the bones. The trochar is Ihen removed for free outlet of the urine under pressm-e of the disten- tion or if it does not flow through the aspirating needle suction with the syringe will start it. If distention has been extreme only about half should be withdrawn, otherwise hemorrhage into the bladder may result from undue removal of pressure from the capillaries. After withdrawal of the instrument there is usually no leakage or infection of the cellular planes, especially if the needle is chosen. A small dressing 176 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS with collodion is sufficient. This relief of the bladder combined with other measures will often make an impassable stricture ])assable or remove other cause of the retention and ])ermit other forms of treat- ment. Major operations are perineal drainage through a combined internal and external urethrotomy or through the "button-hole" operation or a su]n-apubic cystotomy. Urctltr()fo))iy is described under the Treatment of Stricture on page 390 and need not be repeated here. Suj)ra}>ubic cysfof(»in/ contains the following details: It is less fre- quently done than perineal drainage and in selection of case respects those benefited by topical ajiplications as ])art of the procedure. As in any laparotomy the instruments and supplies are scalpels with short and long blades, scissors, hemostats and ligatures, forceps and retractors both sharp and blunt, long and short blade, illumination for the cavity of the bladder, needle-holder, needles and sutm-es, drains and dressings. The ])re])aration of patient and field is standard for any major opera- tion antl the anesthesia may be local with careful infiltration of the nerves of the skin and muscle planes and the posture is supine, giving the landmarks of the symphysis pubis below and the umbilicus above for the incision, which passes above the former for about three inches in the middle line through the superficial field between the rectus muscles down to the extraperitoneal fat. Ilemostasis and retraction follow and then the fingers in the deep field are passed laterally to reach the fold of peritoneum as it turns forward and inward over the viscus and makes an interval easy of detection and separation from the bladder so that freedom of its transverse border is immediate. A needle with stout silk suture is now passed into the bladder high up on each side as elevators and retractors between which a stab of the bladder is made and the outflow caught on gauze. Carefid diagnosis and treat- ment of the m-ethral condition must be made from within the bladder forward as part of this operation, as discussed* under Treatment of Stricture by the Retrograde Operation after Cystotomy on page 402. As little separation as possible of the bladder from the s^Tiiphysis is made so that the deep field is above and not behind this joint and pocketing of drainage is avoided. After suitable enlargement of the wound in the bladder and inspection and suitable applications or other required treatment to its cleansed cavity are made, the drainage tube is inserted and the wall stitched with two or more layers of Lembert mattress sutm-es down to it. The tube is stitched to aponeurosis, fascia or skin with light catgut and the abdominal wound is reason- ably closed with layer sutures of catgut and silkworm gut for the skin. A large standard dressing receives the drainage or one of the various suction devices may be attached to the tube to keep the bladder free of accumulation. Aftertreatmeni. — Immediate steps secure regular drainage of the bladder associated with irrigation as already described and with urethral treatment as required, and dressings changed every two to four hours for absolute freedom from decomposing urine. The drain is URETERITIS, PYELITIS AND PYELONEPHRITIS 177 removed on the third to the seventh day and the skin stitches on the seventh to tenth day if possible. Nursing, diet and medication are according to indications. Remote aftercare prevents relapse of urethral conditions from which the cystitis arose and any cause tending to reproduce the cystitis. After secondary intention has healed the wound, therefore, all the aftertreatment of stricture and posterior urethritis, given on page 399, and that for cystitis, stated on page 329, must be in evidence as prophylaxis of persistence or relapse. The comments acknowledge that this operation is without much danger, but must have the caution of not wounding the peritoneum. Shock is minimal, benefit great and end results of great value, often preventing a pan- cystitis with contracture. Constitutional aftertreatment of cystitis is sufficiently indicated in each of the foregoing measures and includes fit attention to systemic causes and to local causes. These are enumerated in the clinical section but of special importance are restoration of the bladder and urethral mucosa to as near their normal condition as possible and the relief of pus foci in the prostate, seminal vesicles, posterior urethra and finally in stricture formations. Any such lesions persisting largely defeat the result because they invite active relapse within themselves and within the bladder. Cure. — Cure pathologically can occur only in the mildest cases. The process may be checked so that normal physiology results and only scattered sequels such as infiltrations remain. Symptomatically in general a weakened bladder results so that any exciting cause, such as diet, drink and exposure to cold, may be followed by a relapse particu- larly if the patient has a catarrhal or other tendency. In the severe cases mild relapses are very frequent and a few patients have a sub- cystitis more or less constantly without other disadvantage. In other words, like every other mucosa that of the bladder may never really recover if deeply damaged. Bacteriologically disappearance of the gonococci is most important together with its pyogenic allies. URETERITIS, PYELITIS AND PYELONEPHRITIS. Occurrence. — ^As complications of posterior gonococcal acute ure- thritis these three conditions are rare and regularly caused by invasion of kidney, pelvis and ureter on one or both sides by the gonococcus, in pure culture least commonly, but in mixed culture most commonly. As in so many other urogenital infections the staphylococcus, strepto- coccus and Bacillus coli communis of the pyogenic group are the usual associates. Definition. — Strictly infection of the ureter alone is ureteritis, which rarely occurs excepting with the pelvis, constituting pyelitis. Almost invariably the latter term carries with it involvement of the ureter. In ureteropyelitis, therefore, the kidney substance itself escapes more or less fully. Pyelonephritis means involvement of the parenchyma 12 17S COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS of the kidney in the infection, so that signs of inflammation of the kichiey are regularly present. Varieties. — ^'aricties arc considered as primary and secondary as to origin; acute, subacute, chronic and relapsing, compHcated and uncom- plicated as to course; mild, severe and intense as to degree; nongono- coccal and gonococcal as to cause; unilateral and bilateral as to loca- tion. Of these the primary cases do not concern this work as it deals only A\-ith their relation to antecedent gonococcal infection, thus bringing all cases under the secondary class. For the same reason the nongonococcal grouj) may be merged into the gonococcal, remembering that catarrhal pyelitis and supI)urati^■e pyelitis have the same but less marked clinical pictures. As to mode of infection ascending cases and descending cases are distinguished. In the former the ureter becomes dilated and the organisms travel upward from the bladder or pass along the lymphatics to the kidney but in the latter the kidney is invaded by bacteria through the bloodstream or the lymphstream and after free production of pus in the urine the process descends along the ureter. Etiology. — As in all infections there are predisposing and exciting, local and systemic elements. The predisposing systemic causes are those diatheses which incline through low resistance to infection and catarrhal conditions. Occasionally these become exciting systemic factors. The predisposing local elements are congestion and irritation of the kidney, pelvis and ureter by food, drink, drugs, exposure, exertion and traumatism. Injudicious use of the balsams is not an infrequent distm-bance of the kidney. Kidneys depreciated by antecedent medical nephritis or tramnatism are much more vulnerable to invasion by the gonococcus and other organisms than are sound kidneys, hence the scarlatinal nephritis of childhood is often a precursor of these compli- cations. The exciting local factor is regularly the gonococcus, with or without the pyogenic group. The avenues of invasion are the ureter, the blood- stream and the lymj^hatic channels. (1) Through the ureter the gono- coccus ascends from the bladder in continuity of their mucostc, induced by back pressure of obstruction chiefly through stricture, prostatic abscess and hypertrophy. The mouths of the lu-eters are commonly gaping, their sjihincters relaxed and inactive so that an open channel exists from the bladder to the pelvis and the kidney. (2) Through the blood current the gonococcus reaches the kidney as infarcts originating in severe lesions of posterior urethritis and prostatitis. In these cases the pathogenesis is the same as in gonococcal infection of joints, tendon sheaths and endocardium. The absence of cystitis is essential as in this form the nephritis precedes and the ureteropyelitis follows. (3) Through the l^inphatic channels the gonococci reach the perirenal substance along the lymphatics which follow the course of the ureter. From foci so established the pus invades the kidney sub- stance so that the nephritis is again the first element and the pyelitis and ureteritis second. URETERITIS, PYELITIS AMI) PYELONEI'IIRITIH 179 Cases in literature are very fr(;(nu!rit and tli(;ir nunii)er iniglit he indefinitely quoted. The following few, however, are proof of the oeeur- rence of this complication either through the gonococcus in pure culture or through its association with other pyogenic organisms. Ilagner^ has recorded 27 cases of his own, 9 with pure and IG with mixed gono- coccal invasion. Sellei and Unterberg^ report 5 cases of infection of the kidney with the Bacillus coli communis and gonococcus together. Bransford Lewis^ discusses the general pathology and subject. Pathology. — The lesions are unilateral or bilateral. Primary cases without known precursor of acute or chronic infective focus are rare and do not concern this work. Secondary cases are the rule, especially after gonococcal cystitis, acute and chronic posterior urethritis, pros- tatitis and seminal vesiculitis with or without abscess. The exciting organism is the gonococcus more frequently with the pyogenic group than without them. The essence of the process in ureteritis and pye- litis is gonococcal infection of the mucosa and submucosa, characterized by congestion, desquamation, infiltration, thickening, mucus- and pus- formation, bleeding and ulceration, all in severity proportional with the activity of the organisms. The renal substance is hyperemic in sympathy only and does not share directly in the infection. The tissues involved are, therefore, the lining of the ureter, the pelvis of the kidney and its calyces, in the mucosa alone in mild cases or the submucosa and stroma of the canal in severe cases. The temporary lesions are seen only in mild degrees which hardly pass beyond the catarrhal stage, but the permanent results appear after severe or repeated attacks and are characterized chiefly by thickenings, fibrosis, stricture and kinking of the ureter and thickening deformity and sacculation of the pelvis. The associated lesions are practically always the antecedent infections in the distal urinary tract in ascending forms or in the proximal urinary tract, namely, in the kidney in descending types of hematogenous or lymphogenous origin. The essence of the process in pyelonephritis is a gonococcal attack upon the parenchyma of the kidney, so that the element of infection of the kidney is preeminent. The tissues attacked are the stroma, glo- meruli, proximal tubules and distal tubules in a generalized or focalized infection. The abscesses are of microscopic or macroscopic size, in multiple spots and streaks. General nephritis of variable degree may occur in which the epithelium is degenerated, the glomeruli congested, infiltrated with small round cells, hypertrophied or atrophied, the tubules hypertrophied and dilated or atrophied and obliterated and filled with blood, pus and casts. Temporary lesions hardly ever occur as the kidneys are invariably damaged, but the degree may be so slight as to leave physiologically serviceable organs, in that sound por- tions compensate for lost or damaged areas. The permanent lesions are the scars of the abscesses and the sequels in the secretory portion of the organ just described. The associated lesions are the precursors 1 Med. Rec, 1910, p. 568. = ggrl. klin. Wchnschr., 1907, sliv, p. 1113. 5 Jotir. Cut. and Gen.-Urin. Dis., 1900, x-^dii, 395. ISO COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS of the infection in the distal urogenital tract and in the pelvis and mvter in the descending form with the kidney first involved. Symptoms. -There are ini])ortant ditterences between the ascending anil descending types of the disease. A. The following conditions are intrinsic chieHy for (t.srcndliig infec- tion of the ureter, y^r/r/.v and hidnei/ which connnonly proceeds in the order of parts named although the i)rocess may he so severe as to constitute one entity. Careful description respects subjective and objectiA'e, systemic and focal symptoms during invasion, establish- ment and termination. All vary with the acuteness and severity of the attack and all are fewest in the mild lesions. The mild symptoms belong necessarily to the less extensive as well as the less severe lesions and are consequently seen in ureteritis and pyelitis without involvement of the kidney in any process more than congestion. On the other hand, the severe symptoms obviously are inherent in the more profound and intense lesions in which the kidney is greatly compromised, so that these patients, therefore, have all the sxTnptoms of profound nephritis. 1. The period of invasion of pyelitis is not well marked, being as a rule merged with the antecedent source of the gonococci. The systemic subjective symptoms are either practically absent in mild cases or in severe forms follow the rule in most infections with sudden onset of anorexia, nausea, vomiting and constipation, chill or chilliness, fever, perspiration and prostration. The patient gladly takes to bed and ai)pears sick. The local subjective symptoms are discomfort, dragging, positive pain, pollakiiu'ia, dysuria, anuria and referred pain. In mild cases discomfort and dragging and in the severe cases posi- tive pain are present. Pain in the kidney region on deep inspiration, coughing or other motion is also often complained of. The pain is due to the congestion, the irritation of the urine upon the diseased mucosa and the passage of pus and mucus down the ureter acting much as gravel and calculi do. Pollakiuria is often marked and adds to that already existent from vesicle and urethral conditions. Dysuria is usually of reflex origin and likewise temporary anuria. Pain may be referred to the normal side in unilateral cases and is then due to con- gestion of the healthy kidney during its compensatory effort. Referred pain may also be sympathetically in the testicle and cord of the same sifle, and is due to the descent of slugs of pus and mucus, exactly as in migrating ureteral calculi. The systemic and local objective symptoms of the invasion are very difficult to distinguish from the antecedent condition in the m-ethra, prostate, seminal vesicles or bladder in either the ascending or descend- ing cases, unless it be perhaps, the conditions within the urine which on analysis reveals the advent of pelvic and at tunes renal elements previously known to be absent in well-followed cases. The systemic and local subjective and objective symptoms of the stage of establishment are the same as those just described with the degree much more marked. In fact, it is dm'ing the establislmient URETERITIS, PYELITIS AND PYELONEPHRITIS 181 that the symptoms are usually complained of enough to render the diagnosis positive. The insidious onset and invasion more or less masked by the preceding com])lifated urethritis render very early recognition most difficult. 2. The inmsion of jjyelonejihritis is a much more severe and i>ros- trating condition with all the foregoing symptoms present, including scanty urine, loaded with pus, blood, casts, bacteria, detritus, albmnh), and high specific gravity. As a rule it is acid at first, then alkaline as the age of the disease advances. The establishment in subjective symptoms is marked by continuation of the chills or chilliness, fever, debility, pain, oliguria and at times crises of anuria. The picture is one of multiple pus foci in the kidney or of general suppuration of the parenchyma which involves a severe infectious condition with rapid pulse, fever and extreme weakness. If the ureter is draining well and if the pus is evacuated into the pelvis rather freely instead of being retained in abscesses, the symptoms are apt to be less, but if retention is present either through occlusion of the ureter or through phlegmon- ous nephritis, then the s;vTiiptoms are all augmented. The pain may be unilateral or bilateral and is greatest when the ureter is blocked and the first steps of pyonephrosis present. Even if one kidney is involved, the congestion of the normal kidney through double duty may lead to pain in it for a time. The pain is referred as in calculi to the loins, down the ureter, to the bladder, testis, penis and even the thigh. The condition of the ureter and passage along it of masses of pus and detritus are probably the origins of these referred pains. Oliguria is seen during the invasion as long as the congestion of the normal kidney in unilateral cases lasts and in bilateral cases until the kidneys may begin to improve. Anm-ia which may be temporary and then augment all the other symptoms or ' persistent and then end fatally is not uncommon in extreme cases. Profuse perspiration of the skin always accompanies either of these symptoms. The systemic local objective symptoms of the establishment verify the foregoing con- ditions as of renal origin. The strength of the patient is on inspection obviously attacked so that he looks feverish, infected, sick and pros- trated. Palpation of the kidney zones is not absolutely diagnostic unless the patient is able to relax his abdomen and the kidney is enlarged. Occasionally one of both organs are found enlarged, tense and sensitive with tenderness along the ureter. In unilateral cases the afflicted kidney shows these signs while the normal one may be only tender, and, of course, in bilateral cases these data may be elicited on both sides equally or on one side considerably more than on the other side. 1. Laboratory findings, if the ureter is draining, are a scanty urine of high specific gravity, acid in recent, alkaline in older cases, especially those with retention and decomposition of the urine in the pelvis of the kidney, serumalbumin from the blood and nucleoalbumin from the pus, multiple casts, including epithelial, blood and pus casts, pus cells in various stages of degeneration, red blood cells in moderate 1S2 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS or marked amount, mucus and other detritus. The iionococcus in pure or associated culture with many other organisms is present. 2. If the ureter is not draining, then the urine may show only the con- ditions of the antecedent cystitis in ascending cases or of the previous com])licatcd urethritis in descending cases. With one kidney involved and its ureter blocked, the congested normal kidney maA- show the characteristic elements of its disturbance. Sedimentation of the m-ine shows the usual layers of dense pus and detritus at the bottom followed from below upward by a layer of less specific graAity containing the blood, then one with mucopus and less blood, and finally one of mucus and urine itself. Cystoscopy may be advisedly done, if the declining stage of the urethritis and cystitis is present. This procedure will settle the diag- nosis, especially when combined with ureteral catheterization. The latter step will recognize not only the side affected in unilateral cases but the more involved kidney in bilateral cases, particularly if reten- tion and decomposition are present on one side and not on the other, which would sometimes giAC respectively alkaline and acid lu'ine. B. Desceiidiiig pyelonephritis, pyelitis and ureteritis re\'erse the order of infection of parts and change the clinical picture in the following intrinsic terms. As previously stated, the som-ce of the infection is the blood current or the lymphstream from some active gonococcal focus in the genital system without compromise of the bladder. The renal lesions, tlierefore, come first, either in the kidney substance itself, or in the perirenal tissues, respectively as multiple or solitary abscess or general suppuration in the kidney or its annexa. From this condi- tion the pus passes sooner or later through the kidney substance into the peh'is, down the ureter and into the bladder, setting up suppm-ation wherever it reaches. The systemic and local subjective and objecti\e symptoms are the same as those described for the ascending type, except that at the outset there is greater intensity of the renal factor, essential to purulent nephritis. Daily urinalysis will show a i)rofoand nephritis even before macroscopic pus appears. After this, urinalysis reveals all the physical, chemical, microscopical and bacteriological features w^hich accompany free pus in the urine. This brings out the practical fact that e\-ery case of severe gonococcal infection with confinement to bed requires examination of the urine daily or every other day for the earliest possible discovery of such extensions and involvements of the kidney. Termination of Ureteritis, Pyelitis and Pyelonephritis.- — The outlook of complications of gonococcal acute m-ethritis which involve such organs as the kidneys is essentially grave in virtue of the permanence of damage inherent in the action of the gonococcus. 1. Pyelitis and ureteritis in mild forms are followed by complete recovery with no sequels, but such are relati^'ely rare. In the more severe forms a damaged and w^eakened mucosa remains behind with thickenings and indurations in the ureter or a tendency toward relapses URETERITIS, PYELITIS AND PYELONEPIl lUTIS 183 or frequent attacks of catarrhal inflammation. Fiotii 1liis l)iisis the kidney may be later on involved as a remote sequel. 2. Pyelonephritis has a grave outlook for the kidney itself and for life in some cases. Mild involvement of the kidnc^y may be followed by damage so slight as to permit full function of the sound portioji of the organ, but severe attacks usually mean loss of one kidney function more or less fully in the form of chronic pyelitis, chronic; pyelonephritis, pyonephrosis or abscess and perinephritic abscess combined with the former conditions and, of com-se, with profound changes in the ureter, as stricture, kinks and infiltrations. When both kidneys are involved the outlook for life is dismal. The patients die by septic absorption, uremia, failure of the opposite kidney to compensate during the acute onset or by secondary infection sometimes after the first kidney has become destroyed or by the initial intense infection. Diagnosis of Ureteritis, Pyelitis and Pyelonephritis. — Diathesis, low resistance and previous attacks of nephritis are usual in the history, often combined with acknowledged habitual or incidental errors in diet, drink, drugs, exposure and traumatism. In true gonococcal cases of ascending type facts are elicited concerning severe anterior urethritis rapidly invading the posterior urethra and bladder and then reaching the kidney either by direct ascent of the ureter or by indirect attack through the bloodstream or lymphstream. Complicated gono- coccal urethritis especially of the abscess type in the prostate and seminal vesicles is more apt to present the infarct variety of renal involvement. Symptoms subjectively are the onset of profound infection with digestive disturbance, fever, perspiration, prostration and the feeling of being deeply sick. Discomfort increasing to varieties and degrees of pain in the renal zone, pollakiuria, dysuria, referred pains and the usual colic, temporary anuria and the like mark the local signs. Objectively, the patient is really sick with high fever and changed pulse. Palpation usually demonstrates one or both kidneys changed in one or more particulars as to size, tenderness and consis- tency. If the ureter is draining these signs are less than when it is occluded. Tenderness and bogginess along the affected ureter are not uncommon. Cystoscopy offers recognition of an absolutely or rela- tively normal bladder, recipient of pyuria from one or both ureters showing, as a rule, profoundly altered mouths. Catheterization of the two ureters establishes their permeability and the degree of disease in one or both kidneys. Functional tests complete the picture and doubt as to .r-ray findings is removed by the shadow catheters and silver salt solutions. Laboratory details cover the bacteriology of the pus recovered and the elements of destruction of the affected kidney, while treatment directed to the source of the infection indirectly aid in its control. Exact anatomic diagnosis is often not reached until the kidney ite under operation by nephrotomy or nephrectomy. Chronic ureteritis, yyelitis and pyelonephritis are manifested with a history of acute urethritis followed by cystitis and ascendmg infection or of metastatic hematogenous invasion during se^'ere complications 1S4 COMPLICATIOXS AND SEQUELS OF ACUTE URETHRITIS of the disease. Subjectively one notes low-grade iullanimation with definite absorption if the ureter is not occluded so that drainage into the bladder is constant; but if it is occluded tlisconifort, pain, oliguria and anuria are not unconunon, whereas objecti\'ely fever and fe\erish- ness, obvious infection, sickness, prostration, the i)resence of a tender mass over tlie kidney zone increased by accumulation of pus decreased by its evacuation may be present. Cystoscopy and ureteral cathe- terization with separated urines are absolutely essential while the laboratory determines the kidney efficiency and the constituents of the specimens — physical, chemical, microscopic and bacteriological. During occlusion the unatl'ected side shows relatively normal urine. Treatment aids in the diagnosis through the fact that antiseptics and mild measures relicNe less active cases while exposure of the kidney followed by drainage or removal supplies the anatomical diag- nosis. Diiferential Diagnosis. — Distinction is often required between other conditions causing enlargement of or pus accumulations hi other abdominal organs and ureteritis, pyelitis and pyelonephritis. The latter tenn embraces more or less fully the older term pyonephrosis. Such conditions are on the left side, enlarged spleen and neoplasm of the stomach; on the right side, enlargement of the liver, inflammatory and calcareous distention and neoplasm of the gall-bladder; and on both sides, subphrenic and perinephritic abscess among infections and among neoplasms benign and malignant degenerations of the kidne\', new growth of the colon or of the retroperitoneal tissue. Of this partial list all have no urinars' signs discoverable by cystoscopy, ureteral catheterization and functional test except perinephritic abscess in some cases by outward extension from a localized infection of the kidney and except neoplasms of the kidney which often give pus and blood in the urme and changed function of the organ. In general, these three means of in^'estigation with .r-ray added are the chief means of differen- tiation. Enlarged spleen is suggested by the histor}' of leukemic tendency, malarial infection, or hepatic enlargement from any cause. The s\Tnptoms are usually slight when referred to the spleen itself but comprise weight, draggmg and pain. The changes in the organ are recognized by its position, relation to the ribs, mobility, consistency and shape. Enlargement of the other lymph glands will further prove the diagnosis of leukemia. Palpation and percussion of the liver will discover any hypertrophy which is the basis of the splenic enlargement. Radiography is of great ad\antage in rulmg out the kidney as the organ affected and finally, cystoscopy, separation of the urines and functional tests prove that the urinary system is not at all compromised. In the laboratory investigation of the blood shows that the process is not purulent and that malaria or leukemia may be present. The urine as obtained from the bladder and by ureteral catheterization is normal. Treatment, usually medicinal, directed to the leukemia or malaria or the enlargement of the liver is the last detail of diagnosis. URETERITIS, PYELITIS AND PYELONEPHRITIS 185 Neoplasm of the stomach offers gastric indigestion as the chief general picture of the history. (Ihronic gastritis, hernaterncsis, acute recurrent attacks of indigestion and inanition are cliief aniojig the subjective symptoms. The tiunor, if pal]>af)le, is objectively relatively mobile and in cases of profound involvement cachexia is the rule. The mass may be moved directly from the kidney area. Full urological investi- gation with the cystoscope, ureteral catheters, functional tests and laboratory analyses rule out the kidneys and ureters from considera- tion. Radiography is of great service with or without the ingestion of bismuth. In the laboratory test-meal observations must not be omitted and often present changes in the chemistry and digestive power of the gastric juice and special evidence from the quantity and quality of detritus and epithelia found in the lavage. Examination of the blood for secondary anemia and signs of cancer and the exclusion of proof of pus-processes should be done. Signs of anemia due to the cachexia of old cases are present. Treatment medicinally directed to the gastric disturbance, is an element of proof, and surgically aimed at exploration or removal of the mass is the final detail of diagnosis even when the tumor cannot be felt easily through the abdominal wall. Enlargement of the liver, more usually new growth than cirrhosis in differentiation from renal disease, is often difficult of recognition. The history of new growth is often barren of details except indefinite diges- tive disorders, discomfort, and irregular shooting pains. In cirrhosis, syphilis may be admitted and alcoholism with attendant digestive derangement apparent. The subjective symptoms are hepatic dis- order, biliousness and jaundice which sooner or later sometimes occur with piles and other intestinal disorders through venous obstruction. Pain when it appears is apt to be constant and nagging and cachexia marked. Objectively, if the enlargement is general or extensive it changes the whole organ and pushes it downward, but if local its position and relation may be nearly normal. Radiography may show definite increase in the liver shadow at one or more points and the patient does not complain of any urinary disturbance or disorder. Urologic investi- gation is required because the element of pain, however, is in the general region of the kidney. The three standard steps of cystoscopy, ureteral catheterization and functional test should be carried out, and result negatively. In the laboratory analysis of the mixed urine in the bladder and of the separated specimens shows healthy kidneys and that of the blood is free of signs of pus production, but sooner or later shows the anemia of cancer and in cirrhosis often a positive Wassermann test. Treatment by exposure of the liver locates and measm-es the neoplasm and syphilitic treatment may benefit cirrhosis and thus the diagnosis be completed. Inflammation, calculus or neoplasm of the gall-bladder much resembles the findings of the history just given for the liver itself. Inflammation and calculus are apt to give a rapid onset while neoplasm has a slower onset and then the invasion of any one of the three may be followed by ISC COMFLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS active and severe sufferings, in the subjective s\in])t()nis of deranged (.ligestive function, l)oth gastric and intestinal. -lauudice is freciuent and anemia with emaciation not nnconnnon. (Jail-stone colic is intense, characteristic and debilitating. Objectively, cachexia suggests cancer and a tumor or thickening in the region of the ninth rib ])oints to the gall-bladder. A'-ray often fails but nuiy show the shadow of stones or neoplasm. The only element })ointing to the kidney is the location of the pain and of the enlargement as the gall-bladder corresponds rather well with the upper border of the right kidney. There are, however, only negati\'e findings on urological analysis of the case by cystoscopy, ureteral catheterization and functional test. Laboratory specimens of blood contain bile, and signs of anemia or neoplasm and all those of the urine are negative. INledicinal treatment is usually of little ^-alue in the diagnosis which is fully established by laparotomy and appropriate steps with the stones, inflammation or neoi)lasm. Subphrenic (ibsccroach of the ureter or downward toward the s>in])hysis pubis for reasonable access to the bladder. In the iliocostal space the general planes passed dupli- cate those given for the vertical incision. The resection of the twelfth rib is often practised subperiosteally in order to gain space, about two inclies of the rib, often including its tip being rcn\oved and division of the costovertebral ligaments is a less radical step for the same purpose. The pleura often dips below the rib and must be spared. The cautions of the incision are the ilioinguinal nerve, peritoneum, colon, pleura and the sheath of the erector spina^. The iliohypogastric nerve is sensory and may be divided if encroaching on the upper part of the wound but the ilioinguinal is partly motor and must be spared in the lower portion. The peritoneum and pleura, if woimded, should be carefully closed with banked Lembert sutures and the bowel simi- larly managed, if damaged. Invasion of the sheath of the erector spina^ is of little importance except that it opens another plane of possible infection and should, therefore, be avoided by keeping lateral to its border. The separation of the kidney is digital, if the fat is healthy and soft, and by blunt dissection if the fat is diseased and adherent and must reach complete exposure imless the fatty capsule is to be removed. Presenting parts are first approached and, therefore, in the anatomical terminology, the lower pole, posterior surface, outer border, anterior surface, upper pole, mesial border, hilum and pedicle in the order given are liberated. The cautions of the separation are aberrant vessels in resistant strings of fat requiring division between double ligatures and adhe- sions about the pedicle denoting doulile mass ligatures or penetration with the aneurysm needle and ligature in sections. Either method is followed by terminal ligature of each vessel as it presents in the cut end of the pedicle. The delivery of the kidney upon the loin is easy and safe provided the vessels are not too short ancl that the perinephritis has not been so dense as to fix the kidney pedicle and that the patient is not so fat as to materially increase the distance from the great vessels to the surface. The organ must reach the skin with little or no traction, otherwise shock is certain iind tearing of large trunks probable with hemorrhage hardly equalled elsewhere in the body and at the bottom of a deep and inaccessible wound. The isolation of the pedicle rests on the anatomical fact that the pelvis is most posterior and lowest of the structures at the hilum. Hence the finger hooked around the structures below the lower pole URETERITIS, PYELITIS AND PYEWNEPIIRfTIS 193 will embrace the ureter, which may })e easily separated witli another finger or blunt scissors, while either the kidney is turned backward toward the skin and inward toward the spine or its lower pole elevated for slight tension on the ureter. Digital or blunt instrumental dis- section of the ureter should be carried downward quite to the brim of the pelvis. The ureter may be found against the parietal peri- toneum, as it is held out of the way toward the middle line of the body, through adhesions to the serosa and with the general direction over the outer border and anterior surface of the psoas magnus muscle. The tube should be liberated from the brim of the pelvis to the kidney and then the pelvis of the ureter is freed first posteriorly, then its lower and upper borders and finally its anterior surface if the fat is healthy, but if hardened with infection, dissection is stopped practically at the lower pole of the kidney. Thus the vessels are brought into view with the artery in the middle and the vein in front in typical cases but often the bifurcations are atypical. Division between double ligatures of the ureter as far down as possible is the next step with cauterization of both stumps with carbolic acid and alcohol, thermocautery or electrocautery. The distal stump is advisedly stitched to the subcuta- neous fascia near the lower angle of the wound for ready reach in case of secondary remote trouble with it. The proximal stump may be used as a tractor on the kidney and a guide to the vessels of the pedicle with judgment and gentleness. After isolation of the pedicle in degree according to pathologic con- ditions, a renal pedicle clamp is placed across it next to the kidney and closed tight enough to stop circulation but not to cut through the veins. Further separation of the vessels may be possible. A ligature is passed proximal to the clamp, that is, between the aorta and vena cava and the clamp, but not so close to the great vessels as to slip through pulsation and pressure or so near the clamp as to slip through too short a stump. When the ligature is seen to close the vessels fully, as tied, the kidney is cut free and removed and the mouth of each vessel gaping in the end of the stump is seized with artery clamp and ligated for safety. The cautions of removal refer to the dissection and the ligation. As to cautions of dissection one notes that: (1) the pelvis should not be minutely freed at the pedicle amid adhesions but the ureter should be tied low down and (2) free extension of the mcision downward and inward is required for full management of the ureter. As to cautions of ligation oiie defines that: (1) the ureter is doubly ligated, divided and both stumps cauterized; (2) clamps are closed only to stop bleeding without risk of cutting or tearing through the veins of the pedicle; (3) vessels are ligated between the clamp and the body and not between the clamp and the kidney, that is, proximally and not distally; (4) vessels are ligated during relaxation and not dur- ing tension or traction; (5) adherent pedicles are best ligated twice in mass or twice in halves in mass if transfixion is possible rather than after dissection of individual vessels, which usually tears the veins; 13 194 COMPLICATIOXS AXD SEQUELS OF ACUTE URETIIRITIS (6) clamps may be left on pedicles too tough to 1)0 llgated and removed in four or live days; (7) division of the vessels is made aAvay from the clamp for proper lengtli of stump against slipping of the ligature; (S) all exposed mouths of vessels in the stump should be indi^■idually ligated. The drainage to the stiunp of the ureter and pedicle and pocket of the ui)i)er pole is proN'ided with cigarette druins reaching the surface at the lowest angle of the wound, after careful toilet of the cavity.' Suture of the planes of fascia and muscle is carefully done do^^^l to the drains and the skin is closed with silkworm gut e^•ery inch or less. A very large dressing should be ai)])lied in layers and protected by a many-tail or ordinary abdominal binder, so as to permit frequent removal during the period of free oozing of pus, serum or blood. Ajiertreatmeni. — The immediate aftertreatment respects the wound and the other kidney. As to the womid the dressing should be inspected every ten minutes during the first hour and at longer inter- vals during the first day for secondary hemorrhage or undue oozing. The dressing should be changed down to the deepest layer in the later case and again watched at brief intervals in order to be siu-e that the oozing is checked. The drains are replaced as soon as loose and those from the pedicle are last disturbed. The stitches are cut out from the seventh to the tenth day and if clamps were left on the pedicle they are slightly loosened on the fourth day and removed on the fifth or sixth day. As to the other kidney, the aim is to promote its increased function. The diet should, therefore, be antinephritic and salt-free until the organ is known to be fully competent. In the earlier convalescence the ^lurphy drip one hour on and one hour off or proctoclysis a pint at a time is a good stimulant. Hot packs in severe cases are essential and, if well borne, will often tide the patient over the dangers of acute uremia. As to the antecedent urethritis and cystitis proper aftertreatment requires their cure along the lines described under each, otherwise either or both will remain as foci of relapse or reinfection. These lesions are therefore of great importance in the full restoration of the patient. The remote aftercare continues drainage and dressing of the wound along strictly surgical lines so that in from four to eight weeks the cavity should be closed without sinus. Nursing, diet and medication are according to indications and frequent urinalysis. The remaining kidney is protected by warning the patient against any errors leading to congestion or other disturbance, such as excesses in diet, drink, exercise and exposure. After several months if the kidiiey is found to be secreting normal urine the ordinary conditions of life may be resumed. Cure implies a healed wound without sinus or other sequel and a normal kidney on the opposite side. Nature may be slow in supplying the second detail so that the remote aftercare is usually extremely URETERITIS, PYEIJTIS AND PYELONEI'II h'lTIH 195 important. Pathologically, cure of the kidney by rerriovul is impos- sible but of the less affected orp;an is the expected result and the relief from the danger in a destroyed and infected organ is obvious. Syrnp- tomatically, cure is restoration of the opposite kidney from signs of overwork, congestion and perhaps early inflammation or infection to full and normal function and bacteriologieally the absence of organisms in the urinary system is in gonococcal complications entirely essential. Nephrotomy is a much less severe operation than nephrectomy and in a certain sense exploratory in the selection of case of severe lu'etero- pyelitis, pyelonephritis, calculus, abscess of the kidney or perinephric abscess. All preliminaries are the same as for nephrectomy, including preparation of the patient and field, incision, superficial and deep fields, isolation of the kidney and its delivery on the loin. The examination of the kidney includes palpation, needling, fluoros- copy, control of hemorrhage and penetration. As to palpation, the delivered kidney is supported on the palmar surfaces of the fingers passed about its pedicle and then the opposite hand in regular order examines the ureter, pelvis, calyces and parenchyma, from upper to lower pole and from hilum to free border for irregularities of surface and consistenc}'^, indm-ation and tension, fluctuation and calculus. The retained kidney in the depth of the wound may be felt in the same systematic but less thorough manner when it cannot be delivered. As to needling or multiple puncture of the kidney for similar diagnosis it should be said that the method is no longer in favor except in verifica- tion of definite points detected by palpation. It is not reliable, rather unsafe and best omitted but does not include aspiration of suspected abscesses with a needle and syringe. It consists in stabbing the paren- chjona one or two dozen times through and through with a needle, aiming to strike any pathological focus, especially stones. As to fluoroscopy, much may be learned by having a good .r-ray machine in the operating room and the portable hand screen available with which the kidney and pelvis delivered on the loin are inspected for infiltrations and stones. As to control of hemorrhage, one recognizes prevention and relief. The prevention implies compression of the vessels to avoid the bleeding in a mobilized and delivered kidney. Digital or rubber guarded clamp compression is available, just to stop the circulation and always without traumatism of the vessels. The best clamps have rather thin jaws which meet first at the tips and gradually spring together, per- mitting the pedicle to be seized in the free interval and gradually compressed while the tips of the jaws steady the blades. The control requires tampon or suture. Tamponade of the wounded kidney is unreliable but often unavoidable when the organ is fixed in the wound and cannot otherwise be reached. Firm pressiure with the outer di-ess- ing under adhesive plaster passing two-thirds around the body and frequent inspection for signs of failm-e of the packing must not be omitted. Suture is much more reliable and comprises two lines or one line of mattress stitches always of plain, never of chromic gut, without 196 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS constriction, dimplini; or lividity of the orpin within thv bi<,'ht of the ligature. As to penetration of the kidney for digital or instrumental explora- tion, a cut is made at the junction of the lower and middle thirds, about a quarter inch ])osterior to the vertical niidi)lane. is carried into the ])el\is in dt>pth and then enlarged to admit the little or the index finger, which should easily reach all the cavities of the pelvis. Splitting of the kidney from end to end may be performed for wide exposure, diagnosis or removal of pathological foci. Single abscesses are incised over their most ])romincnt dependent ])oint and stones removed by access on the same i)rinciplc. Calculi in the ])elvis may be removed by p>'elotomy — division of the wall foUowed by removal of the stone and banked suture. Drainage of the kidney, as in pyelitis, hydronephrosis and ]\vonei)hrosis is accomplished by reduction of the mass of the dis- tended organ through e^■acuation with the aspirating needle or trochar and cannula, then by penetration of the pelvis as just noted combined with gentle breaking down of all minor pockets into one major cavity and finall>- by suturing into the mouth of the kidney wound with very fine plain catgut, one or two ^•elvet-eye, soft-rubber catheters leading from depths of the cavity through the lower ])art of the kidney to the skin. Patency of the lu-eter should be proved with ureteral catheters and other instrmnents before the operation is ended. The suture of the kidney brings the hahes of the divided organ or the lips of the wound together gently with two or one layer of mattress sutures always without constriction. The deep and sui)crficial fields are closed with layer sutures in the fascia and muscle planes down to the drains emerging at the lower part of the skin incision, closed with silkworm gut sutiu-es. The cautions of nephrotomy are: ( 1) Padding against infection of the planes and pockets of the wound during the operation; (2) drainage against retention in the recovery; (3) proof of patency of the ureter; (4) removal of offending stones, masses and the like; (o) control of hemorrhage with packing or suture; (6) drainage of the kidney, pelvis and cavity as needed; and (7) restoration of the kidney to its bed as nearly as possible in its normal relations to avoid kinks or other com- pression of the ureter. Aflcrlreatment. — Immediate steps require regular cleansing of the tubes into the pelvis; irrigation of this cavity with sterile water, nitrate of silver 1 per cent, or arg\Tol 10 per cent.; renewal and shortening of the cigarette drain when loosening at the end of about a week; frequent renewal of dressings for cleanliness against pus and for proof of hemorrhage during the first day. Nursing, diet and medication are those recognized for any type of inflanunation of the kidney. Stimu- lation of the skin relieves the congestion of the kidneys should reflex oliguria or anuria arise. Cure, pathologically, so that the afl'ected kidney is fully normal probably ne^'er occurs, but its physiology may be restored to normal by the surgical treatment of affected points in the removal of concre- ACUTE RETENTION OF URINE 197 tions, either or both, followed by compensatory hypertrophy. This is symptomatic cure and is the exy)e(;ted result in most cases and in particular many ureterites and i^yelites which have not involved the mucous membrane seriously and have not com])roniised tli(; kidney beyond severe congestion and without true infection or inflammation, Bacteriologically in gonoccocal .disease relief from the y^resence of this organism is most important and one cannot speak of cure while it is present on smear and culture and while the positive complement fixation test persists. ACUTE RETENTION OF URINE. Definition. — Acute retention of urine may be described as inability to evacuate the bladder, due to conditions within and about the urethra locally or within the central nervous system symptomatically leading to muscular spasm and paresis rather than to paralysis. As a complica- tion of gonococcal acute urethritis^ it is not to be confounded with the retention of stricture of the urethra, hypertrophy and neoplasm of the prostate and organic nervous disease. Etiology. — The causes of acute retention as indicated in the defini- tion are local, that is, urethral, as periurethral and centric or nervous. The urethral factors are edema and spasm of the sphincter. Within the urethra the edema of the mucosa may be inherent in the severity of infection or arise from irritation by instrumentation, alcoholism, food, sexual excess, exposure and exertion which may similarly cause spasm of the sphincter by their direct irritation. The spasm may also be of reflex spinal origin through the inhibition of such complications as gonococcal acute prostatitis and seminal vesiculitis. Outside the urethra by direct obstruction or by the same reflex influence, prosta- titis, seminal vesiculitis and cowperitis may be elements. The centric or nervous factors are seen chiefly in the acute complications within the cerebrospinal axis, which go with severe absorptive septic types and are chiefly nem*itis, meningitis and myelitis. They lead to temporary paresis or spasm, as a rule. Varieties. — Retention of lu-ine during a gonococcal infection in clinical classification is acute, occurring during an acute or declining urethritis; and relapsing, appearing during exacerbations of gono- coccal chronic urethritis or during chronic hypertrophy of the prostate. The latter w^ill be more fully discussed under these subjects. The retention of organic cerebrospinal disease does not concern this work. Symptoms.— The patient shows in his subjective history sudden inability to void urine at all for a longer or shorter time or only in a few drops at each potent effort. Distention of the bladder causes excruciating agony. The objective signs are a bladder which is well above the s\^uphysis pubis on palpation and percussion, protected by muscular rigidity and a urethra obstructed by any of the periurethral or endourethral causes. Centric nervous cases give their o^-n peculiar 198 COMI'JJCATJLLW'S AXD SEQUELS OF ACUTE URETHRITIS picture as iHscussed later in Clia])ter TTI under Centric Nervous Com- plications on ])age 2',\\). Diagnosis. Acute retentit>n of urine is considered only with its relation to urethritis and must have in its history the elements of obstruction, edema, muscular spasm, traumatism or excesses as to the urethra or the factors of i)ressure and sjiasm from ])r()statitis and \esiculitis as to periurethral conditions. The history of centric nervous disturbance in brain or cord followed by acute retention of urine is foreign to our subject. Obviously, if central ner\'ous disease is sug- gested by the case in addition to the urethral infection, full neurological investigation for sensory, motor, reflex and trophic changes in the nerves and for signs of cerebral disease must be carried out. The chief complauits are inability to urinate at all or only slightly, with pain and the shock or prostration of overdistention. Objectively, the bladder palpates and percussess far aboN'c the symphysis and projects downward into the rectum. Urethral i)ali)ation often develops the site and nature of the obstruction. Tlie laboratory must show^ infec- tious material w'ithin the urethra, most commonly gonococcal but rarely any of the other organisms causing urethritis and fully dis- cussed under that subject. Kelief of the obstruction, m the treatment, settles the source of the trouble and the diagnosis and suitable meas- ures directed to the urethritis or its complications pre^•ent relapse and likewise aid in the proof of the exact form of retention. Treatment. — Gonococcal acute retention of urine is in its significance usually minor if reflex, as during the in\'asion of severe acute forms of posterior m'cthritis, prostatitis and seminal vesiculitis but is major if obstructive as is seen in stricture of the urethra and prostatic or other periurethral abscess. Prophylaxis is indirect and applied to attention to the causes by avoiding the sources of edema of the urethra and irritation by instru- mentation, alcoholism, improper food and drink, indirect and direct sexual excitement and physical exertion. Sedatives should quiet early reflex inhibition in posterior urethritis, prostatitis and seminal vesiculitis. Earl\' diagnosis and treatment of pressure by extraurethral pus are preventives of major retention. Abortive measures relieve the edema by active hydrotherapy in hot penile, sitting and body baths, by reliable sedatives such as morphin and bj^ evacuation of pus accumulations in any of the periurethral structures. The reader will note the necessary particulars in Chapter IX on General Principles of Treatment on page 483. Curative Treatment. — Physical measures are hardly available. Until relief of the retention massage is impossible, but then valuable for such antecedents as prostatitis. Hydrotherapy is active, especially hot urethral irrigations with adrenalin solutions 1 in 1000, rectal irrigation with hot normal salt solution through the double current tube or the prostatic cooler, and sitting baths hot until the skin is made very red. They all relieve the congestion and edema and fre- quently the retention so that the patient may evacuate his urine into ACUTE RETENTION OF URINE 199 the sitting bath. Vesical irrigation is of value in cases dependent in cystitis. General baths eliminate and relieve the kidneys and Turkish baths are more efficient in cases dejjendent on kidney involvement. Hot packs are added for the same purpose. The heliotherapy requires a 500 C.P. therapeutic lamp very warm but not too hot moving steadily about over the field and applied up to intense redness of the skin but without pain or blister affecting the lower abdomen, lower perineum and back. Its results are the decongestion by profound hyperemia and the relief by diaphoresis. The medicinal measures are sedative for the reflex nervous element by systemic administration including morphin and codein and their allies unless contraindicated by nephritis. Urinary diluents and neu- tralizers of recognized types soothe the entire urinary tract and elimi- nants and diuretics are available in kidney cases. Urinary antiseptics combat the infection and probably no combination is better for its urinary influence in all respects than the following formula whose elements are both adjuvants and corrigents of each other: I^ — -Hexamethylenamin 7.5 grains (0 . 5 gramme) Benzoate of soda 7.5 grains (0 . 5 gramme) Qistilled water up to 1 dram (4.0 c.c.) Mix, make a solution and mark: Take one teaspoonful every four hours, with a glass of water, or three times a day , two hours after eating, as improvement occurs. By local administration the bladder is evacuated with the catheter, as subsequently stated, and much benefit results from the instillation of a few drops of nitrate of silver solution 1 per cent, or 2 per cent., which reduces the edema and congestion and often quickly controls the infection on which these rest. The quantity instillated must be only 2 or 3 drops otherwise damage and not benefit will ensue. All other local measures, such as irrigations, hand injections and instru- mentations, are necessarily stopped until the tendency to retention has disappeared. The surgical measures, nonoperatively, include the use of a small velvet-eye soft rubber or a soft lisle-thread catheter very gently passed into the bladder after previous irrigation of the urethra with very hot normal salt solution containing adrenalin 1 in 1000, followed by irrigation of the bladder. In the nature of retention leaving the antiseptic fluid in the bladder for evacuation and retrojection of the urethra cannot be employed until the patient begins to urinate even imperfectly. Retention catheters are used for the more severe cases but always with hesitation and on the least sign of irritation with instant removal because their foreign body action makes the underhdng condition worse. Irrigation of the bladder through such retention catheter is both possible and necessary. Operatively evacuation of pus accumulation in periurethral structures is preeminent, such as Cowper's glands, the prostate and sometimes the seminal vesicles. The operations are described under each heading. Cure of stricture of the urethra as a frequent underlying cause is imperative. 200 (VMI'LICATJOXS AXD SEQUELS OF ACUTE UREriilUTIS Aficrtrcdtnirnt.- — Tlu> iiiimoiliato aftertrratiiUMit is to soothe and quiet the bhulder witli urinary secUitive dihients and antiseptics and also the nervousness of the patient reflexly and mentally aiiri remotely is to alleviate the antecedent and consequent conditions both medical in the urethritis and cystitis and sur^it-al in abscesses and stricture. Cure, path()logicall\', must respect the underlying bases and so far as the retention is concerned should be complete but so far as damage of the urethra and its annexa is concerned may be very incomplete, as already demonstrated under the pathology of eacli lesion. Symp- tomatically relief of the retention is absolute either through catheterism or operation followed by SN'stemic and local medication for the infec- tion whose bacteriologic destruction is essential for cure. CHAPTER III. COMPLICATIONS AND SEQUELS OF ACUTE UUETHP.mS. ((Jo7itinved.) COMPLICATIONS OF POSTERIOR GONOCOCCAL ACUTE TJRETHmTIS.—iContimied.) B. Extragenital or Systemic Group. Clinical Importance. — The gonococcus with its toxins may invade all systems of the body with complications which are the constitu- tional, systemic or extraurogenital manifestations. These compli- cations will be discussed under the name of the system involved, as in the following subdivisions. Varieties.^Cutaneous, digestive,, circulatory, respiratory, central nervous, special sensory and locomotory complications are seen, each respecting its own system. 1. Cutaneous Complications. Occurrence. — The skin is not often affected but somewhat more in males than females and usually in the severe persistent gonococcal infections during other complications with absorption and toxemia. The occurrence of drug rashes during such cases makes it important to eliminate these as the possible lesions. The end of the first month is the common date of appearance. Their relation to the gonococcus and the toxins must be elucidated. Their clinical importance is rela- tively little. Varieties. — Penile cutaneous folliculitis, condylomata acuminata, erythema, purpura and keratoses are most often seen. The first two are the most common and important. Their significance marks most of them as immaterial, especially folliculitis, er3i:hema, purpura and keratoses on account of their rarity and occasional difficulty of identi- fication with the gonococcal involvement; but condylomata acuminata are important. General Diagnosis. — The reader is referred to books on diseases of the skin because more than outlines in this work would be redundant. A cutaneous complication during a gonococcal m-ethritis or its com- plications must be more than a coincidence. There must be absorp- tion and circulation in the blood of the gonococci or their toxins in order to link the manifestations in the skin with the infection. Treatment. — The lesions are cured along dermatological principles in soothing applications during acute irritation followed by stimula- 202 COMPLICATION'S 'ax6 SEQUELS OF ACUTE URETHRITIS tioii during iiululcnt and chronic stages — combined, of course, with relief from the j^rincipal focus of absorption. Full details are referred to works on Perinatology. CONDYLOMATA ACUMINATA. Synonyms. — Cantrell and Stout' give the following list: Pointed wart; moist wart; fig wart; cauliflower excrescence; verruca elevata; venereal wart; Ger. Spitzencondylom, Spitzenwarze; Fr. Vegetations dermiques. Fig. 53. — Condylomata acuminata, confluent form. Extensive condylomata acu- minata of gonococcal origin filling the entire corona and preputial fold extending far forward on the glans on the right side as far as the frcnuni. Preputial excoriations were present on the left side but do not show in the photograph. (Author's case.) Definition. — These are warts or true papillomata usually of venereal, not infreciuently of nonvenereal origin, afl'ccting the modified skin commonly over the glans and within the foreskin of the male, less commonly the cutaneous sheath of the penis, and over the external and internal labia and even the thighs of the female. The nonvenereal origin of these warts is important, otherwise unjust suspicion will be lodged against the innocent. Extragenital situations for these papil- lomata are the anus, axillse, umbilicus and interdigital folds of the toes. 1 An American Text-book of Genito-urinary Diseases, Syphilis and Diseases of the Skin. Bangs and Hardaway: 1899, p. 956. COND YLOMA TA A C UMINA TA 20.: Etiology.— Tendency to warts is definitely known and is a predispos- ing cause of the lesions under discussion. It is well, therefore, to look for other papillomata, on the hands, for example, especially when the case may be nonvenereal. Another predisposing factor is retention, decomposition and irritation of the smegma, thus repeating the con- ditions of apposition, excoriation, moisture, warmth and retention of perspiration in the extragenital forms. Added to these elements in the venereal cases is the gonococcal infection with its penetrating, proliferating influence and in the nonvenereal cases, the microorgan- isms of the skin. That warts may be infectious is suggested by the case of Payne, quoted by Cantrell and Stout,' who after having removed a wart with his nail had one develop beneath the same nail. Fig. 54. — Intraiiretliral warts. The mass entirely filled the meatus, causing a high degree of obstruction. They did not extend far up the canal so that removal with scissors was easy. (Author's case.) , Pathology. — As in all other warts, the essence of the process is pro- liferation of the papillary layer of the cerium and thickening and cornification of the epidermis with increase of connective tissue and vascularity. The cells of the rete are highly developed while the horny layer is scantily changed. Without treatment the warts are permanent lesions, and increase in size and number to remarkable limit. After removal no material scars persist. The associated lesions are regularly the gonococcal urethritis in acute, declining or chronic 1 Log. cit. 204 COMPLICATIONS AXD SEQUELS OF ACUTE URETHRITIS stage and the balanoposthitis which both causes and is produced by the warts. Occasionally these lesions are found within the meatus as well :is in the situations noted undt>r definition. Symptoms. — The warts themselves by their actual presence and tlischarge in retractible foreskins are the only subjective sjinptoms, but in irretractible foreskins the irritation of the discharge from the chronic relapsing l)alano])osthitis is the chief conii)laint. The objec- tive signs are in the loose foreskins under the eye or in the tight fore- skins through a urethroscopic tube the papillomata themsehes, which are like the cock's comb or cauliflower, usually pedunculated but less connnonly sessile, vascular, from j)inhead to lima-bean size, with a yellowish foul discharge or slimy crust. Subpreputial irrigation must be done in tight foreskins before a full examination can be made. The termination of these warts is indefinite persistence with relapsing balanoposthitis unless removed by treatment and their clinical signifi- cance is that tlie sodden condition of the parts which they uiduce is a direct avenue for syphilitic infection. Diagnosis. — Common warts on the finger during childhood, ecze- matous and nonresistant conditions of the skin are frequent admis- sions in the history proving a tendency of the patient to papillary hypertrophy, to which is added the irritation of the gonococcal jjus especially in folds of the skin of the prepuce in the male and the \'ulva in the female. Subjective symptoms are the flow or drop of pus from the urethra or vulva, furnishing the infection of the foreskin in man or pudendum in woman, followed by the gradual or rapid develop- ment of the warts in scattered, confluent or general distribution. Objective examination ^'erifies the presence of the warts and the causa- tive pus and determines their features as similar to a cock's comb, sessile or pedunculated and foully odoriferous and accompanied by the chronic drop and excoriating balanoposthitis or vuhitis. In the laboratory by smear or culture the infectiousness of the ])us is pro^-ed as often due to the gonococcus alone and equally often to other organ- isms commonly found in the skin, associated with the gonococcus or independent of it. Section of a wart determines its benign character, while treatment is easy remoA'al with caustic, knife or electric spark leaving behind no infiltrated base, thus p^o^'ing its simple N'errucous nature. Relief of the urethritis, balanoposthitis or ^'ulvitis pre^'ents relapse and again shows the lesion to be noncancerous. Differential Diagnosis is concerned with syphilitic condyloma, includ- ing the moist papules of the secondary stage of syphilis, and malignant neoplasm. Condyloma latum differs from acvmmatvvi hi always being associated with syphilis in one of its periods, usually the secondary, less com- monly the tertiary stage. A careful history, therefore, elicits the fact of secondary or tertiary syphilis with the development of the condy- loma or positive blood tests may be admitted with the chief complaint of a painless, moist sore under the foreskin or within the folds of the vulva with thin watery or blood-stained discharge and without any . CONDYLOMATA ACUMINATA 205 other sensation except occasional ardor urina; if urine touches one. Examination shows a broad, sessile, fissured exuberant growth never pedunculated in its attachment, with a serous, serosanguinolent or seropurulent discharge from which the Treponema pallidum may commonly be recovered. Characteristic cord-like lymphatic trunks and bean-like or shot-like lymphatic glands are always present. 'J'he laboratory determines the organism of syphilis in the discharge and in the tissue whose sections exclude malignant neoplasm. Treatment with mercurials, locally and interjially, c;ombined with the iodides or with the newer arsenical compounds is of immediate and corrobora- tive efi^ect and diagnostic proof. Neoylasm differs from condyloma acuminatum in the age of the patient, through its history and in its onset under entirely different circumstances from those of infection. Cardinal symptoms describe a growth under the foreskin or within the folds of the vulva of an ulcerous, painful, infiltrating mass often accompanied early with involvement of the lymphvessels and glands. All the symptoms of chronic phimosis and chronic balanoposthitis are common antecedents. Examination on exposure of the growth reveals the infiltration, raised, hardened edges and bleeding surface of an epithelioma with hardened l^mphtrunks and glands connected with it. The laboratory rules out infection with gonococci or the Treponema pallidum and in the section of tissue develops the neoplastic character, while all measures of treatment along the line of stimulation and cauterization fail to heal. Excision of the penis or a wide portion of the vulva along with • the glands affected finishes the diagnosis by submitting the specimen to the laboratory. The following case report of condylomata acuminata in an infant of remarkable degree is given by R. R. Smith. ^ No gonococci were demonstrated in the discharge. It is seldom that so luxiu-iant a growth of condylomata is seen as the following case: B. S., infant, aged nineteen months. Mother states that neither parent has had syphilis to her knowledge, but she had had gonorrhea nine months before the child was born, but without discharge at the time of birth. Child always w^ell except for occasional diarrhea and without discharge or irritation about the genitals within mother's observation. Apparently wdthin three months the entii*e growth as presented in the photograph developed, beginning on one labium. Fair nourishment, paleness, normal teeth and no skin lesions or scars of lesions w^ere noticed on examination. The growth about the ^Tilva is demonstrated by the illustration. The growth was remoA^ed siu-gi- cally and the diagnosis of condyloma acuminatmn was made by a pathologist. No gonococci were discovered. Treatment. — Both prophylaxis and abortion apply in all then- general principles. 1 Am. Gynec, 1903, II, iii, 515. 206 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS Curative Trcaimcni. — I'sually all relief fails unless the antecedent gonococcal chronic urethritis is relieved, because removal of the warts will be followed by relapse unless the irritation of the discharge is absent. Fig. 55. — Condyloma acuminatum in a child, aged nineteen niontns. (Case of Dr. R. R. Smith.) Curative measures have the following details and are all important: The management is the same as that in any other gonococcal chronic disease and physical methods come to the fore with fulguration of the warts with the high frequency current of Oudin, representing electro- therapy in this field and fulfilling special service in the condylomata of the meatus and the urethra. Its application is simple with the ordinary high-frequency machine developing the current of Oudin. The spark gap is from one-twelfth inch to one-eighth inch and the switch is usually half open. Local anesthesia may be ajiplied but is not absolutely necessary. The cm-rent is applied until blanching or mild blackening occurs which is followed in a few days by the shedding of the lesions. As a rule, a few are treated at each sitting until all are remo\ed. [Medicinal measures consist in drying powders applied to the field of this or other operation and occasionally to the warts themselves if CONDYLOMATA ACUMINATA 207 they are few and scattered. They keep the base of the wound clean and prevent moisture from which these lesions proceed. A service- able powder contains: 0.5 drams (2 . grarnrnf.s; I^ — Calomel, Powdered alum, Bismuth subnitrate, of each Mix, make a powder and mark: External application as directed. Small condylomata acimiinata may be removed by painting them with the following solution: IJ — Salicylic acid 0.5 drams (2 . grammes) Glacial acetic acid enough to make a thin paste. Mix, make a thin paste and mark: Apply to the warts as directed until the surface is white. The .surgeon and not the patient should carry out these applications. The wart may be surrounded by a thin layer of white vaseline to protect its annexa and then the paste is -applied rather Jiberally but without flooding and with the crystals of salicylic acid worked into the surface. Excess of acetic acid is removed with slips of blotting paper and then the application dries in the air and a small dressing protects the lesion, which will drop off in seven days or less. Several warts may be so treated at a time until all are removed with the one caution that the normal surfaces must not be attacked by the solution and that none must be allowed to reach the urethra. Apposed sur- faces are kept apart by cotton loosely packed in. Surgical measures deal at once with underlying phimosis and para- phimosis at the same time that the warts are clipped off. Marked growths are always best removed under local or general anesthesia with forceps and scissors, including their bases, followed by gentle stimulation with 10 per cent, silver nitrate solution to still bleeding and prevent infection. The little wound is sutured if possible, and a heal- ing powder applied. Warts of the skin are apt to be hard vegetations, easy of removal with closure of the base, while warts of the mucosa and modified skin are a little less easy of suture if their bases are exten- sive. Warts of the meatus may be clipped off with care not to injure the lips and with attention to healing to prevent stenosis; but like these growths farther in the canal the high-frequency ciu-rent of Oudin is preferred to scissors. Warts about the anus and within the rectmn are dealt with in exactly the same manner with incisions converging toward the anus in general correspondence with its normal folds. Through the proctoscope growths higher up may be fulgm-ated. Aftertreatment. — Sm-gical dressings for cleanliness and primary imion are required. The catgut stitches are absorbed. Secondary union is usually without deep scar. Cure pathologically and s^auptomatically involves removal of the wart with its base, bacterial relief from infection and ablation of offending foreskin or other underlying anatomical cause, and these lesions are regarded as annoying but not grave. 20S COMPLJCATIUXS AM) 6KQUELS OF ACUTE URETHRITIS 2. Digestive CovqMcations. Occurrence. — When coin])aral witli tionococcal arthritis, the digestive manit'estations are rare but are imich more coiiuiioii than tlie cutaneous lesions. Varieties. • Acute, subacute and chronic as to course are tlie chief chnical forms which are again sul)(H\"ided as to site into buccal, anal, rectal and rectoanal. These are rather connnon, but esophageal, gas- tric, intestinal and colcmic are without record in literature. Peritoni- tis is seen occasionally in males but frequently in females. Significance. ~ Stomatitis and ])roctitis usually occur by direct trans- ference of i)us and are both obstinate and intractable and ])eritonitis is a severe invalidating and not uucommonly fatal condition. The clinical importance of these complications is great and of si)ecial con- cern for transmission of the disease to the innocent. Etiology .^ — Invasion by the gonococcus is regularly the exciting cause, engrafted on absence of resistauce in the body at large, or locally through same antecedent disease. Septicemic gonococcal urethrites are a])t to have digestive complications. Diagnosis. — The jiroof is of imi)ortance and is limited by difficulties of cultiu'e of the gonococcus, both alone or associated Avith other organisms. The gonococcus dies easily in unfavorable pabulum and surroundings and is probably destroyed by the various digestive secretions. Treatment. — Exposed surfaces are freed of the infecting gonococcus and restored to as nearly normal as possible. Special surgical meas- ures are required in proctititis and peritonitis. GONOCOCCAL STOMATITIS. Occurrence. — Bacteriologically proved stomatitis is rare, especially in comparison with widespread sexual perversion. Prostitution deter- mines a greater frequency among females than males, and ophthalmia causes it among children more than adults. Etiology. — The gonococcus is present either by direct contact or by indirect deposit during bacteriemia. Pathology. — The lesions are much the same as in other squamous ei)ithelial mucos?e — hypersecretion, desquamation and supi)uration. Symptoms. — The stages of invasion, establishment and termination designated by the three pathologic processes just named are the same as elsewhere in the body. Diagnosis. — The gonococcus must be detected by smear and culture and ill s('i)tic cases the gonococcal com})lement fixation test is required. Differential Diagnosis. — Determination of the cause distinguishes gonococcal stomatitis from simple acute and chronic inflammations, scarlet fever, measles and typhoid fever, diabetes, syphilis, scorbutus and metallic poisoning. Consultation with a dentist is always advis- able. GONOCOCCAL ACUTE PROCTITIS 209 Treatment. — Prophylaxis is of the eyes and nose. Local antiseptics to destroy the infection followed by astringent and healing lotions and proper care of the gums and teeth by a dentist are sufficient. In septic cases treatment of the primary focus is essential. GONOCOCCAL ACUTE PROCTITIS. Occurrence. — When compared with several other complications of gonococcal acute urethritis, rectitis is not often seen but it is more common than ^ stomatitis. Among European authorities, Jullien^ believes that it is present in nearly 5 per cent, of all cases, which is an estimate far in excess of experience in America. In the Genitourinary Clinic of the House of Relief in New York City, for seven or eight years under the charge of the writer, with an average weekly attendance of about 150 cases, very few examples of it indeed were encountered. Taylor- says: "This affection is more or less frequently observed in countries in which sodomy is practised and it sometimes occurs in America." Full bacteriological proof is necessary comprising the three general steps of smear, culture and complement fixation in order to establish diagnosis. It is found more often in female than male adults, owing to the incidence of prostitution upon the former sex, on the other hand, however, so-called "male prostitutes" almost invariably have it, likewise boys who have been the victims of homosexual perver- sions. Varieties. — Acute, subacute and chronic forms as to clinical course are recognized and as to site anal, anorectal and rectal, localized and generalized. The tendency of the disease to become chronic renders the mergence of the three clinical forms into one more convenient for description. Primary cases due to artifacts and secondary cases fol- lowing other infections are seen. The rapid ascension from the anus into the rectum likewise renders clinical subdistinction unnecessary. In fact, the anal condition is prominent only in virtue of severe lesions above this muscle. Etiology. — Penetration of the gonococcus into the rectum by con- tinuity from the anus or by accident from instruments or fingers or by sexual perversion is regularly the exciting cause. Thus the entrance of the organism is either direct or indirect. As to indirect access, the predisposing factor in females is gravitation of the pus from the vulva and vagina upon the perineum and the anal region in the recum- bent position, and its pocketing between the nates and the funnel- like form of the anus. The frequency of gonococcal infection in women without anorectal complications renders this cause unimportant and almost inert. Penetration within the sphincter ani muscle is also ren- dered difficult by tonic action which results exactly as does the similar state of the sphincter vesicae in preventing progress of the gonococcus into the bladder. Growth of the gonococcus upon the anus is also 1 Rev. int. de med. et de chir., 1905, -svi, 109. 2 Genito-urinary and Venereal Diseases, 3d edition, p. 95. 14 210 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS liiiulered b>' the sqiianious ciiitlielium tliciv, which is poor soil. It is probable, therefore, that some cause is always present i)lanting the organism above the limits of the muscle. As to direct access, on which depend true primary cases, instrumental infection of, the rectimi with douche nozzles prc\'iously used for the ^■agina and then for rectal cneniata is connnon. The ^^■riter had a patient who vigorously washed his genitals clean of gonococcal pus with a sponge and employed the same sponge at the same sittings to bathe his anus, with the result of gonococcal anoproctitis. The most common direct cause is sodomy, intercoiu'se through, the rectiun or coitus per anmn. Less usual is infection of the rectum from sinuses entering it from extensive gonococcal abscesses of the prostate and Cowper's glands. Norris^ notes " three cases resulting from the rupture of a pyosalpinx into the rectimi." Pathology. — The lesions of proctitis must largely be inferred from the behavior of the gonococcus in all other mucous membranes. The essence of the process is infection and penetration of the gonococcus into the mucosa, followed by temporary lesions in acute cases, such as congestion, edema, proliferation, infiltration, purulence and hemor- rhage. Tendency to chronic thickenings in older cases are seen as permanent lesions exactly as in the urethra, so that the wall of the bowel loses its elasticity and even becomes narrowed. Likewise proliferation of the mucosa into condylomata acimiinata is common. Associated lesions in the ischiorectal fosste such as abscesses are seen which proceed from associated organisms like the Bacillus coli communis and in the wall of the rectmn as fibrous deposits of semicartilaginous density, and if a sinus from a periurethral or periuterine complication has preceded the rectal involvement its featiu'cs will be obvious. The involvement is usually confined to the terminal four inches but the whole rectum may suffer. Symptoms. — The periods of invasion, establishment and termina- tion with subjective and objective findings may be distinguished. Compared with other gonococcal infections the subjective invasion is relatively little; Luys- for example, says: "As a rule, anorectal gonorrhea is characterized by a complete absence of subjective symp- toms." This can be only relatively true and the symptoms must depend on the severity of the inflammation and the comparatively less irritability of the rectiun than of the urinary organs. On the other hand, among older writers, Taylor^ and among more recent authors Norris^ describe marked and positive symptoms of the disease corresponding with the writer's experience. Heat and discomfort are first seen, which, in the subjective estab- lishment become marked and are followed by pain, irritation, discharge and functional disorder. The pain is due to the congestion, excoriation, ulcerations and fissures and the stimulation of the bowel to empty I Gonorrhea in Women, 1913, p. 396. ^ Text-Vjook on Gonorrhea, 1913, p. 233. ' Log. cit. ■• Loc. cit. GONOCOCCAL A C UTE PROCTJ TIS 2 1 ] itself, which may be accompanied by all the irritation of general proctitis. The discharge is at first a serous moisture not greatly apparent riy)on the anus but rather acconj]:)anying the stools, and later be(;omes puru- lent and even bloody. Severe anal involvement is followed by folli- culitis, minute ulcers and even fissures with their spasm and tenesmus. The early irritation of defecation becomes the agony of proctitis with its diarrhea containing pus and sometimes blood. Eczematous involvement of the anus, perineum, thighs and buttocks by secondary infection of the skin is complained of. The objective symptoms are in suspects of sodomy a funnel-form anus through the unnatural practice and its force. The signs of inflam- mation may be comparatively little or marked, so that frequently proctoscopy and digital exploration are required for diagnosis. Such procedures the acute and severe stage forbids, but with subsidence of suffering they may and should be carried out. If the anus is involved it is reddened, edematous, the site of folliculitis, ulcers and fissures and surrounded by a zone of eczema extending to the perineum, inter- gluteal fold, buttocks and thighs, all bathed in a seropurulent or puru- lent. Irritating discharge. The sphincter may be relaxed and moderate prolapse present. Venereal warts similar to those in genital gono- coccal infection are common. All these conditions are repeated within the rectum itself. Jullien^ gives three cardinal symptoms: the con- dyloma, the drop and the fissure. The condyloma aciuninatum is pathognomonic when about and within the anus and rectum. It is delicate, friable, vascular, fimbriated and pedunculated or glossy and sessile and usually covered with thin, slimy pus. A case in the author's practice had the warts of various size and form distributed numerously and universally over the lower portion of the bowel for at least iixe or six inches and accompanied by the characteristic mucopiu"ulent discharge and perianal dermatitis. To such conditions the term pro- liferative proctitis or proliferating rectitis has been applied. The discharge or drop is gonococcus-laden and resembles the "morn- ing drop" of chronic urethritis in being invisible until eversion of or pressure on the anus brings it to the front exactly as stripping the urethra in either women or men discovers the droplet of pus. In females pressiue upon the anus from within the vagina is efficient. The drop is sometimes from a chronic folliculitis of the anal verge. The fissure is single or multiple and if the former is commonly pos- terially or under cover of a condyloma. The termination follows a slow course of doubtful duration, excepting in very mild cases, due to the gonococcus, its penetrating power and possibly the natural local uncleanliness. The mild cases reach a cure without sequels or complications in about the same period as a m'etlu'itis, namely, one or tw^o months. The severe and general cases, however, become chronic and have sequels. Chronic infiltration and contractiu-e are not uncommon. The bowel thus narrowed causes obstruction of 1 Rev. internat. de med. et de cliimrgie, 1905, xvi, 109. 212 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS function, then chronic inflannnation of the rectum alone at first, and hiter of the intestine above it with dii^'estive disorder and nudnutri- tion. Complications. — A common terminal (•om])li('ation is a slimy jnis about the anus and its annexa, with sodden eezematous skin and ten- dency to inelasticity and stricture above. lirunswic-le-Bihan' recog- nizes three complications: acute and chronic ])erirectitis and stricture. Acute perirectitis or ])erii)roctitis is ischiorectal abscess containing rectal and intestinal organisms, notably the liacillus coli communis, entered by lesions of the wall caused by the gonococcus which is ordi- narily not found in the pus or the walls of the abscess due to vul- nerability of the organism, and its difficulties of growth, especially in the presence of such abundant other flora. Chronic perirectitis or periproctitis is really an infiltration of the perirectal tissues into semicartilaginous density with inelasticity and resistance as a bait or strip, palpable to the finger and visible to the eye b.y its bulging and inertia. Symptoms of obstipation, pressm'e and weight of foreign sulistance and constipation, with pain and tenesmus due to the mucous proctitis associated with the lesion, are common. Gonococcal stricture of the rectmii, as in the m'ethra, follows more or less deep destruction of the mucosa with ulcers, scars, general thickening, condylomata and widespread cicatrization. This process is within the rectal wall while that of chronic peru'cctitis involves the tissue outside it alone, or the wall in addition. Both have much the same symptoms as just described on page 211. Cases in literatm-e of importance have all been published since the development of bacteriology, and therefore rest on absolute proof. The fullest historical re\iew of gonococcal proctitis is giN'en by Mermet.^ Tuttle^ gives full bacteriologic proof of gonococci in the pus of these three patients as does also Grift'on^ in one patient. Hartmann'^ demon- strated gonococci in an ulcer of the anus. These positi\'e findings in the cases of Tuttle, (iriffon and Ilartmann render them acceptable. Without full bacteriologic })roof in smear and culture earlier case reports which omit such proof must be disregarded or discounted. Bumm*' seems to have been the first authority to have established the identity of the gonococcus in the rectum and is so credited by Luys in his Tc.ri-J)(H)I: on (lonorrhcd. Diagnosis. — The clinical atlmission or denial of sodomy in the history or of other source of contamination, sudden, severe onset, short period of intense symptoms followed by subacute or chronic tendency with condylomata or antecedent or accompanying genital gonococcal infec- tion all tend to estal)lish the diagnosis. The subjecti\'e symptoms are during the acute period rectal pain, burning, irritation, frequent semi- 1 Reported by Fournier: Bull, de I'Acad. de med., 1907, Ivii, 501. 2 Gaz. des hop., 1896, Ixix, 5.31, 559. ^ jsjew York Med. .Jour., 1892, Iv, 379. * Presse m6d., 1897, p. 71. ^ Ann. de gyiiec. et d'obstet., 1895, xliii, 77. * Der Mikro-Organismus der gonorrhoischeii Schleimhaut-Erkraukungen, Wiesbaden, 1885, p. 49, and Arch. f. Gyniik., 188-4, xxiii, 339. GONOCOCCAL ACUTE PROCTTTrS 213 diarrheal evacuation, mueopunilent and purulent disf;harge and occasionally bleeding. In the subacute stage these subside in degree but the follicular proctitis which usually supervenes may cause much discomfort and the chronic warty growths, fissure or follicular abscess and pus about the anus are complaints in the chronic stage. The objective symptoms are cardinal and include (1) the condylomata acuminata about and on the anal muscle and in the rectum, (2) the drop of stringy pus appearing under eversion or other pressure upon the anal muscle and (3) the fissure representing an infected follicle with abscess, sinus or ulcer and chronic drop of pus as the final result. The "funnel anus" with perianal eczema marks the pervert. Proctos- copy during the acute stage is not as a rule desirable but will reveal all the signs of severe inflammation, redness, edema, exfoliation, pus containing the gonococcus. Folliculitis in the subacute and chronic periods is characterized by inflamed and occluded or discharging follicles, infiltration, adherent strings and scabs of pus leaving a raw surface and frequently containing the gonococcus. The chronic period shows one or more follicles degenerated into sinus, ulcer or fissure and condylomata acuminata above the anus as well as on and external to it. These may extend several inches up the bowel and be extremely numerous — one case of the author showing several dozen of them. The laboratory findings are very important. The fact that the Micro- coccus catarrhalis is gram-negative in its early periods and gram- positive in its later developments and closely resembles the gonococcus, makes careful bacteriology absolutely essential, combined with the use of the proctoscope for the distinction of objective symptoms. Often an active folliculitis will be found within the rectiun or at the anus, whose pus when carefully secured will be free from other organ- isms than the gonococcus and settle the question. Smear, cultiu-e and complement fixation test make up the chain of e^^dence. Treatment is of no direct aid in the diagnosis with the exception that removal of the adherent scab and strings of pus furnish good specimens for the laboratory as does likewise evacuation of foflicles. Antigonococcal antiseptics are also of suggestive value. On this general subject Lynch^ says: "In gonorrheal proctitis the anus has a rather tji^ical appearance. Where the disease is acquired innocently, especially from massage of the prostate, the sphincter is spasmodicaUy contracted and the mucocutaneous membrane is red; but after the disease has existed for some days, the skin becomes macerated, and is covered by a mucopm'ulent discharge. In the case of sexual perverts, the skin around the anus is thrown into edematous folds. It has a cyanotic or bluish-red appearance, and is covered by mucus mixed with pus. In some cases the mucous membrane is pro- lapsed, and it is with difficulty that the speculum can be passed very high. Here and there we see flakes of mucus and pus resembling those of severe peritonitis. The flakes are adherent to the mucous membrane, 1 Diseases of the Rectum and Colon, 1914, p. 278. 214 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS and when remoNod leave a raw, bleeding surface. The mucous mem- brane in all cases bleeds very easily." Differential Diagnosis is concerned chicHy with catarrhal i)roctitis and syjihilis and chancroids of the anus. Catarrhal differs from gonococcal proctitis in the absence of any history of anteeeilent infection or of perversion; in the much less intense subjective symptoms and in objective symptoms of haxing mucus and mucoi)us rather than ])us as the dischariiv; in the freedom from the strintjcs and scabs of i)us leaving bleeding surfaces when removed and like the free pus containing gonococci; in the failure of laboratory findings to detect the specific organism or the eom])lement fixation test and in the promi)t res])onse to simple treatment of the catarrh. Si/jihilific differs frovi gonococcal proctitis in the absence of an\' gonococcal findings whatsoe\'er in the history and in the presence of abundant signs of syphilis elsewhere in the body and in the blood as a Wassermann test. It may appear about the anus as moist papules, condylomata lata and gumma each having its own features. The moist l)apules resemble the mucus patches of the mouth in being slightly raised above the surface, siu'rounded with indolent inflammation and infiltration and in having a moist "varnished" siu-f ace, serous discharge and the Trei)onema pallidimi abundant. This process does not extend materially into the rectmii ])roper, and bears little resemblance to gonococcal warts. The condylomata lata might be regarded as exag- gerations of the moist papules in being sessile, slightly raised above the surface, sun-oimded by inflammation and infiltration, fissured, and co\'ered with moist, thick discharge. The organism of syphilis is in the discharge and the sm-face and substance of the outgrowth. These likewise do not extend above the anus in themselves but may provoke a secondary infection of the rectmn of catarrhal or purulent type. The gumma is essentially a neoplasm although of temporary character under treatment, deeply infiltrates the tissue and may be a prominent and extensive mass, occurring singly or severally. It is of peculiar purple lividity, and has a decided tendency to necrosis at the center whose secondary infection may extend up the bowel. The condylomata acmninata, on the other hand, are not sessile but pedunculated, finely and coarsely fibrillated and lobulated exactly like a cock's comb, dry rather than moist unless between closely apposed surfaces, bleed easily, are very friable and in smaller examples will break oft' in the fingers. Their discharge contains only the gonococcus. Exceptionally these condylomata are found without the presence of gonococcal infection but with the existence of uncleanly habits and deep folds of the skin especially around the anus and genitals where eczema intertrigo is very common. They then represent a hypertrophic change in the skin due to the eczema and the infection of the organisms present normally in the skin but augmented by the uncleanliness of the victim. The history' therefore points only toward syphilis and away from gonococcal infection in the long incubation, development and course of the chancre, appearance and progress of the secondary symptoms r;r,\ocoCCAL ACUTE PROCTITIS 215 of which these cutaneous anal signs are only a part or of the tertian* symptoms with the incidenc-e and ulceration of the gnunma. The subjective s\Tnptoms haAe just been sufficiently stated and should be corroborated by objective examination, both of the general symptoms and of the local outgrowths of the disease, without omission of search for the Treponema pallidum and the Wassermann or Xoguchi com- plement fixation tests for syphilis as the chief elements in the labora- tory e^'idence, which after all is final. The treatment, systemic and local, against s^"philis is so prompt in its results that it has been called the "touchstone" of diagnosis in these cases, and is of great service in cases giving negative or contradictory laboratory* reports. Chancroidal differs from gonococcal proctiii^s in being primarily an external ulcerative process and secondarily a pmiilent infection of the bowel which may not occur at all. The history* is that of pen'erted sexual congress or of the presence of chancroid about the genitals and its appearance at the anus by autoinoculation. The subjective s^^np- toms embrace all the irritation, pain, spasm, bleeding and discharge of fissure in ano and the objective findings reveal the tApical chancroid with "mouse-eaten or gnawed"' base and overhanging ragged edges and purulent slightly hemorrhagic discharge. Proctoscopy, if possible to the patient, reveals a purulent proctitis without the development of condylomata acuminata within the boweh without adherent scabs and strings and without any of the other signs of gonococcal proctitis, including the gonococcus itseh. The laboratory" investigation proves the presence of the bacillus of Unna and Ducrey and freedom from the gonococcus in the ulcer and its pus and the pus from the bowel. The gonococcal complement fixation test is negative. Treatment against chancroid and other ulcer is available. The bowel requires no attention unless secondare- infection of it shall have occurred. Curetting and section of the sore will reveal the I'nna-Ducrey baciQus in the substance of the growth and in the discharge and sloughs from its surface. Treatment. — In the discussion of gonococcal conditions, significance shows that proctitis is one of the more important compHcations through the lesions produced by direct infection, incidentally through carelessness or intentionally by perversion. The latter is a factor in these cases of grave social moment. The prophylaxis of the disease pro^"ides against transmission of pus from the genitals to the rectum by instructions concerning -clean hands and disposal of dressings as shown in detail in the printed shps of instruction given in the early paragraphs on treatment. Abortion reaches its aim by early and judi- cious attack on the first symptom of bacteriologically proved infection. The particulars of management are enumerated in Chapter IX on General Principles of Treatment on page 4S3. Curaiive Treatment. — ^Removal of exudate is the first step and irri- gation is the first method during the period of discharge followed by expectant applications in the chronic period. The stool should be soft and pultaceouSj as in fissura in ano, as 21G COMPLICATIONS AXD SEQUELS OF ACUTE URETHRITIS produced by the folKnviiig foriiuila iii one or two movements ca day, black and foul-smelluig, concerning Avbich the patient should be warned. ]^ — Flowers of sulphur, Sulphate of magucshmi, of each 1 ounce (30.0 grammes) Mix, make a powder and mark: One to fout tcaspoonfuls, as needed, for soft movements. The physical measures are, in hy(ir()thera])y rectal irrigations as soon as the intense symptoms disapjK^ir, at lirst sohent and cleansing to remove mucus and pus, then antiseptic and stimulating. Sitting baths, hot to produce redness of the skin, decongest the deep pelvic circulation and soothe the diarrhea and tenesmus. In electrotherapy fulguration removes the warts by the same procedure as tletailed in this technic for condyloma acuminatum, substituting the proctoscope for the urethroscope. The medicinal measures are standard attention to the urethritis. During the acme, extreme irritation forbids active treatment, but the sphincter may be stretched under nitrous oxide gas anesthesia, as in fissure, and Irish moss lubricant, containing a small amount of novocain or alypin may be inserted as sedative. JNIorphin and opium suppositories check the pam and the tenesmus, aided by soft stools. ]\Ioist antiseptic dressings receive the discharge and keep apposed surfaces from chafing. Serumtherapy offers no advantage. Local administration is involved M'ith the declinhig period exactly as in urethritis. Through the double current rectal tube or two catheters inserted, side by side, warm normal salt solution or weak boric acid water are rmi in until the return is clear, followed by solutions of potas- sium permanganate, 1 in 10,000 to 1 in 4000; silver nitrate, 1 in 20,000 to 1 in 5000; bichloride of mercury, 1 in 10,000 to 1 in 5000. After these, argyrol, 3 to 10 per cent.; protargol, 1 to 2 per cent.; collargol, 10 per cent.; silver nitrate, 0.5 to 1 per cent., may be instillated and retained. In the still later periods the proctoscope or the small Sims speculum in either the knee-chest or the Sims posture is employed for making light applications of nitrate of silver in more stimulating and caustic strengths, 1 to 25 per cent., and its allies to ulcerations and indolent granulations anfl for fulgurating warts from within the canal or surgically removing them. The anal eczema indicates cleanliness by washing with castile soap and water and thoroughly dr^'ing w'ith a towel, aided with dusting powders, such as equal parts of boric acid, th.Miiol iodide and bismuth subnitrate. Painting of the eczema with 10 per cent, nitrate of silver is a strong healing agent against the infec- tion and the relaxation. Dressing to receive the irritating discharge and to separate the surfaces is essential and should be at first moist antiseptic gauze or cotton followed by the same liberally dusted with stearate of zinc and boric acid powder or by a soothing ointment, such as equal parts of 10 per cent, ichthyol and 10 per cent, boric acid. The surgical measures begin with overstretching of the sphincter ani muscle to correct tenesmus and to permit applications more readily. Through a small Sims speculum or the 10 cm. proctoscope the mucosa GONOCOCCAL PERfTONITTS 217 is directly treated and warts may be fulgurated in the exact manner prescribed for urethral growths or surgically ablated. In the latter technic they are drawn forward and clipped through their bases after ligation, so that the wart and its pedicle are ablated. The raw stump may be touched with 10 per cent, silver nitrate. Folliculites are incised, cauterized, drained and dressed in miniature like an ischiorectal abscess. Fissures are incised througli the granulating zone to sound muscle tissue and dressed, after the preliminary stretching of the muscle. Sources of discharge are so far as possible located and approjjriate appli- cations made to areas of indolent granulation and to pockets accumu- lating pus. A small cotton tampon soaked in suitable medications may be inserted through the speculum until the next defecation. Aftertreatment. — The chief aim is to restore the mucosa to normal after the infection is removed, which may require weeks and months, exactly as in the urethra. Avoidance of constipating or diarrheal diet and drink is required and full hygiene of the urethritis must never be omitted in order to avoid reinfection. Cure, pathologically, means no panproctitis, with its cicatrices and chronic catarrhal discharge, and s^Tiiptomatically there must be no relapse of the catarrh or the infection from any uncured fissure, follicle or wart and no excoriating mucous or purulent discharge; and bacteriologically the gonococcus must be permanently absent after repeated smear and culture test and the flora of the bowel restored as nearly as possible to the normal. Cure of the urethritis to the standard previously described is a foundation of proper result in the rectal disease. Cessation of unnatural practices is absolutely indicated. GONOCOCCAL PERITONITIS. Significance. — Although the peritoneum is not actually an organ of the digestive tract, it is so intimately associated with it that sjTiiptoms of peritonitis are locally chiefly digestive. For this reason it was regarded logical to include the complication of gonococcal peritonitis under the heading of complications of the digestive system. Its significance recalls the fatal results and the late sequels and invalidism which mark peritonitis as one of the most important of all the sequels of gonococcal infection. In the male it is fortunately rare, because there is no direct connection between the urogenital system and the serosa, but in the female it is lamentably more common because the mucosa of the tubes is directly continuous with the serosa. With modern and improved treatment of gonococcal disease it is much less common in either sex than it was in previous generations. Occurrence. — In actual frequency gonococcal peritonitis is in the male a rare disease, never primary but always secondary to or associated with disease of the seminal vesicles, prostate and perivesical region, with burrowing of the pus in the deep celhdar planes until the peri- toneum is reached. It is much more common in the female, owing to the fact that the Fallopian tubes open directly from the peritoneal 218 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS cavity. In chiUlren it is most common and nsnally of fulminatine; type. The disease in women and children is discnssed in (diai)ter XI on jiaues ()12 and lil"). Varieties. — Acute, subacute and chronic, locaUzed and partially or generally diffuse are the forms seen, of which the most usual are (1) in the niale, acute localized; (2) in the female, acute and ])artially diffuse within the ])elvic cavity and (o) chronic relapsinj^with adhesions, es])ecially seen in women. Etiology. ^ — The gonococcus, with its pyogenic allies, is the exciting factor, A\hik" the associated disease is the predisposuig condition, notably coni])lications in spermatocystitis, jn-ostatitis, both with abscess and iini>hement of the surrounding tissues. Fuuiculitis of severe type is a particularly common cause especially where the vas deferens reaches the wall of the bladder from the inguinal canal and, in direct contact with the i)eritonemn, passes along it to its am])ulla at the l^ase. The ])eritoneal annexa of all these organs in the rectovesical cul-de-sac are the point of onset of the peritonitis. Pathology, — Primary cases never occur, because the gonococcus cannot reach the ])eritoneum except through complications in and break down of neighboring organs in more or less direct relation with this membrane, t'econdary cases are, therefore, the one rule. The essence of the process is extension to the serous sac of the abdomen of the gonococcal infection, with or without its common pyogenic allies from a previous jjoint of infection — invariably a complication in the peri- lU'ethral structures in the male. The tissues invohed are the organs in such complication and the peritoneum locally in the strict sense or diffusely within the cavity of the true pelvis or throughout the peri- toneal cavity as a whole. The temporary lesions in cases of recovery are those essential to gonococcal invasion — congestion, inflammation, exfoliation, infiltration and purulence, which is relatively scanty in fluid amount but copious in fibrous products with secondary delicate adhesions. The permanent lesions are extensions of these processes into dense adhesions, which displace the intestines and the organs, especially in the female, to severe compromise of function, digestive and sexual. The associated lesions are those of the causati\'e or pre- cedent involvement, while the bacteriology is, as stated, the gono- coccus with or without its common pyogenic aids. Mixed infections are commonly the most severe. S5miptoms. — As in any other peritonitis the gonococcal form has much tlie same local and general subjectiA'e and objective syndrome dm'ing the periods of invasion, establishment and termination. The initial s.Miiptom of the invasion is usually local, as a severe sudden colic, which in children is intense and prostrating. This is followed by chill and chilliness, high fe\er and the other common signs of infectious invasion. In the establishment the subjective systemic symptoms are continuation of the rigors, with high variable temperature, nausea, vomiting, first of bilious and later fecal type, constipation from par- alysis of the bowel and exceptionally diarrhea. The objective systemic GONOCOCCAL PERJTONTTIS 210 signs at the corresponding time are the high variable fever, parti<:u- larly in children, a rapid, tense pulse, intense anxious mind, due usually to the pain and the character of the toxemia. The subjective local signs are extension of the colic into severe pain (;onfined to the pelvis, the lower part or the whole of the abdomen, while tlic objective }>oints, less in localized than in generalized disease, are tenderness and muscular tension over the seat of the pain, gradual inflation until the whole abdomen is "ballooned." Motion and touch augment the suffering exemplified by the anxious, sallow, haggard expression. Jicctal examination commonly reveals the causative focus in the seminal vesicles, prostate and annexa, and sometimes localized tenderness in the cul-de-sac to the examiner with a long finger. The termination in mild local cases is full recovery, with or without adhesions, which may lead to secondary rectal and intestinal difficulty. More extensive cases may also permit recovery, while the intense generalized involvements commonly terminate fatally. Diagnosis. — Recognition of two facts — the peritonitic process and the gonococcus as the exciting agent — is the basis of the diagnosis. The history is completed by the antecedent intense gonococcal infec- tion with numerous and severe complications, especially those of the prostate and seminal vesicles, with absorption systemically and with extension into the annexa of these organs locally in the male and in the female duplicate processes in the womb, tubes and -ovaries. The subjective sjmiptoms are those of intense pain localized in the region of the affected organs with a tendency to advance and extend. Diffi- culties with bladder and rectum may be present. The objective signs are those first of the initial gonococcal condition and its complications, and. second those of the localized peritonitis. In the female through the rectum the cul-de-sac of Douglas may be perceived to have lost its usual freedom and smoothness and to have been replaced by infil- tration and adhesions, in association in the male with the diseased prostate, vesicles and vas deferens and in contact in the female with the boggy uterus and invaded tubes and ovaries and sometimes the bladder in either sex. In the male the peritonitis may be suggested by extensive tenderness along the course of the vas deferens within and just above the inguinal canal. On the whole the general character of the fever is less variable and intense in pure gonococcal peritonitis than in the true pyogenic form excepting children and the sudden onset of localized abdominal pain during the activity of any of the essentially severe complications of gonococcal m'ethritis followed by the other classical symptoms of peritonitis will practically settle the question. The laboratory findings ofter suggestive factors in the decision such as the presence of gonococcal infection in the urogenital organs, especially of its complications in those organs which are particularly in relation with, for example, in the male the bladder, prostate, seminal vesicles and vasa deferentia and in the female, the tubes and ovaries. It is obvious that the final decision as to the identity of gonococcal involve- ment in the peritonemn cannot be reached without recovery of exudate 220 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS from the i>eritoneal cavity which m tlie male is extremely (lifTiciilt, hut in the female in oi)erative cases is much easier when the organs within the pehis are freed of adhesions and exposed for the securing of specimens. Only in this sense is treatment of value in the diagnosis. The compleinent fixation test is very apt to be positive. Differential Diagnosis. — Peritonitis arising during a com])li(atcd ure- thritis may hv due to the i)yogenic organisms conunonly found with the gonococcus in these cases but its recognition would depend on its more active and progressing character and the distinction of the pyo- genic germs to the exclusion of the gonococcus in the ])us. This would well-nigh be impossible except as an element of operative intervention or autopsy. Treatment. — The fatal issues and invalidating sequels in their significance identify peritonitis as a grave complication and ])r()])hy- laxis oH'ers no direct means, but efficient indirect means by earl>- and proper attention to the comi)lications in the female involving tube and ovary and by free e^•acuation and drainage of pus accmnulated in the male among the cellular planes of the pelvis seen in abscess of the seminal vesicles, prostate and pancystitis. There is no aborti\^e treat- ment because when the infection has once reached the i)eritoneum it cannot be checked but it may be localized and prevented from becoming diftuse. Proper treatment may therefore be abortive of generalized disease. The student must learn the essentials of management in Chapter IX, on General Princii)les of Treatment, on page 4S3. Curative Treatment. — ^This is active and prompt, but is often of little avail and yet may save seemingly hopeless cases and limit severe infections to one part of the abdomen. 'i'he physical measures offer the ice-cap or the ice-water coil to the abdomen or hot poultices in the hydrotherapy according to the prefer- ence of the patient and the benefits of each form of treatment. The ]\Iurphy enteroclysis belongs under this heading. The heliotherapy requires a 500 c.p. therapeutic lamp slowly wav- ing o\er the affected part for at least thirty minutes four times a day and persisted in until subsidence of symptoms, which is induced by the intense hyperemia, increase in the resistance and activity of phagocytosis followed by relief of the pain. The electrotherapy applies the hot electric coil, if heat is beneficial, or the .r-ray in the chronic stages to promote absorption of extensive exudate. The cm*- rent is 3 milliamperes, backing up a 4 inch spark gap at the negative terminal of the a;-ray tube placed at a distance of 10 inches from the part, imder the protection of 3 mm. of aluminum upon either 4 layers of chamois or 1 layer of sole leather. The duration is fifteen minutes but varies with the result and the frequency is alternate days for ten treatments and then two times a week. Unfavorable reaction is unknown in competent hands. All medicinal measures suggest small doses of calomel or sul])hate of magnesium to avoid stasis of the bowel followed by paralysis and GONOCOCCAL PERITONITIS 221 distention but are given cautiously if there is diarrhea. Small doses of opium derivatives to ease spasm and pain arc rcfjuircd ; the use of large doses of opiates to control all spasm and pain is no longer advised on account of its disadvantages of constipation, prevention of absorption of exudate, masking of new symptoms and sometimes depression. On the other hand, a single large dose will relieve the shock of intense jjain, especially in a perforating case. Splanchnic vascular paralysis with secondary cardiac paralysis is seen in diffuse peritonitis and Kolt/J gives pituitrin for the low blood-pressure, ileus and ischuria of such paralysis. The surgical measures never neglect the focus of onset, such as spermatocystitis, prostatitis and pancystitis, any or all with abscess and involvement of the surrounding tissues. The nonoperative means are Fowler's position and Murphy enteroclysis as noted on page 415. The operative technic rests on the severity of the symptoms and the type of the infection present. The latter is often impossible to determine. Operation may be immediate or postponed with both dangers and benefits. Immediate interference may excite an inflam- mation which would otherwise decline and postponed operation has the dangers of advance in old and of appearance of new lesions with adhe- sions and invalidism, relieved only by later operation. Its benefits make the operation one of election, greater safety and often better immediate and remote functional results. Minor operation is blood- letting in sthenic patients, with localized peritonitis a small quantity of blood being withdrawn. Even multiple leeches helpfully reduce pressure and remove toxins. The major operation is laparotomy by incision, evacuation and drainage of the abdominal cavity, without or with flushing, irrigation or mopping. The selection of case concerns local and diffuse peri- tonitis. The local cases have focal inflammation, symptoms and exu- date, with comparatively little systemic disturbance, much as is seen in some forms of appendicitis and pus tubes. Relief comes with incision, evacuation, cleansing and drainage analogous to an abscess. The generalized peritonites have diftuse abdominal pain and most intense systemic symptoms in contrast, especially in cases of general peri- toneal septicemia proceeding from postoperative infection, puerperal fever, strangulated hernia, intestinal obstruction and the like. Relief of these cases is not unlike removal of accumulated poison from the stomach. Operative energy against the cause of the peritonitis is imperative. The instruments and supplies are scalpels, scissors, forceps, hemo- stats, ligatures, retractors, sponge-holders, gauze sponges, intestinal pads, return flow irrigation tube, assorted needles, including intestinal needles, needle-holders, sutures, drains and abundant hot, normal salt solution. The preparation of the patient usually omits catharsis and of the field is the standard iodin application for the skin and the 1 Miinchen. med. Wchnschr., September 17, 1912. '2J2 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS anesthesia is general and well witliin any danger of depression. Etiier for its stinnilation is preferred. The posture is supine or Trendelen- burg's, according to accessibility of the essential deep field. The land- mark is the middle line of the body from the sym])hysis pubis to the xiplu>iil cartilage. The incision in localized peritonitis is over the jioint of most prominent symptoms, most commonly the pelvis in gonococcal cases in lx)th sexes, and in generalized peritonitis it is extended upward to give free entrance to the infected cavity. The midline is preferred, marking the superficial field between the recti muscles or through the sheath of one with separation of the fibers or pushing of the muscle aside. The deep field embraces all pockets in diti'use peritonitis, com- monly reaching the pelvis last, because the most dependent, and embraces in local peritonitis the obvious center of accumulated pus. Distended intestines are aspirated free of gas and Huid and the needle holes are stitched tight. The steps of operation are individualized according to serous exudate, purulent exudate and fibrinous exudate, with the modern tendency to do as little mani])ulation as possible, and far less than formerly. In localized peritonitis, usually purulent, the pus is evacuated through the wound walled off with gauze from the general peritoneal cavity if not so by adhesions. The walls of the abscess are gently mopped clean and free drainage, Avith cigarette gauze drains or rubber tubing fenestrated but without sharp edges or corners, is established. A copious dressing covers the wound often narrowed to near the drains and after two or three days, cleansing and drainage are encouraged by gentle irrigation. In generalized peritonitis, if serous, the abdomen is opened through the middle line and as much of the exudate made to escape as possible, so as to turn the balance of the infection in the patient's favor by" eliminating much infectious material. The wound is then sewed up without drainage and commonly recovery occurs. Much credit is due to Iv. T. Morris^ for the development of this simple, safe plan. If the exudate is seropurulent or purulent a larger incision and irrigation with the return-flow, soft-rubber or metal tubes are required in many cases. The dependent pockets of the cavity are gently washed first until the return is clear, so as not to float mfectious material gravitated into them about the cavity. After this the coils of the intestine may be cleansed by washing and gentle mopping, always with the protection of hot towels against chilling. As little fluid as possible is left in the abdo- men and cigarette drains are carried to all depths. Counterdrainage through the loin is less commonl}' emplo}-ed than formerly, but may be reserved for extreme cases. The stasis of the bowel in any form of i)eritonitis, through disten- tion, is relieved by aspiration of gas and fluid contents and often by injecting into it concentrated solutions of sulphate of magnesium. In the fibrinous or plastic peritonitis, with the intestines patched with ' Lec-turcs on Appendicitis and Notes on Other Subjects, 1S99, pp. 64, 65, 66 and 84; Dawn of the Fourth Era in Surgery and Other Short Articles Previously Pub- lished, 1910, pp. 39 and 117. GONOCOCCAL PERITONiriH 223 fibrin and adherent in many places, it is usual to remove the loose exu- date from the cavities with irrigation and mopping in tlie sarn(; rnaiiner as described, leaving little or no fhiid behind, an/l to mop tlic less adher- ent patches away. Adhesions are gently broken down and the raw surfaces sometimes turned in with Lembert stitches to prevent return if the patient's condition permits, but if Nature's processes have been efficient they may be left alone. If a perforation is walled ofl" it must be exposed and closed with banked Lembert stitches. Cigarette drains may be used into any pus cavities in these cases. The cause or source of peritonitis should in most cases be sought and remedied if other conditions of the patient and operation permit. When gonococcal infection is suspected as the sole cause the tendency to delay operation is great. Drainage is not used in the serous cases and is much more sparingly employed in the purulent and fibrinous cases than formerly, and lastly counterdrainage through the loin is a final resort. In the milder cases the tendency is to follow Morris's teaching of opening the abdomen, evacuating much of the exudate, closing it and leaving the disease to nature and medicinal means. Suture is by layers, with careful closure of all dead spaces. Aftertreatment. — In the immediate steps for from three to seven days the drains are left alone and loosened without pulling, when they give way themselves and they are omitted when the temperature is nearly normal and the discharge scanty. The outer dressing is kept clean by frequent changes and a special day and night nursing is advisable. Diet is nutritious and light but sufficient to maintain strength and gradually increased with the improvement. Vomiting indicates nutrient enemata if no diarrhea prevents. The gentle use of calomel aids the action of the bowel and liver, and stimulation against absorption is required. The remote aftertreatment observes attention to the gonoccocal focus and restores the defective nutrition and depreciated strength of the patient. Anemia is often common for long periods due to the infection and adhesions and invalidism often require late operations for their relief. Cure. — Cure involves not only saving the life of the patient but so far as possible restoration of the abdominal contents to as nearly as possible normal positions and full physiological function. 3. Circulatory Complications. Occurrence. — The cardiovascular system does not escape gonococcal infection. The antecedent focus is always severe and profound. The arteries and veins are not often in\'olved. As a less uncommon but severe complication, the heart, in its valves, lining, muscle and sac, may be attacked at any period of acute or chronic disease. These lesions are beyond doubt, as frequent autopsies have proved the organism in the serous membrane and the blood. Luys reports at least 100 proved cases in literature.^ Males seem to be more fre- quently attacked than females. 1 Text-book on Gonorrhea, 1913, p. 226. 224 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS Varieties.— Classification of cardiat" foin])li('atloiis is, as to site, endo- cardial [the most connnon) and pericardial and myocardial (the less common and almost always secondary to endocarditis). All tliree may occur as one intense disease process. A. Cardiac Complications. GONOCOCCAL ENDOCARDITIS. Occurrence. — Endocarditis is frequent, important and jjractically always ])riniarv with reference to myocarditis and pericarditis. Varieties. — Clinical subdi\isions are primary, secondary, acute, sub- acute, chronic, complicated and uncomplicated. The valvular forms are aortic, mitral, pulmonary and tricuspid. Etiology. — A severe gonococcal focus is present — urethral, prostatic or seminal vesicidar. The endocarditis appears after or during the gonococcal bacteriemia. Pathology.^ — The suppurative gonococcal fo2us is essential. In the heart are found ^'al^'ular inelasticity, thickening, vegetation, ulcera- tion, perforation, deformity and sometunes thrombi. INIyocarditis and pericarditis may be associated. Symptoms. — Conditions duplicate those of any other septic, acute endocarditis in subjective and objective syndromes and physical signs. The termination is also similar. Treatment. — The treatment is as described at the end of this subject on page 230. GONOCOCCAL MYOCARDITIS. Clinical Features. — INIyocarditis is always associated with endocar- ditis in occm-rence, etiology, pathology, s\Tnptoms and treatment. GONOCOCCAL PERICARDITIS. Occurrence. — Pericarditis is rarely primary, but usually secondary to endocarditis. Clinical Features. — Varieties, pathology, symptoms, diagnosis and treatment (lui)licate those of other forms of this lesion. Diagnosis. — Hecognition of the primary, septic, gonococcal focus is essential, also definite, subjective and objective cardiac syndrome with complete laboratory analysis. Differential Diagnosis. — The gonococcus alone is the deciding factor. Treatment. — The gonococcal point of absorption must be (tiu-ed. The cardiac conditions are managed the same as those of other types of each disease. B. Vascular Complications. Varieties. — Aortitis, phlebitis and thrombosis are the three lesions seen in gonococcal septicemia. All are rare in occurrence. GONOCOCCAL SEPTICEMIA, BACTEREMIA AND TOXEMIA 225 AORTITIS, PHLEBITIS AND THROMBOSIS. Occurrence. — These vascular signs are very unusual except in septic bacteremia. Pathology. — The gonococcus is added to the common lesions of acute inflammation of other origin. They are associated with those of the cardiac foci and the septicemia. Symptoms. — The characteristic syndrome is present as seen with other infections, together with that of the primary gonococcal focus. Diagnosis. — Many cases requu-e postmortem data. The primary gonococcal lesion must be proved and the case recognized through its symptoms and other laboratory evidence. Treatment. — Original lesions must be cured. Cu-culatory conditions are managed in the usual ways. GONOCOCCAL SEPTICEMIA, BACTEREMIA AND TOXEMIA. Definition. — Gonococcal septicemia is a condition induced by the absorption of septic products from a gonococcal process; bacteremia is an analogous state in which the living gonococci are present in the blood, and toxemia is a disease-process of the blood containing poison- ous products, due to the growth of gonococcus in the blood. These three terms are used more or less indefinitely and interchangeably to denote generalized infection with the gonococcus. The term gonococ- cemia^ is sometimes used. Significance. — Gonococcal septicemia and its analogues, bacteremia and toxemia, give a new interpretation to gonococcal infection founded on the advances of modern bacteriology and hematolog}^ In the older and even best authorities, such as Taylor,^ in America, definite men- tion of these lesions is entirely omitted. Knowledge of this patho- logical entity converts gonococcal infection from solely a local into occasionally a systemic disease, intrinsically due to the penetration of the gonococcus from an antecedent focal lesion into the blood and its circulation there, with secondary deposit in almost any organ or tissue, or due to the absorption of septic products and their circulation, through the blood stream. In this detail it duplicates any other form of septicemia and its allies. While strictly not a circulatory complication, the blood as an organ is primarily and in a sense preeminently concerned. For these reasons, therefore, in this work it is treated as an involvement of the circulatory system. Probably no extragenital complications of gonococcal infection what- ever, excepting such accidents as ophthalmia which may occur from mediate or instrumental transference, may arise without the presence of septicemia or bacteremia in mild or severe degree. This rule 1 A hybrid word gonohemia meaning literally seed or semen in the blood, -which is as far as possible removed from gonococcal septicemia, is sometimes used and vdthout etymological reason or excuse. * Loc. cit. 15 22() COMPLICATIOXS AND SEQUELS OF ACUTE URETHRITIS undoubtedly liolds in nianitVstations within tho cutaneous, central and peripheral nervous and locomotory systems, as later described and exemplified by rashes, meningitis, neiu-itis and neuroses, myositis, arthralgia and arthritis, periostitis and the like. All these lesions may be embraced under the hemic classification, because none can arise without the action of the bacteria or their toxins circulating in the blood and primarily depositing at various and numerous points and secondarily extending. The cardiac foci are therefore the ])ericardium, endocardium and the muscularis, and the vascular locations are the chief trunks of the aorta and veins followed by thrombosis and the hemic site is tlie blood itself regarded as an organ with a fluid matrix and floating cells. Arthritis belongs to the same class but is discussed in itself, likewise metastatic abscess. That gonococcal infection as a cause of death is not a medical curi- osity is shown by numerous thoroughly diagnosticated cases in litera- ture. Examples of such rei)orts are the following: Brewer^ has noted a case of fatal gonorrheal infection with autopsy report; Cornell^ describes a case of gonorrhea rendered fatal by its sequelje; Fenwick^ has observed a case of gonorrhea ending fatally; Kossmann^ has seen two cases of death in consequence of gonorrhea; Post^ saw one patient die directly from the gonorrhea, and Robinson'' discusses systemic infection from gonorrhea with report of a fatal case. Occurrence. — In general frequency, septicemia is rare when com- pared with the vast number of gonococcal sexual involvement in men, women and children. Never primary but always secondary to such genital lesions, it is more frequent in males than in females, in pregnant than nonpregnant women, and in children than adults. Males suffer most doubtless through the greater incidence of the disease upon this sex in the general nature of their social relations, while low resistance is doubtless at work in pregnant women and children. It is more common in posterior than in anterior urethral disease, and in complicated than uncomplicated cases, although initial anterior disease has been known to cause it. Of the complications the extraurethral lesions, such as prostatitis, seminal vesiculitis and epididymoorchitis in the male, and salpingitis and ovaritis in the female predominate in its occurrence, and not uncommonly in old rather than recent cases, in which subjec- tive symptoms may be practically absent. Varieties. — Varieties co\er the major subdivisions of the hemo- poietic system as shown in the clinical section but their treatment had best be considered under septicemia, bacteremia and toxemia, because it is ob\'ious that none of them can arise without these basal conditions. The cardiac lesions are endocarditis, pericarditis and myo- carditis, the vascular invasions are aortitis, phlebitis and thrombosis, 1 .lour. Cutan. and Gen.-Urin. Dis., 1897, xv, 260. 2 Montreal Med. Jour., 1900, xxix, 100. 3 British Med. Jour., 1899, ii, 1.544. * Miinchen. med. Wchnschr., 1900, xlvii, .39.5. 6 Boston Med. and Surg. .Jour., 1887, cxvi, 417. « Med. News, 1890, Ixix, 230. GONOCOCCAL SEPTICEMIA, BACTEREMIA AND TOXEMIA 227 and the hemic disease is tUc. septicemia, bacteremia and toxemia. Metastatic abscess belonjijs in this class, })ut is sei)arat(;ly discussed for convenience. Arthritis is in a class by itself also, but Ixjlon^s to this general group of lesions dependent on the circulation of bjictcria ;ind their toxins in the blood. Etiology. — 'i'he factors are predisposing and exciting, systemic and local. The predisposing elements are lowered general vitality, shown by a naturally poor resistance to most diseases, a history of which is commonly obtainable, or from the actual presence of such systemic disease as diabetes, nephritis, syphilis and tuberculosis, and likewise lowered local vitality due to rough instruments, unskilful application of instruments, and congestion from venereal excess, alcoholism, concen- trated solutions, and undue frequency or activity of treatment. The exciting cause is regularly the gonococcus either in pure infec- tion or associated with other organisms of the pyogenic species, notably the streptococcus, staphylococcus, and the Bacillus coli communis, which add to the seriousness of the case. It seems that as long as the gonococcus persists in active or chronic, anterior or posterior, com- plicated or uncomplicated urethritis, septicemia may at any moment suddenly appear, with or without assignable cause. The ports of entrance are in the mucosa, points of denudation, or ulceration through the inflammation, or of traumatism through instrumental or other treatment, and are in the organs involved in any complication or in local destruction or abscess formation of even minute size and chronic type. It is peculiar that so few cases of gonococcal septicemia occur in the ordinary circumstances and course of the disease so that one may say that perhaps the organism does not usually thrive in the blood stream. If this were otherwise metastases containing the gonococcus would be the rule instead of the strange exception. Hematology will later decide this point. The basis of the complications of septicemia, bacteremia and toxemia is therefore the presence of the gonococcus or its products or both within the bloodstream and their diffusion through the body. Three avenues of origin are described: that is, hemic and lymphatic, involving perhaps, chiefly the bacteria themselves, and toxic involving, perhaps, mostly the products from the antecedent condition or source, or from the growth of the organism after reaching the blood, or after its deposit in various remote organs. The order of frequency of these origins is, as stated, hemic, lymphatic and toxic. Thayer and Blumer^ were the first to prove during life pure cultures of the gonococcus in the blood, while Uysing^ followed by demonstrating it in the hinphstream. Such proofs, however, are most difflcult even in the presence of active septicemia, probably because the organisms are not numerous, relative to the bulk of the blood, and through their tendency to penetrate tissue they may still further undergo apparent reduction in nmiiber; 1 Arch, de med. exper. et d'anat. path., Paris, November, 1895. Johns Hopkins Hosp. Bull., 1896, \di, 57. 2 Inaug. Dissert., Kiel, 1900. 228 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS and furtheniu)ro, the tochnical tliflieulty of cultivatiiii;- the gouococcus, especially Avlieii present in mixed infection, cannot be o\erlooked as an obstacle. These factors excite the circumstance of difficulty rather than facility in findins; the organism, although it grows best in media containing human blood serum. Pathology. — Primary cases of gonococcal sei)ticemia are unknown, as this ct)mplication and its allies is always a consequence of urethral or other local infection. The pathogenesis does not diti'er in any mate- rial detail from that of se])tieemia from any other organism and its l)roducts. The essence of the j)rocess is the circulation in the blood of the gonococcus with its septic and toxic products, after a ])ort of entry has been created on the surface of the mucosa, within the substance of a gland like the prostate or the cavity of an organ like tlie seminal vesicle or Fallo})ian tube, through inflammatory or accidental factors or both. The organs and tissues in^'ol^'ed hiclude all. None escape, although most commonly the serous membranes are first and chiefly involved, perhaps through their structural analogy with tlie mucous membranes. Thus there are found in the circulatory system endo- carditis and ])erlcarditis; in the respiratory, ])leuritis; in the digestive, peritonitis; in tiie nervous, meningitis; and in the locomotory system, arthritis and tenosjuovitis. The "meninges are not serous, but delicate and susceptible tissues. Temporary lesions may be said to occur only in the least involved tissues and m cases of recovery which seem to comprise about two in every three cases. Permanent changes, however, are very common in the serosae attacked, and the associated lesions are naturally the antecedent condition or complication, and finally the bacteriology is always the gonococcus alone or in associated ijifec- tion. Symptoms. — As in other septicemia, that caused by the gonococcus has a various and uncertain symptom-complex, with on the whole no new features, and indistinguishable from such other septicemia, excepting ]:)y hematology and the history of localized antecedent gono- coccal iuAolvement, uncomplicated or complicated, acute or chronic. Subjective symptoms in the strict sense are, excepting rarely in mild cases, absent. The patients are too ill in severe cases in degree and the disease is too rapid in progress to permit a subjective picture. The o})jective s\Tnptoms, on the other hand, predominate and vary widely in their constancy, association and degree. Periods of invasion, establishment and termination may be distinguished usually by systemic less often than by local conditions. The latter are commonly foci of the deposit or infarct in some important organ or system, as part of the general septicemia and Imcteremic process, and constitute practically a new group of complications of extragenital type, such as endocarditis, meningitis, and arthritis, as examples. No description may be given for all cases and reports in literature emphasize the pre- dominance of one s^'mptom over another largely in accordance with this element of infarct. All the sjTnptoms are, therefore, elements of a general systemic disease, while definite syndromes mark the invasion GONOCOCCAL SEPTICEMIA, BACTEREMIA AND TOXEMIA 229 of a given system preeminently over other systems. 'J^he general course may be mild, severe or intense. The period of invasion is usually accompanied by sudden decrease or even cessation in the local symptoms, such as a urethritis or one of its active complications, or the invasion may suddenly issue out of a clear sky, that is, during the seeming absence of any local activity. There are commonly chill and chilliness, a sudden high fever with wide variations, or a moderate fever of more or less constant range (accord- ing to the resistance of the patient) with profuse i>erspiration and digestive disturbance. After establishment the symptoms continue and commonly augment. The perspiration is followed by sudamina, or a variously papular eruption containing the gonococcus. The digestive disorder is nausea, vomiting, diarrhea or constipation, all of moderate or severe degree. The fever is of the true septic type, low in the morning, high at night, with wide differences, or more constant in its average and much less in its range. The nervous system at first is stimulated into active delirium and then depressed into stupor, coma and death. The circulatory system early shows cardiac weakness, disturbance and insufficiency. Splenic and hepatic enlargement have been noted. Except in the cases of short duration and fatal outcome emaciation and anemia are profound. Protracted cases may show carphology, low muttering delirium, subsultus tendinum and finally wasting death. The blood test reveals the gonococcus alone or with associated organ- isms in the blood, leukocystosis of from ten to thirty thousand, and anemia. The kidneys reveal various forms and degrees of acute nephritis usually with exudation of albumin, casts, blood and pus. The objective local symptoms of the foci of deposit and infarct may complicate the picture at any time, and distract the attention from the general to such local manifestations. Thus the chief symptoms may be due to the endocarditis, pericarditis, arthritis, pleuritis, pneumonia or meningitis, which in its turn is very difficult to distinguish in its symptoms from those due to the septicemia itself. The terpaination is fatal in only 30 per cent, of cases, according to Luys,^ but cases favorable at first may later have a lethal issue. The outlook for health is otherwise, especially when any of the CDmplica- tions produced by the septicemia arise as just stated. Relapses are not uncommon as might be expected from the natm'e of the chronic foci from which these cases often arise. The most serious cases are those with cardiac involvement as few escape without materially damaged valves. Cases with recovery usually have a slow coiu-se until good health is restored. The mild cases result in full recovery. In fact, it has been shown that a few cases of gonococcal urethritis have the organisms circulating in the blood without active septicemia. Diagnosis. — The only facts in the history are that the s\Tnptoms arose during the course of acute vicious gonococcal lu-etlu'itis or at the onset of acute complications or in the exacerbation of chronic urethritis and 1 Loc. cit., p. 35. 230 COMPLlC.VriOXS AXD SEQUELS OF ACUTE URETHRITIS its complications ami even varclx' in the midst of (luicsccut conditions with nnex})lained canse. Inasmnch as the snhjectixo symi)toms chipHcatc tliosc crt' scpticcMnia from other organisms, bacteriological research will alone distingnish the gonococcal form from all other forms and will require isolation and culture of the gonococcus from the blood and from such foci -as may ai)i)ear in the skin, joints and the like. For objective signs it is well to search the urogenital organs in males and females for an unsus- pected and nu)re or less active and even comparatively inactive focus. The presence of such a lesion in acti\'e form should at once attract attention. Laboratory proof is essential. It has been suggested that the moments of intermission and remission in the fever of septicemia are, as in malaria, the best times for looking for the organisms in the blood. The gonococcal complement deviation test is still in its develop- ment, but should never be omitted in these cases. It is perhaps par- ticularly helpful in the female in whom so many unsus])ected deposits of the disease occur. It thus follows that in many patients, males or females, a clinical cure is reached before a serological cure, a fact which only emphasizes the importance of serology in this antl allied diseases. Treatment is not an aid in the diagnosis except as it may uncover and relieve an obscure focus of origin of the absorption and furnish suitable exudate and specimens for the pathologist. Differential Diagnosis rests almost solely on identification of the gonococcus in discharge, exudate or secretion of sexual glands and circulating in the blood and on the complement fixation test for its presence in the system. Treatment. — To larger works on general surgery and medicine is resigned the amplified treatment of septicemia but the following suggestions are of great value. Prophylaxis ofi'ers no direct relief, as the patients show low resistance, early bacterial and toxic absorption and their results. Indirect prevention, however, underlies the best possible conservative treatment of severe gonococcal lesions and the evacuation of pus foci, such as abscesses in the seminal vesicles and prostate. Abortion is ipso facto impossible because the disease is well established at the earliest possible symptom. Chapter IX on General Principles of Treatment explains the essen- tials of management on page 483. Physical measures cannot be applied in the acute stages as the patients are too sick and the character of these measures tends to dis- turb quiescent foci. In hydrotherapy liDt-packs for elimination through the skin and support of the kidneys are valuable and enterocl}'sis adds stimulation of the circulation, cleansing of the blood through absorption and probably elimination by bowel, kidneys and skin. In the chronic period of sur\iving cases as passi\-e muscular activity massage is ad\'ised and hydrotherapy for stimulation and elimination and for the treatment of some focal disease such as the remnant of the original complication. The heliotherapy is actinic, thermic and eliminant in its function GONOCOCCAL HEl'TICEMIA, BACTEREMIA AND TOXEMIA 231 for selected cases and is ai)i>lied with a 500 c.j). lamp with a suitable reflector travellhig slowly over the surface in the manner described under Peritonitis, page 220. The duration is from a half to one hour at each sitting and its frequency is several times a day, and in an institution even oftener. Alternation with electrotherapy is well. Its results are intense hyperemia, relief of vascular spasm, nervous irrita- tion and pahi and increased phagocytosis. The electrotherapy consists solely in diathermy on local manifesta- tions or foci in any organ. The electrodes must be each of the same size, never smaller than twelve square inches in area (3 x 4 inches), and must be placed at opposite sides of the affected area so that the lesion shall be as far as possible fully within the field of the electrodes. The current is 4 to 5 milliamperes and no more and the duration is from ten to twenty minutes with a frequency of daily at first and later three times a week until relieved. With skill there is no unfavorable reaction, but small electrodes will cause- burns. Alternation with heliotherapy is of value and should be the usual procedure. The medicinal measures are in the acute period very important, but usually of little avail. On account of the negative phase, serum- therapy is rather risky, as it may only add to fatalities. Small doses, carefully watched, are to be tried if at all. By systemic administration, stimulation, support, sedation and elimination are the methods. Quinin is often good as antiseptic and febrifuge and no stimulant is better than alcohol as whisky, champagne and port wine. It is an easily oxidizable food in these cases and is given short of intoxication. Strychnin is p-n excellent nervous and circulatory support and mor- phin is indispensable for pain, restlessness and insomnia, with caution not to mask other symptoms. Elimination through the bowel and skin must never be neglected. In reference to special organs and systems of the body as attacked require treatment so minute that the reader is referred to large works on general medicine for it. The general principles are, however, men- tioned under appropriate headings: Acute and chronic endocarditis, myocarditis and pericarditis are detailed under cardiac complications, aortitis, phlebitis and thrombosis are discussed under vascular sequels of gonococcal disease, while metastatic abscess and arthritis are reserved for separate attention on pages 235 and 248. Other general principles of treatment are important. The bowels must be evacuated through cathartics by mouth and enemata into the rectum and lower colon. The condition of the gastric and recto- colonic mucosa determines tolerance for the drugs administered and the results of treatment. Cathartics of value are the following: Calomel, in yV-grain doses, every quarter-hour, or in J-grain or ^- grain doses every half hour, until the bowels begin to move, may be tried. Soft capsules of castor oil, drams 1 to 2, may be repeated until evacuation occurs, if the patient can swallow them. Magnesium sulphate or magnesium citrate, from 1 teaspoonful to 1 wineglassful, at quarter or half-hour intervals, is a good adjuvant of the calomel after 232 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS its liuiit has been rcaclicd. One or two drops of crotoii oil may be added to one administration of the other cathartics if ileus is threatened in a case of sejiticemia Avith })eritouitis. The enomata may be A\arm normal salt solution which by its bulk stimulates the bowels to mo^•e or soapsuds combined with oxgall, tur])entine, Epsom salts and similar stimulants of peristalsis according to inilication. Slow administration is the secret of colonic eneraata, which are often necessary before a result is reached. Direct absorption hito the circulation of corrigents of the infection may be secured by inunction and intravenous injection. The unguen- tum argenti colloidalis of Crede' may be rubbed into the skin in 1 dram doses once a day and the intravenous injection of 2 per cent, emulsio argenti colloidalis may be given once a day to the limit of 15 grains. The inunctions and intravenous injections may alternate by daj's or by longer periods. The dilution and elimination of the poisons by the kidneys is secured by the intake of large quantities of fluid by any of the following methods. The Murphy drip is of great service and may be applied for periods of one to two hours, with a period of rest between. Normal salt solution is the fluid and the rectal tube is gently passed as high up the bowel as possible. When tolerance of this method fails small eneraata of normal salt solution may be run into the bowel every two to foiu* hours and retained by the i)atient. Free water drinking is likewise of value for this pm-pose when the stomach tolerates it. The siugical measiues are nonoperati^'e and operative, of which, of course, the latter are by all means the most important. The non- operative details differ in no respect from the means already spoken of under medicinal measures. The management of dressings is also important. The dressings and drains should be at once removed if there has been an operation, such as for prostatic abscess, to cleanse the wound, evacuate accumulated pus and exudate and otherwise remove a source of absorption through this path. No subsequent dressings or drains must again repeat such retention. The operative measures are major and minor operations, dependent entirely on the nature and extent of the ])rimary nidus and the acces- sibility of the secondary septicemic foci. Among the rahior operations are to be mentioned the free opening, evacuation, drainage and dressings of abscesses, the infusion of normal salt solution under the skin or its injection into a vein and the trans- fusion of blood. The technics of all these ])rocedures are so familiar that they will be omitted here. The intravenous injection of 2 per cent, magnesium sulphate in | to 1 pint doses daily for days or of 2 per cent, emulsion of colloidal silver (Crede),^ in 15-grain doses daily, for several days, belongs in this category. A needle is simply passed into the vein exactly in the .method followed in the administration of salvarsan. The major operations are attacks on all accessible foci of infection 1 XII Congr6s intemation. de m^decine, Moscow, 1897, v, 349. ^ Lqc. cit. GONOCOCCAL SEPTICEMIA, BACTEREMIA AND TOXEMIA 233 which must be evacuated to prevent further absorption. Involved joints are opened and drained, abscesses of the glands of Cowper, the prostate and the seminal vesicles in the male and the vulvovaginal glands, the uterus and tubes and ovaries in the female must all be freed of accumulated pus. Hysterectomy and curetting are methods of dealing with an infected uterus according to severity of the lesion . In peritonitis as a lesion of the septicemia a rapid laparotomy is indi- cated with judicious irrigation by the return flow method of all pockets followed by thorough mopping out and multiple drainage and finally by the use of Fowler's position. The exact technic of all these opera- tions belongs to works on general surgery. If an operation has been done stitches must be removed and the wound cleansed of even trifling foci of pus because it must be remembered that many of the most intense infections have little accumulation of pus about the wound. It must be remembered that in generalized peritonitis of severe type little treatment is of avail and that death is prompt and dreadful from the suffering of the patient. On the other hand, localized peritonitis of the pelvic type, especially in women, is a hopeful disease when treated promptly and well in accordance with the foregoing methods. In general, gonococcal peritonitis is less severe than that due to the strep- tococcus and the staphylococcus. When combined with the latter, however, it becomes equally deadly. In localized foci treatment succeeds well as the evacuation of abscesses, the removal of stitches and the cleansing of wounds all followed by the application of the tincture of iodin and the insertion of an alcohol wet di-essing. Intravenous Injections of Magnesium Sulphate. — This method is limited in literature to streptococcic bacteremia. Harrar^ reports a number of remarkable results of these injections when admuiistered to patients suffering from living organisms circulating in the blood- stream. This method is inserted here in this work because a certain number of systemic infections during gonococcal lesions are associated with the streptococcus. It is possible that this method may be of value when organisms other than the streptococcus are circulating in the blood. As described by Harrar the following details are embraced in the technic of the injections: "A 2 per cent, solution of chemically pure magnesium sulphate is prepared with freshly distilled water. This is filtered and sterilized in half-liter flasks in an autoclave. This solution will not hemolyze human red blood cells, and I have found by expe- rience that prepared in this way it will not cause any temperature reaction in the patient. Formerly a 1 per cent, solution of magnesiiun sulphate in physiological salt solution was employed, and a chill or sharp temperature rise frequently followed the injection. A simplified salvarsan apparatus is preferable for the injection but the ordinary infusion set will answer the pm-pose quite as well. It is important not 1 Am. Jour. Obst. and Dis. of Women and Children, 1913, lx\dii. No. 5. 234 COMPLICATIONS AXD SEQUELS OF ACUTE URETHRITIS to cut (Icnvn upon the vessel, as l>y direct puncture the same vein can be used a nuniher of times. As many as eiii;lit punctures of the same vein liave l>een nuide on (Htl'eriMit occasions. The secret in j^etting into the vein is to make it markedly })rominent. This is (U)ne by temporarily placing a constricting rubber tube about the upper arm just tightly "enough that the faintest pulsation may still be felt in the radial artery. If the constriction about the upi)er arm is too tight, the arterial as well as the venous circulation will be cut oii" and the vein will not distend with blood. The needle is inserted in an oblique direction, the spurting of blood from the open end indicating proper entrance into the xem. The rubber tube of the reser\'oir with the solution Howing is then rapidly slii)ped over the shoulder of the needle. The reser\oir is held at not more than one foot ele^■ation, which will run in 400 c.c. of the solution in about twenty-minutes. The injection should be made much more slowly than the ordinary saline infusion. "The patient ex])eriences a sensation of heat toward the end of the injection, and frequently feels faint, although the pulse usually gains in quality'. A small drink of hot whisky or aromatic spirits of ammonia will steady her. Occasionally the respiration assumes a sighing equality, but no decrease in rate or in depth of the respirations has been observed. It is quite evident that the dangers are not so marked, the drug is not so toxic, when given intravenously, as when em})loyed intra- spinously where it is applied directly to the nerve tissue. I have given as much as 400 c.c. of a 2 per cent, solution intra^'enously simul- taneously with 400 c.c. by hypodermoclysis, representing 10 grammes or 250 grains of the drug, with no alarming effects. Whereas by intra- spinous injection for the production of anesthesia, or in the treatment of tetanus, IMeltzer^ advises 1 c.c. of a 25 per cent, solution per 20 pounds of body weight, or about 25 grains for a 130-pound individual, as the safe limit. The injections should be repeated every second or third day according to the course of the infection as revealed by the temperature chart. "The method has now been employed in fourteen cases at the Lying- in Hospital. In five of these there was a streptococcic bacteremia as proved by blood culture. The other nine were all severely infected women with high temperatiu-e and acutely ill with streptococcic toxemia, with pure growth of streptococci on uterine culture, but with negative blood cultures." As already stated, it is more than probable that this method will be of great value in cases of gonococcic septicemia of the mixed type with the streptococcus as one of the invaders. His series of patients Harrar^ estimates as now fifteen or twenty cases of proved bacteremias, with success in about 50 per cent., without looking up actual records. He recently employed it in a case of colon bacillemia with prompt im- provement after one infusion and disap])earance of the bacilli from the blood in a very ill woman with pyelonephritis of pregnancy. » Jour. Pharm. and Exp. Thcrap., 1909-10, vii. 2 Personal letter to the author, December 18, 1916. GONOCOCCAL METASTATIC ABSCESS 235 The effects of the injections are an air hunger if the fhiid is too rapidly administeretl. The first dose is usually followed by a fall in the temperature and by a decrease in the number of orj^aiiisms in the next blood specimen. If such second l)]ood culture is sterile no otln-r injection is given. If, on the otiier hand, there is no improvement in the clinical condition or in the blood examination the injections are repeated, every second day, with no ill effects if care is exercised as to all the details. Harrar in a personal letter to the author states that he has given fifteen injections on one case and that the average is from two to seven injections. In his article Harrar draws the following conclusions : 1. In the quantities and dilutions described, magnesium sulphate is absolutely harmless when administered intravenously to women suffer- ing with puerperal infection. 2. Magnesium sulphate is of more value early in the course of the infection than after secondary localization has occurred. In the chronic cases of secondary thrombophlebitis or pyemia it does not appear to be of benefit. Its action seems to be chiefly upon the organisms circulating in the blood. 3. It shortens the course of the bacterial toxemias in w'hich the bacteria cannot be demonstrated in the blood by culture, and antici- pates the establishment of a bacteremia. 4. It has reduced our mortality in puerperal bacteremia, especially in streptococcemia, the most fatal form of puerperal infection, from 93 per cent, to 20 per cent. Ajtertreatment. — When the patient survives all immediate measures are directed to the care of the surgical procedures necessary for the heroic combat with the disease. The remote aftercare continues attention to the kidneys, which may otherwise .pass into chronic nephritis, and to the circulation and the blood, lest similarly the cardiac muscle be damaged and anemia of troublesome type supervene. Sequels from organs damaged by operation or the disease must also be corrected and in short chronic invalidism avoided. Cure. — Relief of the infection in the immediate present and restora- tion of health in the early future are the standard of cm-e. Pathologi- cally, removal of all lesions is often impossible but symptomatically the patient may live for years in comparative or absolute good health. GONOCOCCAL METASTATIC ABSCESS. Significance. — The abscess is a sign of acute or chronic septicemia and absorption manifested as a cutaneous or visceral deposit and as a proof of the seriousness of the septicemia. Occurrence. — True metastatic abscess as a sjTnptom of gonococcal septicemia or bacteremia is of rare appearance. It is not possible for it to arise in any other manner. The site of such abscesses may on theoretical grounds be in almost any organ but those reported in litera- ture are chiefly in the skin, or organs opening from the skin. 230 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS Etiology. — The gonococcus circulating in the blood is the exciting cause, A\hile knveretl local resistance is the predisposing factor such as is found in fracture, uifancy and the like. Symptoms. — Added to the symptoms and signs of the original gt)no- coccal infection and the secondary septicemia are the local conditions of the abscess Avhicli Aary with the situation. In literature, ^Y. Y. ("ampbell' details a compound fracture case in a patient with a six weeks' gonococcal infection, followed by suppuration of the fracture, due to the gonococcus, established by culture. J. Kerassotis^ has rejiorted a gonococcal abscess of the mastoid regions, secondary to a urethritis, with cure of both conditions together. Y. Meyer,^ before the BerUn ^Medical Society, presented a patient with superficial right middle felon following a profuse gonococcal vaginitis. The same organisms were cultured from the pus of the felon. Cassell,^ during the discussion of F. Meyer's case just cited, described an example of gonococcal ophthalmia in a newborn infant with early secondary arthritis and dorsal abscess which contained a pure growth of the gonococcus. Lang^ has detailed a case of urethrocystitis followed by metastatic abscesses in the left metacarpal regions. Klausner''' and Reenstierna'' fully establish the origin of their cases, Klausner in an abscess of the bm^sa over the tuberosity of the tibia and Reenstierna one in the left upper arm. Diagnosis.^ — A mild or severe septic state marks the history of an intense extending and otherwise complicated gonococcal urethritis and shows the subjective symptoms of the sepsis followed by or accom- panied by those of the abscess, respectively, such as chills or chilliness, fever, digestive disorder, circulatory disturbance, prostration and the like, along with one or more deposits of the pus at almost any point accessible to examination, which verifies all the foregoing syndrome and adds recovery of pus by aspiration or incision. In the laboratory such a specimen must deliver the gonococcus for smear and culture, alone or associated with the pyogenic organisms and the blood may be in a state of bacteremia and positive complement fixation test. Treatment of the original focus of disease limits fiuther extension of the sepsis and thereby the origin of other abscesses. Suitable support against the septic process itself is of value and finally incision and drainage of the abscess prove its identity and secure the specimens for the final demonstration. Treatment. — Abscess itself is commonly easy to treat but the under- lying absorption is diflficult. The prophylaxis is the same as the under- lying bacteremia and toxemia in the care of all gonococcal infection, especially severe cases and complications. Abortion of the cause of the abscesses is impossible but of the abscesses themselves consists 1 New York Med. Joui., February 28, 1908. ' Add. d. mal. d. org. genito-urinaries, 1904, xxii, 516. ' Deutsch. Died. Wchnschr., 1903, xxix, Society Proceedings, p. 226. ■* Ibid. =• Jahrb. d. Wien. K. K. Krankenanstalten, 1892, 1893, i, 514. 6 Dermatol. Wchnschr., 1915, ix, 723. ' Arch. f. Derm. u. Syph., 1914, exx, 870. GONOCOCCAL METASTATfC ABSCESS 237 in the liberal painting of the affected skin with tincture of iorlin or 95 per cent, carbolic acid until white coagulation slightly appears followed and combined with a 95 per cent, ethyl alcohol wet dressing or a wet dressing of 1 in 5000 bichloride of mercury or per cent, aluminum acetate. Full explanation of management is found in Chapter IX, on General Principles of Treatment, on page 4S3. Physical means depend on cessation of the pus-producing process when resorption may be stimulated by judicious massage and the application of the Bier hyperemic treatment. The latter may be applied even earlier to stimulate discharge of pus and destruction of the organism. Massage is an early substitute for physical exercise. Hydrotherapy in cold often reduces pain and congestion in the abortive attempt and in heat promotes pointing of the abscess and light through its heat and actinic power — an admirable adjuvant, as is also electro- therapy when tissue massage is advisable, but only after drainage has been well established. The static brush discharge as already described under Phlebitis is the modality of most service. The medicinal measures during the acute periods avail hardly more than in septicemia and there is special danger in serumtherapy which may be fatal through increase of the infection during the negative phase. All the treatments detailed for the convalescent of septicemia apply here. The surgical measures are both operative and nonoperative and wet dressings and applications comprise the nonoperative means as mentioned under abortion. Operation consists in a deep linear or crucial incision into the cavity of each abscess enlarged with scissors to prevent any overhang of flaps so that the incisions are coextensive with the cavity. Swabbing each abscess with tincture of iodin or with 95 per cent, carbolic acid followed by 95 per cent, ethyl alcohol and then packing it with gauze followed by suitable dressing closes the operation. No sutures are ever used. Aftertreatment. — ^The drains are left as long as there is discharge, decreasing them with filling of the wound and changing them to stimulating dressings, such as balsam of Peru, and associating them with applications, such as 10 per cent, silver nitrate solution, also for stimulation. All the medicinal means suggested in the aftertreatment of septicemia essentially apply. Cure pathologically follows the same rule as in the provocative blood condition and sjonptomatically the abscess must be healed without sinus and only a node of the abscess, infiltration and the scar of the incisions left for slow resorption. Arthritis. — In a certain sense arthritis might be regarded as a circu- latory complication, but it is discussed as a separate subject on page 248. 4. Respiratory Complications. Varieties.- — The gonococcus occurs in rhinitis and pleuritis. 23S COMPLICATIOXS AXD SEQIIU.S OF AVVTE URETHRITIS GONOCOCCAL RHINITIS. Significance. Tlu- I'vcs iimst Itr ])r()t('ct('(l against I'xtcnsion and (lirrct iiioeulaTion. Occurrence.^ Tlio nose is raivly infrctod. The ^ouococciis must be (listiiiuuishcd from tlio Micrococcus catarrhalis and the ^Micrococcus meningitidis common in the nose. Pathology. — The lesions are the same as those of any othei- mucosa (hn-ing uonococcal activities. Symptoms.— In infants and adults are seen chielly purulent discharge, pain, nasal dyspnea, edema, obstruction and all other e\idence of severe rhinitis. Diagnosis.- — The essentials are proof of the source of the infection, the tyi)ical syndrome and the gonococci. Treatment. — Prophylaxis resides in care of the m'ethritis. llhinitis always suggests accepted management, medication and a])])lications to destroy the gonococcus and to restore the mucosa. GONOCOCCAL PLEURITIS. Significance and Occurrence.- — The origin in ahvays septic during bacteremia and the proof is usually on autopsy, luarking the rarity of gonococcal plem-itis. Etiology. — Growth of the gonococcus on the plein-a and in its cavity follo^^'s bacteremia from an active focus elsewhere. Pathology. — The gonococcus is \'irtually the only dift^'erence between this and other purulent pleuritis* Symptoms. — Pleurisy without efTusion is early and later with effusion, each ^\■ith its usual characteristics — all associated with the symptoms of the gonococcal focus. Diagnosis. — The precedent septic gonococcal process must be defined together with the usual s^aidrome of pleurites and the gonococcus in the exudate. Treatment. — ^The gonococci and their lesions must be removed from their original site while the pleurisy is being managed along well- accepted principles. 5. Nervous Com plications. Significance, Occurrence and Varieties. — Nervous complications indi- cate ])rofound absorption. They occur only during bacteremia and septicemia, accompanied by lesions in other organs. Acute forms ])re(l()niiiiate. The foci arc cerebral, spinal, meningeal and peripheral. Etiology. — The gonococcus, with its toxins, is absorbed. Diagnosis. — A primary focus of the gonococcus in a septic case is essential. The typical cerebral syndrome and the organisms in the blood are final. A. Central Nervous Complications. Varieties. — Of cerebral, spinal and nieiiingeal forms, the cerebral is the least common. GONOCOCCAL MENINGITIS 239 GONOCOCCAL CEREBRITIS. Occurrence. — Obscure and rare reports often lack })actcri()lof,n'c"tl proof. Symptoms. — Delirium, mania, meningitis and apoplexy have; })e(;ii described according to the brain elements involved. Diagnosis. — The essentials of proof are the lesions of origin, bacterio- logically established, and the cerebral sequels. Treatment. — The primary gonococcal foci belong to the uroUjgist and the cerebral lesions to the neurologist. GONOCOCCAL MYELITIS. Occurrence. — The cord is more often involved than the brain. Etiology. — Intoxication of the myelon with the bacteria and toxins is the cause. Pathology. — Disseminated or segmentary myelitis as suppurative inflammation followed by subsidence or destruction of the nerves, cells and fibers is present. Secondary muscular, sensory, trophic and reflex nerve changes are seen. Symptoms. — The characteristic stages of onset and irritation followed by subsidence or by paresis or paralysis of muscular, sensory, trophic or reflex function are seen. Diagnosis. — The gonococcus . must be an element in the myelitis. In difterentiation the primary seat of the disease is important. Treatment. — The myelitis must be referred to a nerve specialist while a urologist cures the original focus. GONOCOCCAL MENINGITIS. Varieties.^ — Cerebral, spinal and cerebrospinal are distinguished. Etiology. — The meninges are attached by gonococci circulating in the blood. Pathology. — All the recognized lesions of suppurative meningitis are present through the activities of the gonococcus. Symptoms. — A severe gonococcal infection is followed by septic signs and then by nervous irritation and depression. Diagnosis. — The source of the gonococcal absorption and sepsis must be proved, then follows the syndrome of cerebral or spinal meningitis or both. Autopsy alone gives the final proof. Treatment. — The nervous infection belongs to the general medical or neurological expert. The vaginal focus must be treated by the urologist. B. Peripheral Nervous Complications. Occurrence. — Obvious intoxication from chronic foci foreruns these lesions. Varieties. — Neuralgia, neuritis and neuroses are the common forms. 240 COMPLICAriOXS AXD SEQUELS OF ACUTE URETHRITIS GONOCOCCAL NEURALGIA, NEURITIS AND NEUROSES. Etiology. — Obscure chronic abst)i-})tic)u is the chief factor. Pathology. — The lesions are functional rather than organic, so that true pathology may he absent. The nerves attacked are musculo- cutaneous, radial, median, tibial, sciatic, lumbosacral, lumbo- abdominal and intercostal. Symptoms. — \'arious and typical signs of each are fully described in works on neurology. Neuralgia predominates in pain and sensitiveness. Neuritis may show sensory, trophic, reflex and muscular changes. Neurosis is highly various. Diagnosis. — Definite decision is difficult. Ivelief of the s^nnptoms by cure of the gonococcal focus is important. Differential Diagnosis. — The nem'ites of poisoning (chiefly metallic) infections, rhemnatism, gout and wasting disease must be distinguished. Treatment. — The original point of absorption must be cured by the urologist, otherwise the greatest skill of the neurologist will fail. 6. Ocular Complications. Significance.^ — The eye is a peripheral nerve organ which determines the classification of gonococcal infection of it. Varieties. — Exogenous, proceeding from without the eye, and endoge- nous or metastatic, transferred by the blood current, are the two forms. Etiology. — Direct transfer of the virus may arise through instru- ments and the fingers of attendants upon children and the sick. A primary gonococcal focus is the source of metastases. GONOCOCCAL IRITIS AND CHOROIDITIS. Significance and Occurrence.— Profound eye lesions always mean gonococcal septicemia. The iris, choroid and optic i^rve may be individually or collectively affected. Varieties.- — Primary and secondary forms are usual. Primary lesions represent deposits before a true septicemia is established. Acute courses only are seen. Etiology. — Septic metastasis causes the endogenous form and direct transfer of pus the exogenous form. Pathology. — In iritis there are congestions, swelling, infiltration and exudation of serimi blood and pus, forming hypopyon. Choroiditis shows infiltration of the choroid and outer layers of the retina. Symptoms. — Full discussion must be referred to works on diseases of the eye to which nuist be added the gonococcal focus and septicemia. Diagnosis. — An eye specialist should be called for each case. Demon- stration of the primary lesion and the absorption is easy. Treatment. — The source of the gonococcus must be cured for correc- tion of the septic state while the eye must remain under the care of an ophthalmologist. GONOCOCCAL CONJUNCTIVITIS 241 Electrotherapy is peculiarly serviceable. The positive pole of a high- speed, multiple-plate static machine is grounded, and the negative pole is connected with a specially shaped, high-potential vacuum eye elec- trode. The spark-gap is a half-inch. The strength of current is one milliampere, the duration is for twenty minutes at each sitting, and the repetition for treatment is at first twice daily and then at longer intervals, according to improvement. The results are very quick relief of pain by promotion of absorption of infiltration and exudation. There are no afterresults and the medication of the eye specialist may be applied at the same time. GONOCOCCAL CONJUNCTIVITIS. Significance. — This disease has very great importance in children and adults owing to acute destruction of the eye unless proper treatment is instituted and followed from the outset. In any event a certain degree of damage is assured. The services of an ophthalmologist should be secured as soon as the diagnosis is settled. Occurrence. — Before the work of Crede, in 1881, conjunctivitis in the newborn was very common. It may be safely said that practically all blindness following conjunctivitis immediately after childbirth was due to this one cause. Likewise before the age of bacteriology, gono- coccal conjunctivitis in older children from error in asepsis in institu- tions and homes, and in adult patients themselves from carelessness, was also a very common disease. Relatively speaking, it is now uncommon, wherever ordinary intelligence may be enlisted, both in the care of the eyes of the newborn, of utensils in institutions and of the hands of adult patients. The disease is more frequent in the homes of the poor than in institutions, owing to the frequency of uncured gono- coccal lesions in that class, and their inability and ignorance in provid- ing the means and carrying out the method of prevention and cure. Etiology. — The gonococcus of Neisser is regularly the exciting agent, while the avenue of invasion or predisposing cause is in the newborn vulvovaginitis in the mother, whose discharge directly contaminates the eyelids of the baby. The onset is always within forty-eight or seventy-two hours, in postpartum cases. Long dry labor with its attendant traimiatism, the lack of resistant epithelimn and the absence of tear glands in the eye of the newborn, ^re all predisposing causes. All forms of urogenital discharge at any age and in both sexes should be regarded as sources of serious danger. It is in the declining stage of gonococcal disease in the adult when suffering is over and careless- ness invited that infection occurs. Antepartum or congenital cases due to progress of the gonococcus into the uterus usually after ruptm-e of the membrane before birth have been reported. Incubation longer than foiu" or five days is apt to indicate accidental infection after birth, such as from linen, of the mother or other children, failure of asepsis in the institution and the like. 16 242 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS In older children and in adults, the transfer of the organism to the eye is either through Aarioiis utensils or infected fingers of attendants or the ]iatients themselves. Nurses may readily have such fingers from the insertion of thermometers into the rectums of uifected children, particularly females. It is well to enumerate the other organisms of purulent conjunctivitis especially in young infants which, by this term, may be distinguished from gonococcal conjunctivitis. Among the cocci are i)neumococcus, streptococcus and other pyococci, ^Micrococcus luteus and Micro- coccus catarrhalis. Among the bacilli are those of Koch-Weeks, Klebs-Loefl!er of diphtheria, bacillus of ]\Iorax-Axenfeld, ])neumo- bacillus, true and false bacillus of influenza, streptobacillus and Bacillus pyocyaneus. This large variety proves the need of most careful bacteriological research in suspected cases before conclusions. Pathology. — As in all other mucous membranes the gonococcus in the conjunctiva produces the typical changes in series, congestion, exfoliation, infiltration, suppuration, ulceration and the like. The great delicacy of the membrane in the newborn and even in the adult makes the entire process even more severe than in the lu-ethra. Thus temporary lesions are comparatively rare, and do not occur unless ulceration is avoided by efficient treatment. The permanent lesions, on the contrary, are chiefly the complications and sequels which Pechin^ enumerates as infection of the cornea possibly leading to ulcer- ation, perforation, retrochoroidal hemorrhage, lesions of the iris, sec- ondary glaucoma, leucoma, staphyloma, panophthalmia and anterior polar cataract. Thus the possibilities are extremely severe. Ulcera- tion and cicatrization of the cornea lead to blindness. Symptoms. — The disease manifests itself slightly differently in infants, adults and the aged, being much more severe in the first and the last owing to lowered resistance at the extremes of life. Periods of invasion, establishment and termination may be recognized each with its local and systemic subjective and objective sjTnptoms. Chil- dren cannot always describe their condition which is necessarily often only objective. The period of invasion is shown in infants by dashes or spots of redness in the conjunctiva of the lids. In adults the sub- jective local sjTuptoms are tickling as of foreign body, hyperemia and tendency to rub the eye, then lachrymation followed by a serous or mucoserous discharge with gonococci and with slight thickening so as to gum the lashes. The objective local symptoms are at first on the palpebral, then on the bulbar conjunctiva great redness and edema, so that the latter is even elevated above the cornea which seems to lie in a depression and later shows its bloodvessels prominently. Exfoli- ation of the mucosa is shown by roughness. In the subjective estab- lishment the tickling changes to pain, heat and tension, radiating to the eyebrow, temple and forehead. Photophobia is an early and pro- gressive sjinptom. The objective local signs are that the watery 1 Pechin, Luys: Loc. cit., p. 243. GONOCOCCAL CONJUNCTIVITIS 243 becomes a purulent discharge loaded with gonococci. The redness, roughness and edema become extreme so that it is difficult to open the eye, except with elevators and so that, at times, the upper overlies •\. Fig. 56. — Ophthalmia neonatorum. (After Haab.) Fig, 57. — Total blindness due to perforation of the eyeball and escape of its fluid contents. (De For est. i) the under lid and may be more or less everted. The systemic symp- toms are in all ages a febrile movement, rapid irritable pulse, anxious, 1 De Forest: New York Med. Jour., May 29, and June 5, 1915. 244 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS nervous and tense state. The untreated disease is apt to run an acute severe ratlier than a subacute mild course. Only the most prompt efficient treatment giA'es hope of good result. The termination is favorable only when treatment is extremely prompt, efficient and ]>roperly applied. Fatalities do not occur, although Polit/.er' describes a case in which i)urulent conjunctivitis was followed by meningitis, buj; it cannot be stated bacteriologically whether this infection was gonococcal or not. The report is, however, highly suggestive of possibilities. In modern days full recovery is more and more connnon, owing to early diagnosis and modern anti- septics, but e^'en with these ad\'antages the early involvement of the epithelium over the cornea commonly leads to more or less ulceration and later scar and defective vision. In extreme cases deformity of tlie eyelids themselves is seen and total destruction of the eye as an Oi'gan. Severe cases in a few hours, o\'ernight or in a day, may result in total destruction of the eye. Bilateral cases are somewhat more severe than unilateral, possibly due to the greater difficulty of suitable attention to both eyes. In the extremes of life, infancy and age, the bodily powers are deficient and tlie disease is more destructive. Complications. — Complications are rare and belong to the class of absorption, such as arthritis. The preauricular lymphatic gland is often involved, as it drains the conjunctiva. Diagnosis. — Any ophthalmia arising at or immediately after child- birtli in the infant, or during any period of gonococcal infection in the adult demands the most careful bacteriological investigation, even in the stage before pus is developed, which is the moment of accom- plishing the best early control of the case. Distinction between gonococcal conjuncti\'itis and purulent conjunctivitis, which is excited by the organisms given under the heading of etiology, is very neces- sary. The writer had a case of simple pink-eye appear during a gonococcal urethritis, ha^'ing all the early features of a gonococcal conjuncti^•itis. The patient was immediately referred to an eye clinic where the full diagnosis and treatment were immediately given. Such cases are by no means uncommon and early neglect leads to serious results. The history, therefore, uncovers the incidence of the con- jimctivitis directly after chil(ll)irth by a mother suffering from leiicor- rhea or even without known lesion, or its occurrence during a gonococcal urethritis in the child or adidt with people who are not cleanly in the instincts or its mediate origin from the fingers and utensils of nurses and other attendants of children who have disregarded asepsis. Sub- jective s.Miiptoms are absent in young children, but older ones and adults ma>' describe the rapidly progressing irritation, watery lachry- mation followed by pus, pain and increasing photophobia. The objec- tive symptoms are those of early, fiery redness, edema and exfoliation of the epithelium and pus containing the gonococcus with or without ' Jahrb. f. Kinderheilk., 1870, p. 335. GONOCOCCAL CONJUNCTIVITIS 245 other organisms. The laboratory findings prove the })acteriological cause and should always be carried out immediately, as delay in the distinction of the disease may be costly to the jjatient. 'iVeatment is not of great value in the diagnosis except that the resistance of the gonococcus to ordinary means only corroborates the clinical and bacteriological evidence. Metastatic gonococcal conjunctivitis must always be borne in mind, and is suggested chiefly by the presence of other foci of infection in other parts of the bod\', especially perhaps arthritis. Fig. 58. — Gonococcal ophthalmia in the adult, showing great congestion of the conjunctiva, pericorneaJ injections, free purulent discharge. (Taylor.^) Differential Diagnosis. — Purulent conjunctivitis may arise from a number of infections other than gonococcal, as indicated in the paragraph on etiology. The list of organisms thus present may be repeated. Among the cocci are pneumococcus, streptococcus and other pyococci, Micrococcus luteus and ^Micrococcus catarrhalis. Among the bacilli are those of Koch- Weeks, Klebs-LoefHer of diphtheria, Morax-Axenfeld, pnemnobacillus, true and false bacillus of influenza, streptobacillus and Bacillus pyocyaneus. This large variety proves the need of most careful bacteriological research in suspected cases before conclusions. It is manifest that a mucous sac as small as the conjunctiva and an organ as sensitive as the eye can both react to any infection in practically the same series of symptoms in kind but 1 Loc. cit. 240 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS (lilVering in derive. Thus from the coujunctha \vc hjive redness, s^velHn^. exfoHatioii, discliar^e, discomfort, pain, and from tlie eye, irritation and photo])hobia, which are mild in the catarrhal and marked in the sni)])uratiNe infections. Symi)toms (tf destruction of the eye are omitted because this is a terminal secjuel and the dill'erential diag- nosis must be made preferably durinj]^ the incubation and certainly early in the invasion. Careful bacteriology alone will distinguish all the foregoing bacteriological causes from each other and from the gonococcus. Treatment. — Promptness, consistency and joersistency of treatment are the keys of the problem. Prophylaxis at childbirth consists in the method of Crede, by which the eyelids of the newborn child are washed with boric water and then 1 to 2 drops of 2 ])er cent, nitrate of silver solution are instillated upon the conjunctiva, l^eaction is controlled with normal salt or boric acid solution. If the infection appears, the hands of the child had best be restrained from rubbing the eyes, especially when only one is involved, and in adults the miin- fected eye is protected with a shiekl made either of a ])iece of celluloid cut to tit brow, nose and cheek or a watch-glass of suitable size. Either is placed o^'er the eye and secured on all sides with adhesive plaster of which the edges are fastened with flexible collodion. All dressings should be burned and attendants warned to keep their own hands scrupidously clean and to wear goggles to protect their own e>'es. Abortion of the infection is possible, if diagnosed very early, by irrigation with warm boric acid solution followed by the instillation of the silver nitrate solution twice a day and the use of 25 or 50 per cent, argyroj solution between times. Such measures should be continued several days associated with frequent examination of smears until tiie gonococcus is no longer present. If pus has already developed these measures will fail and may succeed only in the serous and mucous stages exactly as in urethritis. General Treatment in Chapter IX contains all details of management on page 4S3. Curative Treatment. — All measures must be promptly adopted and consistently followed. ^Medicinal measures in the acute stage are by local administration, irrigations and washings of the conjunctival sac with cold boric acid or normal salt solution follow^ed by the instillation of antiseptics. All exudate must be washed away as rapidly as it occurs and the 2 per cent, nitrate of silver solution should })e employed night and morning and the arg\Tol solution at frequent intervals, with care not to induce a chemical irritation by either. Physical measures recognize chiefly hydrotherapy in the irrigation of the conjunctiva sac with normal salt solution or boric acid water to remove the exudate, followed by the instillation of the antiseptic drops such as 2 per cent, nitrate of silver twice a day associated with argyrol 10 to 50 per cent, and in cold applications with small pieces of cotton or gauze fitting the eyeball and passed directly from a cake of ice. aONOCOCCAL CONJUNCT IV IT J ^ 247 Such pads should never be used a second time, so that a great number of them should be prepared. The heliotherapy a])])]ied to the aff(;eted temple, side of the head and neck is a valid and active deconf^cjstant and may be used many times daily for long periods until the skin is quite red. Its decongesting and soothing action equals that of blood- letting with leeches at the temple. 'J'he eyelashes are kept free of pus by gentle mopping. If the cornea becomes involved, iritis is often prevented and always benefited by instillating 1 per cent, atropin solution to keep the pupil dilated, at rest and without adhesions. The silver nitrate is stopped at the same time. Ulcerations of the cornea, synechise and deformity of the lids resulting from this disease are fully discussed in works on ophthalmology. The surgical measures are nonoperative and operative. The non- operative steps are blood-letting with leeches, for which heliotherapy may well be substituted. The operative technic is multiple puncture of the eyelids for extreme edema and if chemosis with its dangers of pressure on the eyeball and cornea appears, the tension and swelling are relieved by dividing the ocular and palpebral mucous membranes with blunt scissors. If this does not relieve then the outer canthus may be cut to give free access to all the cavities and recesses of the membrane. Such procedures belong to the specialists in diseases of the eye. Aftertreatment. — Immediate aftertreatment seeks relief of the chronic catarrh following the certainty of destroyed gonococci and respects possible dangers to the other eye for a definite period after treat- ment is stopped. Relief of the infection in the urethra is a definite element in the aftercare. Remote aftertreatment involves appli- cations of the sulphate of zinc or copper to the gramdar eyelids, Knapp's compression operation if these stimulations fail, various operations on the cornea, iris and eyelids and even enucleation and perhaps the wearing of a glass eye in cases of various deformity or total destruction, respectively. These procedures belong to special work on the eye and are therefore omitted. Cure, pathologically, aims at removal of the infection and the pre- vention of profound damage but often fails of full realization on account of the delicacy of the eye and the rapidity of the process. Disappearance of the gonococci is essential. The eye, sjinptomatic- ally, should be serviceable or even normal and free of catarrh or defor- mity in the eyeball or lids, and bacteriologically without infecting organisms such as the gonococcus or its allies. 7. Locomotory Complications. Synonym. — Gonococcal rheumatism is common, but is nondescrip- tive and without recognition of definite lesions. Significance. — Gonococcal synovial complications denote systemic invasion. The gonococcus and its toxins have selective action on all synovial membranes, and particularly those of the locomotory system. 24S COMPLTCATIOXS AXD SEQUELS OF ACUTE URETHRITIS Occurrence. — Locomotor oom])lIcatioiis are the most common extra- genital manifestations. They are acute, absorptive or chronic relaps- ing in tv'pe. Joint, tendon sheath, muscle, biu-sa, cartilage and peri- osteum may be invohed. They are all focal signs of absor])tion usually proceeding from posterior urethral infection and its comjilications. Varieties. — According to the tissue attacked, there are recognized arthritis, tenosynovitis, myositis, bursitis, chondritis, perichondritis and periostitis. GONOCOCCAL TENOSYNOVITIS. Occurrence. — Tenosynovitis is less common than arthritis. Women (imless pregnant) suffer less than men and children. Neighboring joints are often invohed. The affected sheaths are those of peronei, manual and pedal digital extensors and flexors, radial extensors, mus- cles of the thimib, semitendinosus and semunembranosus. Varieties. — iVcute, subacute and chronic are the com-ses of serous and suppurative exudates. Etiology. — ^Metastatic gonococcal infection is ahvays present. Symptoms. — Those of the focus of absorption and of severe teno- synovitis are the picture. . Diagonsis. — Relief of the focus often proves the nature of the com- plication. Treatment. — Recognized surgical care of the infected sheath and cure of the gonococcal focus are the elements. GONOCOCCAL PERIOSTITIS, PERIOSTOSIS, MYOSITIS, BURSITIS, CHONDRITIS AND PERICHONDRITIS. Occurrence and Etiology. — All these lesions are very rare. Their soiu"ce is regularly a genital focus of acute or chronic gonococcal disease. Clinical Features. — In no respect except early severity, followed by chronicity and the presence of the focus of absorption, do the gono- coccal forms differ from other types. Diagnosis. — Gonococcal infection and absorption must be proved. The organism may occur at the sites of complication. Treatment. — Cure of the sexual lesion is the first step. The other details are good management, protection, hydrotherapy, baking, elec- trotherapy, heliotherapy, Bier's hyperemia and suitable medications. GONOCOCCAL ARTHRITIS. Occurrence. — Involvement of the joints is the most frequent loco- motory and, therefore, extragenital complication of gonococcal disease. In frequency about 2 per cent, of all cases suffer from it and a much higher percentage in the complicated cases, especially those in men with seminal vesiculitis and in women Avith sali)ingitis. It commonly makes its appearance during the first or second week of severe absorp- GONOCOCCAL A RTJIUTriH 249 tive acute or of exacerbations of chronic cases and their coinjjlications. The posterior urethra is the particular starting-point. 'J'he joints are invaded in descending frequency as follows: K'nee, ankle, wrist, fingers, toes, shoulder, hip and teinporoin axillary. 'J'he same joints on both sides, or various joints on one side or different sides of the body may be invaded. Fig. 59. — ^Author's case of short streptococcus arthritis of the elbow. About eight years after infection arthritis- developed in one ankle and the small joints of the hand in addition to both elbows. The ankle is shown in Fig. 60. About 25 per cent, lim- itation of motion was present. The .T-ray picture shows the thickening and deposits in the synovise. Careful bacteriologic search revealed the streptococcus and not the gonococcus and the focus of absorption was in the seminal vesicles and prostate, but the wife of the patient seemed to have escaped any infection. Varieties. — Acute and subacute, progressive chronic and relapsing chronic are the clinical forms as to course, while those as to site of the lesion are arthrosynovitis, arthritis and osteoarthritis, in which respectively the synovia alone, the joint as a whole and the joint with the bone surfaces and cartilages are involved. Etiology. — Arthritis is never primary but always secondary to gonococcal conditions elsewhere, which in the uretlira is anterior occasionally, but posterior usually, either acute or chronic, especially of the relapsing and complicated forms. The predisposing factors are age and sex, which are of little importance although males suffer more frequently than females. Heredity, predisposition to articular lesions and little resistance to absorptive effects of any infection are important. Lessened articular resistance tlu'ough previous attacks of other forms of rhemnatism, gout, injmy, exposiu'e, exertion, and 250 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS occupation Avliicli leads to overuse of certain members are elements of influence. The writer had a case of gonococcal arthritis of the hand in a je\velry-])olisher, whose finu;ers were necessarily almost always overused. rre\"ious attacks of gonococcal arthritis are the most potent predisposition. The excitinij cause is regularly the gonococcus and its toxins, alone or associated with other pyogenic organisms, deposited and developing in the joint and its structures. The source of the organisms, as already stated, is commonly a posterior urethritis, rarely acute but usiuilly rclajising or chronic with com])lications. Of Fig. 60. — Author's rase of short streptococcus arthritis of the aukie. About eight years after infection arthritis developed in both elbows and the small joints of one hand in addition to the ankle. One elbow is shown in Fig. 59. About 25 per cent, limitation of motion was present. The x-ray picture shows the thickening and deposits in the synoviae. Careful bacteriologic search revealed the short streptococcus and not the gonococcus and the focus of absorption was in the seminal vesicles and prostate, but the wife of the patient seemed to have escaped any infection. the last in males the most fertile is seminal vesiculitis, probably due to the small size, functional activity, vascular complicated mucosa, readily occluded outlet and actively absorbing surface. For duplicate reasons in females the tube is the chief source of joint conditions. Cases in which the gonococcal infection is pure and those in which it is associated with other organisms are seen. Indeed, some authori- ties believe that joint involvement cannot occur except through asso- ciated pyogenic organisms, especially the .Streptococcus pyogenes. The joint lesions may ensue upon any other complication or acci- dental infection with the gonococcus. This is particularly true in GONOCOCCAL ARTHRITIS 251 conjunctivitis in children followed by arthritis. Sometimes the passing of sounds through strictures which are still infective will open the avenue for absorption and arthritis. Th(! writer has seen one such case, where polyarthritis ensued npon premature passage of a sound before the bacteriology of the condition was known. Pathology. — The gonococcus with its allies is deposited and grows within the joint, as the essence of the process, and therein makes changes in the synovia, joint tissues and even bone substance in the familiar and characteristic way. Exudate is apt to appear, sterile Fig. 61. — Author's case of gonococcal dorsolumbar spondylarthritis. Absence of cartilage spaces indicates bony ankylosis and loss of lime salts in the bodies of the ver- tebrae, defined by faint shadows, indicates atrophy of long disuse. The sacroiliac region of this patient is shown in Fig. 62. early, later containing the gonococci and finally again sterile. They may frequently be found, however, by sedimenting, centrifugmg and culturing, and no diagnosis is final without these steps. In joint lesions the gonococcal complement fixation test of Schwartz is of particular value, probably because the disease is one of absorption. The organisms have been found in the scrapings of joints, previously negative to aspiration. Thus negative fluid is not absolute proof of the absence of the organism in the joint. Temporary lesions occm* only in very mild cases, including arthralgia and arthrosynovitis, which apparently rarely reach the stage of exuda- 252 COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS tion in any cjreat deirroo. IVrniancMit lesions, on the otlier liand, are much more eonnnon anil in the milder decrees resnlt in fine fibrous adhesions, but in the jjreater dejjrees in dense, fibrous and even bony ankylosis after destruetion of the eartilages. The associated lesions are the secondary changes of disuse in the muscles which become flabby, ]iaretic and e\en atro])hic, and the antecedent lesions of the gonococcus from which the joint involvement ])rocee(led. Fig. (J2. — Author's case of gonococcal sacroiliac spoudj laithritis. Loss of shadow of lime salts indicates atrophy of disuse and loss of cartilat^c space proves bony sacro- iliac ankylosis. The lumbar region of this patient is shown in Fig. Gl. The pathological varieties are arthralgia, synovitis, arthritis, osteo- arthritis and polyarthritis. Arthralgia is really a neuralgia of the joint and has no described lesions. It may be neuritic or mildly syno- vitic and naturally leads to full recovery. Synovitis or arthrosynovitis is practically hydroarthrosis, in which the synovia alone is attacked, followed by puffy swelling, copious exudate usually of serum or sero- pus, never of pus alone. The knee is the usual \'ictim with delayed full recovery. Arthritis involves all the elements of the joints more or less, with rather typical purulent exudate followed by fibrous adhe- GONOCOCCAL ARTHRITIS 253 sions, few or many, slight or dense and disabling. Osteoarthritis adds involvement and destruction of the cartilages covering the bones, and bony ankylosis as a sequel. Polyarthritis is this condition in the fingers or toes, and is frequently called polyarthritis deformans. Com- monly the distal and middle joints of the phalanges are invaded, less frequently the metacarpophalangeal or metatarsophalangeal articu- lations. Great deformity and ankylosis are the rule. Mixed infec- tion is the accepted fact in the last two forms. Fig. 63. — Gonococcal arthritis. Infiltrated synovial membrane, with numerous endocellular gonococci and not a few extracellular gonococci in the connective-tissue stroma. (Finger.i) ' Lovett^ notes the following forms of joint lesions: (1) Ai-thralgia without definite joint lesions; (2) acute serous synovitis with much periarticular swelling; (3) acute fibrinous or plastic synovitis, with little effusion; (4) chronic serous or purulent synovitis; (5) periarticu- lar involvement, such as bursitis and tenosynovitis, ^^^latever the classification, all forms may merge one into the other, without great demarkation. Spondylarthritis is not an uncommon manifestation of gonococcal disease of the joints. Figs. 61 and 62 show the x-v&j photographs of the author's case of spondylarthritis in whom, diu-ing a very severe attack of gonococcal urethritis, the lower dorsal and entire lumbar spine and sacroiliac joints became involved intensely and finally ankylosed. Tuberculosis was eliminated by every known examina- > Die Geschlects-Krankheiten, 1908. 2 Keen's Surgery, 1907, p. 304. 254 COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS tion and test and sypliilis by the absence of a Wassonnann reaction anil all other clinical signs. The .r-ray report by l^r. Byron C. Darling is as follows: "Spondylarthritis or spondylitis deformans: A late stage of spon- dylarthritis in counterdistinction from hypertrophic osteoarthritis, wliii-li latter is characterized by spiu-s or lipping of the bodies of the \"crtcbra\ " 1 . The poor definition and lack of contrast in the roentgenogram is due to the loss of lime salts, the atrophy of disease in the vertebrje, and is characteristic of the condition. The cartilage spaces between the i^osterior articular facets of all the hunbar vertebrae are absent, indicating bony ankylosis. "2. The sacroiliac region shows obliteration of the cartilage space between the sacrum and the ilium, with com])lete bony fusion and the same loss of lijne salts from atrophy of disuse." Symptoms. — Local and systemic, subjective and objective, manifes- tations occur. The local subjective symptoms are pain, heat, swelling and disability. The pain Is prominent mostly in the morning, when, after a night's sleep, the joints are distiu-bed by motion. It is rela- tively least in arthralgia and synovitis, and greatest in arthritis and subvarieties. It may be sharp and cutting or intense and incapacitat- ing, leading to spasm of the muscles in fixation of the joints. In the old chronic cases the pain may be discomfort aroused to acute violence, sudden exertion or exposure. Heat is marked and proportional with the severity of the attack, and its recency, declining with the age of the case. Swelling is absent in arthralgia, but appears with synovitis some- times to a great degree and is always present in the acute or relapsing stages of chronic arthritis. It is represented by exudate into the cavity of the joint and congestion and edema of the joint substance and annexa. In recent cases tension and fluctuation or "dance- of the patella" and in old cases thickening around the joint are seen. Disability is due to pain, swelling, adhesion and muscular spasm. In arthralgia the sharp neuralgic pains in neuropathic indiN'iduais are much complained of as disabling and sometimes become a veritable neurosis of incapacity. In hydroarthrosis the accumulation may mechanically prevent motion, while in arthritis the fibrinous adhe- sions physically Imiit it and their pain on tension rcflcxly checks' it. Bony ankylosis speaks for itself as a source of disabilit}^ Muscular spasm is seen during the acute stages as a reflex protection of the invaded joint, alike in this as in all other articular conditions, inflam- matory or traumatic. The subjective systemic symptoms are those of absorption. The patient has malaise, nervous depression and often irritability. Com- plaint of the atrophy of disuse and of the attendant reflexes and spasms is often made. In arthralgia these symptoms are less manifest and of a higher grade in synovitis and still more severe in arthrosyno- vitis, arthritis, osteoarthritis and polyarthritis. Such a rule would be GONOC'OCCA. L A fiT/f fil TfS 255 expected because these lesions usually indicate absorption in ascendinj^ amounts and increasing activity of the local complication. The objective systemic symj)toms simply verify the foregoing statement b.y the patient, and it will be found that many of them run a low grade of fever and that a large majority of the more severe cases have a positive gonococcal complement fixation test. The local objective symptoms vary with the stages of the disease. In the acute period there are redness, swelling and edema of the skin and joint, reflex fixation, tenderness and pain, and in the chronic periods there are infiltration, bogginess, crepitation, adhesions and ankylosis. These symptoms vary in degree and relation with the severity of the infection. They are least in arthralgia and greatest in arthritis, osteoarthritis and polyarthritis. Atrophy of the muscles with depression or exaggeration of reflexes about the affected joint is a late manifestation of severe cases. When spondylarthritis occurs the disability and other attendant symptoms are most marked. The original urethritis and its complications belong to the local objective symptoms. The termination is favorable as to life unless the general infection is so severe as to lead to septicemia and death, in which the arthritis becomes, therefore, only a small element. It is favorable or unfavor- able as to the joint in accordance with the severity of the lesion. Full recovery follows arthralgia, except in the rare victims of neurosis or of joints irritable to exposure and exertion. Arthrosynovitis follows the same rule, but with greater tendency to nonresistant joints. In arthritis and its extensions into osteoarthritis and polyarthritis defor- mans the permanent damage is great and there is hardly any limit to the secondary lameness. Many patients are seen who for life must endure the loss of half-function in a number of joints. The ■s\Titer had a man in whom 50 per cent, of one elbow, 25 per cent, of the other elbow, 10 per cent, of one shoulder, 25 per cent, of one ankle and about the same amount of one hand w^ere lost in function for life. As in other forms of artlu-itis, relapses are very common, frequently under slight or even unknown cause. Diagnosis. — The presence of m-ogenital gonococcal foci or compli- cations must always be searched for and studied. As already pointed out, gonococci have been found in the blood of many victims of pos- terior urethritis and its sequels. It is, on the other hand, not neces- sary for septicemia or bacteremia to be present for arthi-itis and its analogues to arise. Careful bacteriological research must always be exercised toward gonococcal lesions, and also toward fluid aspu'ated from the affected joints, tendon sheaths and the like, as many authori- ties believe it is the associate organisms, notably the streptococcus, which render the arthritis possible. It is a safe rule to say that few or no locomotory complications should be recognized as indubit- ably gonococcal, unless the organism has been recovered from the antecedent foci, and from the affected joints after repeated search and combined with a positive gonococcal fixation test. The history, 250 COMPLICATJUXS AXD SEQUELS OF ACUTE URETHRITIS tlierofore, involves either h>]X'racute or loiifi-continued active chronic urethritis, both with their ai)])r()])riate coni])heatioiis anil other symp- toms of absor]>tion. The subjective symptoms pass from those of the lu'ethritis o\'er into those of the systemic invasion with deposit of active disease in the joints, chiefly pain, spasm, disability, fixation and "creakinfi;." Tlie objective signs nmst detect the focus from which the disease proceeds, its presence in the joint by heat, redness, swelling, fluid, crepitation and muscular rigidity, and if necessary its precise nature is shown by withdrawing the fluid for the laboratory. The laboratory investigation simply recognizes the morphology and culture characters of the recovered organism. Examination of the blood for the gonococcal complement fixation test is almost always positive. Treatment aids the diagnosis in the point that very rapid subsidence of the synovial inflammation upon surgical or other treatment of a focus of gonococcal infection pro^'es the connection between the two lesions. Keyes^ gives the following table of distinction between common and gonococcal urethritis. TABLE OF DIFFERENTIAL DIAGNOSIS BETWEEN GONOCOCCAL AND SIMPLE EHEUMATISM. Gonococcal Rheumatism. 1. Cause: gonorrhea. No influence of cold in the production of the rheumatism. 2. Very rarely observed in women. 3. Nonfebrile, or much less so than simple rheumatism. Even in acute cases reaction ne\-er attains the habitual in- tensity of rheumatic fever. 4. Symptoms habitually limited to a small number of joints. The affection never becomes general to the same extent as does simple rheumatism. 5. Less movable than simple rheuma- tism, going from one joint to another less quickly. No delitescence; no real jumping from one joint to another. 6. Local pains generally moderate, always less than in simple rheumatism; sometimes remarkedly indolent. 7. Frequently a tendency to hydrar- throsis foUowing the acute fluxion. 8. No sweating. 9. LMne not modified. 10. Blood not furnishing a marked buffy coat. 11. Cardiac complications exceptional. 12. Frequent coincidence with a special ophthalmia, inflammation of the synovial sheaths of the tendons, inflammation of the bursa, etc. The latter localities may be exclusively implicated. 13. Relapse in the course of successive gonorrheas very frequent. Simple Rheumatism. 1. No etiological relation with the state of the urethra. Habitual causes cold, inheritance, rheumatic diathesis, etc. 2. Common in the female, although less frequent in the male. 3. Reactional phenomena much more intense and prolonged than in gonorrheal rheumatism. 4. Symptoms usually involve a num- ber of the articulations; sometimes nearly all of them. 5. Symptoms: movable, ambulatory fluxions; rapid delitescence, jumping from one joint to another. G. Pains always rather intense, some- times excessive, disappearing less rapidly than those of gonorrheal rheumatism. 7. Little or no tendency to consecu- tive hydrarthrosis. 8. Abundant sweats, constituting a symptom almost essential to the malady. 9. Urine specially modified. 10. Blood forming a firm, concave clot with buffy coat. 11. Cardiac complications frequent. 12. Acute rheumatism does not affect the eye; the burste escape, as do usually the sheaths of the tendons. 13. Relapse frequent, but always inde- pendent of the state of the urethra. ' Geni to-urinary Diseases, 1905, p. 55. GONOCOCCAL ARTJIRJTIH 257 The author would add four other distinctions: 14. Gonococci in urethral discharf;e or 14. No gonococci. seminal vesicular secretions, sometimes in the urine in males and in the vulvo- vaginal glands, cul-de-sac of the vagina, cervix uteri and also urine of women. 15. Aspiration of joint frequently re- 15. No gonococci in fluid of joint, veals the gonococcus. 16. Gonococcal complement fixation test 16. Gonococcal complement fixation positive. test absent. 17. Condition of tonsils or teeth not a 17. Tonsils or teeth often source of factor. infection. Treatment of Arthritis, Periarthritis, Myositis, Bursitis and Chondritis. — In these important conditions the prophylaxis is preeminently proper and active attention to the urethritis and its complications, notably in the prostate and the seminal vesicles, which should receive regular examinations during a posterior urethritis for detection for the earliest onset of disease. Cautious instrumentation, avoidance of all traumatism and selection of conservative methods of treatment of urethritis and these complications all belong to prevention of systemic invasion and secondary synovial complications, because any injury of the mucosa during active infection is a wide-open portal of absorption. Abortion is nil but active and proper treatment of a joint or tendon sheath at the first sign may practically prevent extension. Curative Treatment — Curative treatment respects the findings of both pathology and symptomatology. The pathological indications must confine the inflammation to the serous and delimit it from the purulent type and in addition prevent, if possible, more than a true synovitis in contrast with panarthritis or pantenosjmovitis with secondary adhesions and sometimes ankylosis. In short, the lesions are restricted to the temporary and excluded from the permanent tj^^e. The symptomatic indications maintain and relieve the mild as con- trasted with the severe symptoms and decrease the pain, spasm and hydrarthrosis and the systemic absorption and symptoms which denote continued activity of the antecedent focus. Prompt resolution is stimu- lated instead of delayed recovery and above all the symptoms and infection of the primary focus must be relieved after the methods already described under each head. The management secures the benefit of cleanliness, asepsis and anti- sepsis in good hygiene and the great essential is rest in bed to abate the inflammation as a whole and splinting of the parts to soothe the pain, spasm and local inflammation. Exercise is forbidden until the process is termmated and, as in ordinary rheumatism and gout, selected diet and drink are necessary although of comparatively less value. Nursing at least durmg the acute period had best be special and even later when massage and other physical means are useful. The physical measures are among the most unportant and selected according to stage of the disease. IMassage is for the chronic period and keeps the muscles m health, prevents their atony and even atrophy as a substitute for voluntary exercise. Various ointments may be applied 17 25S COMPLICATIONS AND SEQUELS OF ACUTE URETHRITIS diirhig; the massage, of which salicylic acid (2 to 4 per cent.), ichthyol and iodoform are examples. Passive motion of the joints as jiart of tlie massage beginning Avith slight and adding increasing degrees is necessary and in severe cases mechanical treatment Avith the various vibratory and manijnilatijig machines is excellent. IIydrotherai)y employs moist heat or cold. Hot fomentations, poultices and douches are comforting and counterirritant and antiseptic wet dressings may be combined with them. Cold succeeds when heat may fail and may be employed with the ice-bag or the cold-water coil. In the reco\ery period when absorption and elimination are indicated hot, general and Turkish baths are of value. Baking the affected member in a Avell- designed and operated hot-air apparatus is very efficient and Bier's liA-peremic method applied for at least thirty minutes two or three times a day is a prized adjuvant. Strapping for sui)port and uniform pressure is in the later stages comforting and strengthening. The heliotherapy consists in applying a 500 c. p. lamp to the afli'ected joints and their annexa for from fifteen to thirty minutes several times a day as a decongestant and counterirritant. So strong a lamp must never be at rest but always in motion, waving back and forth over the skin. Intense redness without blister is sought. The electrotherapy may be the hot-coil applied to the affected joint for the indications of thermic action or preferably diathermy is applied daily in the manner previously described mider septicemia. For stiffened joints the indirect static spark is generously and persistently applied at first daily, then three times a week. The medicinal measures treat the antecedent point of gonococcal absorption along recognized and already described lines and by systemic application any and all standard antirheumatic medicines may be administered — always up to physiologic action and without disturbing the general nutrition of the patient. While relatively of less value in gonococcal arthritis than in other forms perseverance, full doses, changes and combinations in selection often produce results. The indications are catharsis with salines, diaphoresis with aspirin, urinary antisepsis with boric acid, biborate of soda, benzoic acid, benzoate of soda, or hexamethylenamin, alteration with iodide of potash and mer- cury, and support with quinine, strychnine and iron. The best anti- rheumatics are oil of wintergreen, colchicum, salicylate of soda and salicylic acid combined with bicarbonate of soda. Alkaline mineral waters, such as French Vichy, freely taken are very good. By local application during the fomentations and bakings counter- irritation may be employed, with oil of wintergreen, turpentine, guaiacol and eucal^-ptus. Iodine may be painted on or administered in ointment. Other salves are 20 to 50 per cent, ichthyol and iodoform. Blisters from the actual cautery, strong iodine and cantharides, kept open by strong salves may be used but incur the risk of cellulitis through the break in the skin. Intense counterirritation ma>' be employed by "stripping" the joint with the actual cautery without blisters. Injec- tion of bursoe with a few drops of pure carbolic acid has been tried in GONOCOCCAL ARTHRITIS 259 sacs not related to joints, such as the })nrsti3 beneath the tejidr*)! of Achilles. Semmtherapy appears to give its greatest success in synovial compli- cations and its methods are detailed in the following paragraphs. Autogenous or heterogeneous serums and bacterins may be tried with favor toward the former unless they fail and among the latter toward the mixed or associated bacterins, such as Van Tott's. The secret of success is regular periods of administration, slowly ascend- ing doses, no negative phase or other severe reaction and rather large doses toward the end of the course with proper respites between courses. The treatment may be laid down according to the chart described in later pages of this chapter. The chronic and subacute periods are better than the acute on account of the likelihood of negative phase with increased symptoms. Bacterins are better than serums. The surgical measures are nonoperative and operative. Support of the part with splints and casts introduced nonoperative procedures associated with wet dressings — antiseptic, such as aluminum acetate, or sedative, such as lead and opium wash. Leeches will decongest. Operative technic is based on incision, evacuation, cleansing and suture of joint, tendon sheath or bursse with the tendency of opening the part as little as possible on the principle of Scriba,^ w^hose operation consists of entering the joint with two small trochars and cannulse at opposite sides to permit through and through irrigation first with a cleansing fluid followed by hot bichloride of mercury 1 to 5000 until all pus is removed. The wounds by the trochars are stitched up and a dressing and splint applied. The knee is the best joint for this treatment. Resec- tion of the joint and removal of the tendon sheath are reserved for the oldest and most marked cases. J. Scriba gives a series of cases, of which one was suppuration of the knee with gonorrhea of four wrecks' standing. This was not a mere coincidence as the patient suffered from "acute articular rheumatism." Double incision on each side of the patella and irrigation with 5 per cent, phenol were carried out. This procedure was years before Neisser demonstrated the gonococcus. This case seems to be one of the first if not the first application of double opening and irrigation of the knee- joint in gonococcal arthritis. The credit of this procedure to Keyes, as is made in Watson and Cunningham's work. Diseases and Surgery of the Genito-urinary System, 1908, p. 72, is stated by E. L. Keyes, Jr., in a personal communication to the author to be an error and the method to be one which he himself has never employed. Aftertreatment. — Immediate aftertreatment demands cure of the urethritis. Its relief may antedate that of the s^^lOvial complications. Restoration of the synovial membrane and elements of the jouit to the nearest possible normal condition is the standard. Gradual increase in passive motion followed by mild and the increasmg volun- tary exercise. Adhesions should be gradually broken up by this 1 Ueber die Gonarthrotomie und ilire Indikationen, etc., Berl. klin. Wcbnschr., 1S77, xiv, 640. 260 COMPLICATIOXS AND SEQUELS OF ACUTE URETHRITIS ])rticess or uiulor ether an eH'ort to coiitiiuie normal metabolism con- tinued with proper diet, habits and drinks. Alkaline mineral waters are of great value. Operative cases receive standard and appropriate care and every patient should avoid ex]iosure to cold, wet, strain, injury and overexertion, because synovial nuMn])ranes once infected are very susceptible to relapse or attacks of simple inflammation from such causes. The remote aftertreatment comprises general conniion sense con- cerning the health, strength and resistance of the ])atient and above all absolute avoidance of fresh gonococcal infectioji because such an incident would almost be sure to be followed by absorption and renewed arthritis. The so-called rheumatic diathesis should recei^'e attention. Cure. — Cure, pathologically, in mild cases is probably absolute but in severe infection restricted and limited according to essential destruc- tion of elements of joint, tendon sheath or bursa. Symjjtomatically there should be no pain, fluid, crepitation or adhesions and full or nearly full function and bacteriologically the gonococcus must l)e absent in the antecedent urethral focus and in the s^'novia. COMPLICATIONS OF NONGONOCOCCAL ACUTE URETHRITIS. Classification. — There is a close similarity between these complica- tions and those of gonococcal anterior and posterior urethritis. There is, therefore, a m'ogenital group in which the lesions affect the organs of the sexual and the urinary systems, so that both the genital form and urinary forms are recognized. In most of the nongonococcal infections, however, the iu"inary organs are much less frequently affected, either by the initial lesion or by its complications. The chief exception is the suppurative conditions. A systemic group is also recognized in which the organs of the extraiu'ogenital systems are invoh'ed. The much less se\ere character of the nongonococcal mani- festations makes such complications extremely rare; but it is well to bear these facts in mind. The rarity of all these conditions is the reason for their very brief treatment in this work. Varieties. — Varieties as given in the clinical section are traumatic, catarrhal, diathetic, erupti\'e, pyogenic, syphilitic and chancroidal. Each of these is important but the general principle of treatment is so closely that of gonococcal complications that such principle is assumed in tlie following paragraphs and only differences and distinctions noted. Significance. — Significance, in general, is chiefly minor except the syphilitic because this is essentially a systemic disease, and chan- croidal because it often leads to operation on the glands of the groin, and pyogenic because it may be as vicious as the gonococcal compli- cations. The pyogenic, therefore, closely resembles the gonococcal in severity and character while catarrhal does so in type but less in intensity, although its dm-ation and intractability often suggest the gonococcus. Traimiatic, diathetic and eruptive, may be nonbacterial, COMPLICATIONS OP NONGONOCOCCAL ACUTE URETHRITIS 201 consist in urethritis alone and often have no complications, in which feature catarrhal lesions share. Traumatic inflammation of the urethra may induce epididymoorchitis and cystitis or make anterior disease posterior. As previously stated in the clinical section, minor complications invade the foreskin alone or the mucosa of the urethra alone, whereas major complications compromise the sexual glands and the organs of the urinary system or the general system. Minor complications are therefore classified: (1) Phimosis; (2) paraphimosis; (3) balanitis; (4) posthitis; (5) balanoposthitis, which may occur in any of the nongonococcal forms of infection; CO) folli- culitis seen chiefly in the catarrhal and pyogenic; (7) lymphangitis; (8) lymphadenitis developing rarely in the catarrhal, more frequently in the pyogenic and invariably in the syphilitic and chancroidal lesions. Their treatment, in general, is the same as that for the gonococcal complications modified to meet particular conditions. The removal of the cause is essential in traimiatic, so that solutions too hot or too concentrated and instruments too large, rusty or imperfect, and their application too violent are instantly stopped. Care of the health and addition to resistance are required in catarrhal, diathetic and eruptive forms. Catarrhs elsewhere in the body are often keys of the problem and attacks of glycosuria and uric acid poisoning should be abated as part of the treatment of the complications. Surgical dressings are required in chancroidal and syphilitic manifestations, to which may be added incision of the glands in the groin for abscess and active anti- syphilitic systemic treatment. Pyogenic complications require the full management and all the measures prescribed for gonococcal, because except for the infecting organisms there is no definite distinction between the two. Major complications in the sexual forms include these classes: Cowperitis, prostatitis, seminal vesiculitis, epididymoorchitis and funiculitis and in the urinary forms urethrocystitis, cystitis, urethritis, pyelitis and pyelonephritis. The cowperites are reserved for the catarrhal rarely and the pyogenic very commonly, and prostatitis is occasional in traumatic, more usual in catarrhal and still more common in the pyogenic. Seminal vesi- culitis is produced only by the pyogenic, to W'hich is added epididymo- orchitis, which may also be syphilitic. The urinary forms are seen in descending order of frequency in the pyogenic, catarrhal and s^^philitic complications. Careful distinction must be drawn between the catarrhs, which are the terminal stage of other complications and the catarrhs which originating as such in the m'ethra extend into the annexa or upward along the urinary tract. Treatment in general means that all these complications deviate but little from the methods and measm^es set down for those of gonococcal origin on the ground that the pyogenic germs are the prevailing infec- tion. In particular the sm*gery of these cases is in no wise different. Catarrhal forms require combat of this peculiar weakness by sustain- ing the health and restoring low-grade bodily strength and s^^hilis 2C>2^COMPLICATIOXS AXD SEQUELS OF ACUTE URETHRITIS I'eqiiives active measures with iiieroury, iodides, the newer arsenical preparations, general sii])port and hygiene. Cure, pathologically, in full restoration of the parts may be possible in the milder lesions, snch as traumatic, catarrhal, diathetic and erup- tive, but it is not possible in more destructive jnogenic, syphilitic and chancroidal disease. Symi)toniatica]ly, howcNcr, relief from suffering and symptoms is usually attained except in the more profound pyo- genic disease and bacteriological eradications of organisms and relief from the i)ositive signs in the blood test are the measures of good results. CHAPTER IV. CHRONIC URETHRITIS. General Clinical Features. — Definition and General Principles. — Chronic inflammation of the urethra at any point and due to any cause may properly be described as chronic urethritis, a condition in which the lesions are either more or less stationary with relapses, or slowly progressive with exacerbations. It is rather well to fix this general conception in the mind and then to distinguish each unportant kind as to symptoms, diagnosis and treatment. Varieties. —As already stated the clinical forms are stationary with relapses and progressive with exacerbation. Cure is possible in each type, but usually the mucosa is permanently changed in various ways and degrees which are sequels and will be so described in this work. As to location and extension, there are recognized anterior and posterior, anteroposterior or general and localized, that is, confined to definite single or multiple points either the anterior or the posterior portions of the canal or both. As to cause, nonbacterial and bacterial, of which the latter is practi- cally the only form of clinical importance, unless one regards the relapses of catarrhal urethritis seen in many patients for a few days after instrumentation as examples of chronic disease. The varieties of nonbacterial chronic urethritis, according to exci- tants, are the same as those seen in acute manifestations, but rest on a chronic diathesis, by which comparatively simple factors may lead to long-continued lesions: (1) Traumatisms, thermal from too hot or too cold irrigations, chemical from too concentrated applications, mechanical from too rough introduction or defective forms and kinds of instrument; (2) medicinal, from drugs irritant after internal admin- istration, such as balsams, cantharides, alcohol and tm'pentine and after eating such vegetables as asparagus, rhubarb, tomatoes, straw- berries and the like; (3) physical, from the use of instruments too hot or too cold, with rough sm-faces and faulty introduction. Traumatism may involve any healthy mucosa, but is most potent in the unhealthy cases and rests on the use of rough, rusty or ragged instruments as well as unskilled and forceful manipulation. The offense of an indwelling catheter is a familiar traumatism; and in this class belong masturbation and sexual excitement without coitus. Caution should always be exercised to pass smooth instruments and with gentleness, never to use applications of extremes of temperature or concentration, and never to repeat treatment at intervals too short for a recovery period. 264 CIIROXIC URETHRITIS Of bacterial urethritis, noiiiionococcal and gonococcal varieties are seen, of Avhich the former have the same general but far more mild features than the latter, so that the latter may be regarded as furnish- ing the type for all the others in the clinical manifestation. Chronic suppurative , nongonococcal urethritis may duplicate the ravages of the gonococcus, but is rare and needs no separate discussion, except to note that the pyogenic organisms alone are present. The varieties of bacterial chronic lu'ethritis, according to the excit- ing organism, diii)licate those given in the list of causes of bacterial nongonococcal acute urethritis, but may be repeated here: ]\Iicro- coccus catarrhalis in true catarrhal forms, the Treponema pallidum in s^'philitic t^pes, the bacillus of Ducrey in chancroidal in\asions, and the ordinary pyogenic organisms in simple pus cases, Bacillus coli conununis being often seen. Bacteria are doubtless a factor in the majority of cases, hence the importance of bacterial investigation. 1. GONOCOCCAL CHRONIC URETHRITIS. Significance.— As in acute urethritis, gonococcal infection will be taken as the type and its two varieties of anterior and posterior will be considered together. Anterior and Posterior Gonococcal Chronic Urethritis. Occurrence and Significance.- — The general characters of gonococcal infection in the urethra render the tendencj'^ to persistence of the pro- cess both active and great. It may be safely said that few cases are seen without more or less protracted subacute or terminal stages, although true chronic disease may not ensue. This fact is true in both anterior, posterior and anteroposterior infections. It is prob- able that chronicity is most common in the posterior m-ethra, although in older writers this lesion was more or less doubted. The significance of truly clu-onic gonococcal infection in both sexes is that many of its lesions provoke little or no subjective attention, invite indifference and neglect and thus lead to infection of the opposite sex in the marriage-bed. There is practically no difference between the dangers which the one sex may offer the other in these circiun- stances. Etiology. — The fact that gonococcal infection of the mucosa is not a superficial catarrh, but a vicious, penetrating, infiltrating suppuration, is now fully established through its characters of exfoliation, infiltra- tion, ulceration, purulence, complications and chronic tendencies. This pathogenic nature of the process is the essential or exciting cause. Among the predisposing factors are the ignorance and indiscretion of patients and errors in diagnosis and treatment. The victims are negligent and indifferent in their management, heedless of warning as to the character of the disease and sometimes even vicious in the chances taken of infecting the innocent. Their occupation is often GONOCOCCAL CHRONIC URETHRITIS 205 an offense to the inflammation. One of the worst cases the writer has ever seen was in a raihoad brakeman whose occupation aided the disease in wide extension. Indiscretions are also coinmoii during the most treacherous and uncertain period — that of the decHne. Excesses in alcohol, diet and sexual relations are not uncommon. Thus from the patient little or no cooperation is obtained. Errors in diagnosis, which are commonly those of failure to search for the gonococcus by smear and culture and for absorption by the complement fixation test, are largely responsible for many uncured casco, as treatment is prematurely discontinued even by the physician. Unduly frequent treatment by patient and physician, with concen- trated solutions, improper instruments and the like, tends to augment the natural tendency of the disease to penetrate, become chronic and complicated, by repeatedly adding to the infection the element of thermic, chemical or physical trauma, with secondary catarrhal inflammation. A most important element is poor resistance of the patient to all ordinary diseases which, instead of ending quickly and fully, are apt to be protracted into long periods. Questions concerning his general resisting powers should always be asked the patient as an element in prognosis. A minute subdivision of causes of so important a condition as chronic urethritis cannot well be inclusive and exclusive, because fac- tors in some instances are predisposing and systemic, but in others exciting and local. As a rule the same factors are at work in both the nongonococcal and gonococcal disease in producing a tendency to chronicity. The predisposing systemic factors are, as in acute urethritis, low vitality ,^semi-invalidism and acute or chronic alcoholism. Conditions producing hyperacid, alkaline or crystalline urine, such as gout, rhemnatism, diabetes and lithiasis, constituting the so-called diathetic urethritis, are also important in the presence of gonococcal invasion. Tuberculosis is a factor in depreciating the health and strength, as also are unhealthful occupations. Predisposing local factors are a mucosa vulnerable by previous attacks, even of noninfective urethritis or by injury or any other element tending to leave permanent damage locally. Periurethral disease, as hypertrophy of the prostate in the male and in the female uterine displacement, laceration and deformity, are poor grounds of cure in acute gonococcal infection and directly invite the chronic forms. A more full discussion of the influence of all these factors is given in the Chapter on Acute Urethi'itis on page 19. The bacteriological causes are familiar, being chiefly the gonococcus and secondarily its usual allies, as fully discussed under Gonococcal Acute Urethritis and its Etiology on page21. Pathology. — Gonococcal chronic uretln-itis is never primary but always secondary to one or more acute infections. In general patho- genesis, like the acute manifestations of this infection, the anterior and posterior forms differ from each other chieflj^ in respect to theu' 2GG CHROXIC URETHRITIS perniaiuMit lesions. The essence of the process is gonococcal infection of tlie nuicosa, with or without coni])licatinij; deposits, in the ghuuls and organs hnniediately associated with the m*ethra. The inllannna- tion is of two forms: (1) chronic, persistent and stationary; and (2) chronic and slowly progressive. Both may be subject to exacerba- tions and are at the basis either of sup})urative and catarrJuil inflanuna- tions, more or less associated in the marked cases, or catarrhal alone, after the su])pin'ation has subsided in the milder cases. There are, therefore, cell proliferation in the deeper layers and desquamation of the cylindrical epithelium in the superficial layers, with a tendency toward recovery and substitution of squamous for cylindrical cells. Thv regeneration may ne^•er be complete, so that a kind of variable balance is present betw-een the loss and the restoration of the lining cells. This same type of process is present whether the mucosa is of the lu'cthra, its mucous glands and the prostate in the male or of the urethra, ^'agina and uterus in the female. The gonococci become buried in the depths of the epitheliimi along the m'cthra, in the mucous cri^-pts and in the glands, w-here they may persist for years without great inconvenience to the patient, but with danger of infection of the opposite sex. The tissues involved, therefore, are the mucosa in all its layers, the submucosa and not infrequently tissues beyond this structure, and all in one or more of the foregoing processes. To these should be added the small mucous glands, both simple and compound, and such out- lying structm-es as the glands of Cowper, the prostate, the testicles, the vasa deferentia and the like. The temporary lesions are found only in the catarrhal forms, from which full recovery may be had, whether associated with the chronic suppurative foci without recovery or essentially catarrhal after the suppm-ation has ceased. They are tj^^ified by stratification, infil- tration, desquamation, superficial ulceration and catarrhal exudate. The stages are stratification of the cylindrical epithelium up to many layers, even a half-dozen wherever the mucosa occurs along the lu-ethra and in its glands. Then the other processes occm* and induce the permanent changes in the same distribution. The desquamation and ulceration become deeper, pavement epithelium replaces the upper layer of the cylindrical cells, the infiltration augments and a certain amount of dryness and elasticity occurs, resembling the skin and possessing decreased permeative and absorptive powers, thus rendering local treatment less efficient. Such changes of cylindrical to pavement cells probably always occurs in fully established severe disease, with true chronic termination. The mucous glands about such a focus take on exaggerated activity in compensation for the dryness and thus lead to chronic uninfecting catarrhal discharge, w^hich may never be corrected, and had, in fact, best be left untreated as it is beneficial. The deeper ulcers and infiltrations may result in cicatrices and thickenings, followed by retraction, with deformity of the course and caliber of the urethra or in exuberant granulations GONOCOCCAL CHRONIC URETHRITIS 267 and polypi. By exactly the same steps the mucosal glands are altered, some are destroyed and others hypertrophied with chronic discharge. The loss of mucosa followed by cicatrix and infiltration, and then by deformity in course and caliber, is the basis of organic stricture of the urethra. The associated lesions are chiefly those induced by the organisms of complicating infections, as stated in the discussion of Acute Urethritis on page 82, or those of the diathesis promoting the chronic disease. The complicating lesions are those of the organism involved in this process, too numerous for full discussion when one bears in mind that the pathogenesis is identical wherever the gonococcus and its allies penetrate. In the pathology of the anterior urethra special glandular structures require attention and study. It is well to note rather fully the changes in the glands of Morgagni and Littre which occur in two stages, activity and destruction, and the lesions of the periurethral structures. The crypts of Morgagni during the stage of activity enlarge, hypertrophy and show patulous ducts, and may not greatly progress beyond these points; but in the stage of destruction they suffer chronic suppuration, occlusion and cyst formation and may even lead to periurethral abscess and fistulse. They may disappear by atrophy, sclerosis and retraction. The glands of Littre may suffer similarly by the prominent processes of the gono- coccal infection, that is to say, substitution, compression and occlu- sion. The stage of substitution is as in the urethral epithelium, that of pavement for cylindrical cells, with secondary alteration of the glandular secretion, and even disappearance of the cell and its replace- ment by round-cell infiltration. The stage of compression is due to intense cellular infiltration, with retraction, contraction, pressure and slow destruction of the gland. The stage of occlusion shows the ducts blocked, the contents retained to form simple cysts or suppu- rating foci, which may bm-st into the urethra or the cavity of the affected organ or into the periurethral tissues, thus forming by per- sistence or repetition of the process sinuses, abscesses and fistulse. Suppurating occluded glands, after rupture and discharge, are clinically the most dangerous as sources of infection. The gonococcus lurks in the depths of the glands, in the lowered focal resistance from which for anatomical reasons it is often impossible to drive it, and from which it may proceed to a fresh outbreak through any cause favoring congestion of the m*ethra, such as excesses in food, alcohol and sexual relation. The periurethral tissues may be attacked, especially when many acute infections have been grafted on each other without cure of any or when improper instrumentation has opened up the mucosa for penetration into the outlying structures. Thus the corpus spongio- sum urethrse is infiltrated with round cells, which are finally replaced by fibrous tissue which contracts, retracts and deforms as stricture, or the corpus is invaded by abscess and fistula. 26S CHROXIC URETHRITIS The foregoinc; data apjily both to anterior and posterior gonococcal chronic m-ethritis. but a t'e\\- features of the hitter should recei\-e individual note. In the posterior urethra tiie ])rocesses are infiltration, proliferation and desquaniation, followed by repair and substitution. The infection has a great tendency to reach the subepithelial layers and to penetrate the glands which are essentially connected with the posterior ui-ethra. In the prostatic urethra the ejaculatory ducts in the coUiculus are by the tissue changes often compressed, distorted and strictured, or contrariwise, patulous and inflamed, Avitli chronic discharge, inviting or suggesting spermatorrhea. The prostatic ducts in the sinuses of the urethra are also either infiltrated and destroyed or chronically inflamed with plugs of mucopus or pus. The prostatic acini or glands show changes duplicate to those of the urethra and its glands: (1) The lining epitheliiun may be predominately affected, desquamated and finally atrophied, resulting in a secretion which is stringy, abun- dant, opaque and filled with degenerated epithelial and pus cells; or (2) suppuration may be the chief factor and determine the character of the discharge. Thus two forms of chronic prostatitis are produced. In the membranous portion between the layers of the triangular ligament there are no glands of unportance, but the infiltration, followed by the inelasticity and acted on by the muscles, not infre- quently produces more or less splits, tears and ulcers, which may be the basis of stricture. Granulumata and Fapillomata. — The urethral mucosa, as that in all other parts of the body, when subjected to chronic inflammation shows hj'pertrophy of various elements into caruncles, granulomata, papillomata and polj^ii. The granulomata are granulations, as already stated, of exuberant character on unhealed ulcers. The papil- lomata and the pol^'pi may be, in a certain sense, later sequels of the chronic inflammation, probably as in the nose either the direct result of the inflammation, with more or less retention of secretions, or of changes about strictures, especially in the proximal aspect where re- tention is very abundant. These lesions have been studied by Burck- hardt,^ who divides them into caruncles, condylomata, papillomata and mucous and glandular polypi. Caruncles occiu- most frequently in females at the meatus of the urethra, have a fiery, raspberry-like appearance, a sessile, rather defined attaclmient and a tendency to bleed on contact, through great vascularity. Their microscopic elements are numerous dilated blood- vessels in a mass of pavement epithelium in layers. To contact with urine, the finger or instrmnents in examination and the penis in coitus they are usually excruciatingly painful. Granulomata occur more frequently in males in the posterior urethra, particularly the prostatic portion, have the appearance of a cock's comb and the resemblance to the condylomata acuminata seen exter- iHandbuch der Urologie, 1906, iii, 267. GONOCOCCAL CHRONIC URETHRITIS 200 nally under the foreskin and about the vulva. Their attachment is usually pedunculated, with hcip;ht and width greater than the base, or less frequently sessile, with the base equal to or greater than the other dimensions. Their vascularity is rather sparing. The micro- scopic elements are a few bloodvessels in a more or less fibrous delicate stroma surrounded by a rather thick pavement-epitheliimi covering in layers. Papillomata also occur more frequently in males and in the posterior urethra. In appearance they resemble the foregoing granulomata, adding the presence of definite papilla?. Their attachment is also pedunculated or sessile. Under the microscope the papillae are unmis- takable, with a thick pavement epithelial covering and rich blood- vessels extending through the pedicle and its various papilla?. Mucous polypi and glandular polypi occur in both sexes and most frequently around the neck of the bladder, although they are found at almost any point of the urethra. In appearance they are cystic and translucent, somewhat resembling a white grape, and in attach- ment usually pedunculated, although the earlier developments may be sessile. In microscopic elements they are probably inclusion processes, with a loose soft-tissue stroma and few bloodvessels, covered with a stratified pavement epithelium containing numerous glands. Symptoms in General. — In accordance with whether the disease is of the anterior or the posterior urethra the symptoms will vary and should be individually discussed. The term "anterior urethra," as adopted by urologists, means the luethra distal to the triangular ligament, while "posterior m-ethra" denotes the canal proximal to this structure. The symptoms are subjective and objective, local and systemic. In the nature of things subjective and systemic symp- toms are relatively much less than objective and local, inasmuch as the elements of discomfort and the like have largely disappeared from the subjective local conditions and inasmuch as that of absorption is in the vast majority of cases without complications has also ceased and with it the subjective systemic signs. Unlike acute urethritis, chronic cannot be described as possessed of periods of incubation, invasion, establishment and termination. On the other hand, the acute disease, simply without definite termination, passes into the chronic type which, as previously stated, may have periods of quies- cent persistence, of progTcssing exacerbations and finally termination in a lifelong catarrh or one or several of the more important sequels. The whole progress of posterior chronic luethritis is usually more or less marked by complications. We therefore find great decrease or even disappearance of the chief local s^Tuptoms of acute iu:ethi'itis which were stated as discomfort, pain, pollakiuria, hemorrhage, exu- date and chordee. The terminal modifications of one or more of these symptoms may, however, persist until cm-e or diuing any exacerbation of the process reappear more or less in its entirety as an acute process. Anterior Chronic Urethritis.^ — Symptoms. — The prevailing sATuptom is a slight persistent discharge manifesting itself in four ways, each 270 CHRONIC URETHRITJS constitiitins: a type of case more or less distiiietly. The term dis- charge should be most carefully defined, as any abnormal exudate from the m-ethral walls, fluid and copious in all acute and in some chronic manifestations, but viscid and scanty in the majority of chronic cases. 1'hus the term means an exudate whether it is free pus or mucopus in the early periods, or -watery moisture or jiiunmy moisture, or a thick dro]) at the meatus, and finally merely shreds in the \u-ine. In other words, it is any departure from the normal urine due to infec- tion and characterized by the presence of such urethral exudate and elements when compared with their absence in healthy m"ine. It is well to have patients understand this view of discharge in order to prevent them from ceasing treatment when the free copious stage is gone. In anterior chronic urethritis discharge may show itself, as stated, in four ways: 1. A drop or drops of greenish-white or yellowish pus, thic^k in consistency, appears at the meatus in the morning on rising or during the day at stated intervals between urinations. It seems to possess little tendency to close the lips of the meatus, lies free in the cavity of the urethra, is highly infectious, and usually denotes recent chronic lesions or complications or both. 2. A drop of mucopus or pus appearing chiefly in the morning, with much tendency to gimi the lips of the outlet together. This is a transitional condition, as a rule, between the more free pus of the first class and the watery mucous condition of the next form. 3. A watery discharge, chiefly mucus, most abundant on stripping the lu-ethra and without much tendency to giun the lips. It is apt to be present after urination, but must be carefully distinguished from the drop of lu^ine sometimes late in appearing after this act. It is also to be distinguished from the mucous moistm'c induced by sexual excitement and sometimes by pressure upon the prostate of consti- pated movements. It must, in other words, be of strictly post- inflammatory lu-ethral origin. 4. Shreds alone in the lU'ine without subjective and often without objective sign at the meatus, but constituting, nevertheless, discharge in the sense designated above. Exactly as the sputmn in tuberculosis carries the Bacillus tubercu- losis, any and all these forms of discharge are commonly the means of carrying the gonococcus, and should, therefore, in every case, be carefully searched for the organism before adopting a policy of treat- ment or uttering a prognosis. The patients should receive very careful instructions as to the infectiousness of all these forms of urethral discharge. It is probable that a persistent single drop is commonly the sign of anterior chronic urethritis, for the reasons that so small an exudate from the posterior urethra cannot during the night gravitate forward past the triangular ligament, the pocket of the bulb, and finally the angle where the penile urethra folds itself over the scrotum. If the GONOCOCCAL CHRONIC URETHRITIS 271 discharge in drops is more copious it may come from either the ante- rior or the posterior or the anteroposterior urethra. Careful physical examination including proper urinary specimens will indicate and urethroscopy decide. The influence of the anatomy of the bulb on urethral discharge should be recognized. The bulb of the anterior urethra may often be the chief point of chronic disease, owing to its anatomical conditions and variations. It may be deep or shallow, long or short, with many or few, simple or complex folds of its mucosa over the bulbocavernosus muscle, so that in the urethroscope it resembles a urinary bladder in miniature imper- fectly dilated. Its mucous crypts and glands are numerous and with the ducts of Cowper's glands, if infected, add to the difficulty. Dis- charge may pocket in the bulb and scarcely show at the meatus during the day if scanty, but otherwise if more copious, and moreover, diurnal urination every two or three hours flushes out the urethra so that frequently the discharge cannot accumulate and appear. The genesis of the morning drop is, therefore, that during the hours of sleep the discharge accumulates, gravitates forward to the meatus, where in the fossa navicularis and behind the apposed lips of the meatus it is retained and dried into a small scab comprising that minute quantity of it which appears in the cleft of the meatus. The fold of the penile urethra at the scrotum tends to determine that most of the discharge, unless copious, seen at the meatus is from the ante- rior urethra, but such a distinction is not safe, except in the presence of one of the multiple glass tests, of which, in the opinion of the -^Titer, none is better than the five-glass test of Wolbarst, which the writer carries out in a special manner and adapts to cases of anterior and posterior chronic urethritis without complications in the prostate or seminal vesicles, because such complications require as far as possible separation of discharge from the prostate and the vesicles from each other as three separate specimens. Such distinction is afforded by the seven-glass test of the author, which is fully described in Chapter VIII on General Principles of Diagnosis on page 455, and need not be repeated here. The steps of the author's technic of the Wolbarst fiA-e-glass test are as follows: The meatus is washed and a No. 12 French rubber or lisle-thread catheter is passed to the bulb of the urethra and stopped at the tri- angular ligament. Experience shows how to recognize this point by slight resistance to the catheter. With a hand syringe 150 c.c. of hot normal salt solution are flushed through the urethra from behind forward into a sterilized glass which is known as Glass I, or the Anterior Urethral Glass, Massage of the urethra before introducing the catheter loosens adherent shreds and makes the irrigation more efficient. The uretlira is now gently massaged from the bulb forward and the same step repeated, which gives Glass II or the Control Anterior Urethral Glass. The piupose of the massage is to dislodge discharge adlierent to the urethra but not washed off by the first test. If the disease is in the anterior urethra alone, practically all its products -,2 CllliOXIC URETHRITIS Avill be in Glass I and very few in Glass IT, and tliey will conforni with each other more or less definitely in kind and condition. If the control anterior urethral i:;lass contains much exudate, another wash- ing of the anterior urethra may be given in order to insure against error and this glass may be mixed with Glass II or held as Glass Il-a. Such an extra glass is of great service in coin]ileting the diagnosis of the anterior urethra. The patient, who should be instructed to hold his urine before the test for at least i\\e hours, with the double ]nu-]iose of permitting ])lenty of discharge to acciunulate in the m-ethra, and of urine in the bladder, now passes one glass of urine. This is known as (ilass III, or the Pos- terior Urethral (ilass, as it will necessarily contain exudate from the posterior urethra. Glasses I, II, III will show rather conclusively that the disease is anterior, posterior or both in its situation. Further- more, the differences in the character of the discharge in Glass III, when com])arcd with its i)redecessors, are diagnostic and should be noted. The shreds of the posterior m'ethra are apt to be long, large and lumpy, while those of the posterior urethra are shorter, smaller and filamentous. A small (No. 10 Fr.) catheter is now passed into the bladder with great gentleness and thus Glass IV, or the Bladder Glass, is obtained, and if clear will show that the bladder, m-eters and kidneys are not involved, but if piu-ulent will indicate the reA^erse possibility and the necessity for exploration of the m"inary as well as the sexual organs. A small soft catheter and great gentleness are advisable in order to ehminate any great danger of tramnatism or pressure M'hich might produce the sudden discharge of the glands into the urethra. IMassage of the prostate and seminal vesicles is now performed in vigorous but judicious fashion, and then the patient empties his bladder into one or more glasses, thus producing Glass V, or the Massage Glass, having in it the products of infection in the organs named. If on arrival the patient has not much lu-ine in his bladder, while the cath- eter is in place for Glass IV, warm sterile normal salt solution should be passed into the bladder so as to give artificial means of securing the massage specimen. It will be noted that the IMassage Glass con- tains a mixture of the exudate from the prostate and the right and left seminal vesicles. If purulent material or detritus is found in this glass it is almost impossible to tell whether it comes from the prostate and both vesicles in association or from only one or from any two of these three organs. The seven-glass test of the author largely removes this difficulty by giving the contents of the prostate in Glass V and those of the right and left seminal vesicles in Glass VI and Glass VII, as fully described in the subject of diagnosis. As a preventive against infection it is well to give m-inary antiseptics for a day or two before and after such an investigation. The original Thompson two-glass test is not sufficient for a distinc- tion between anterior and posterior chronic urethritis — a fact which necessitates the adoption of the Wolbarst or other multiple-glass test, GONOCOCCAL CHRONIC URETHRITIS 273 as previously discussed. After study of the results of multiple-glass tests the course of the case may be readily followed by the two-glass method with regard to the amount of pus and the number, character and density of the filaments, combined with frequent microscopic investigation of the latter. At any moment the five-glass test may be repeated in settlement of any question of doubt, but always with the aid of posterior and anterior urethroscopy. It must not be forgotten that chronic discharge in the anterior urethra is often due to infection of the mucous crypts throughout the canal, and of Cowper's glands in the bulb. Follicular chronic urethritis and chronic cowperitis are really complications of anterior chronic urethritis, exactly as their acute lesions are complications of anterior acute disease; and will therefore be treated under that heading. Diagnosis. — ^This is determined on the factors fully discussed in Chapter VIII on General Principles of Diagnosis on page 428. The history shows the acute attack with severe and prolonged symptoms and sometimes improper and violent treatment. These . are followed by the symptoms of the characteristic persistent drop containing pus, watery moisture, gumminess or a thick mass crusting at the meatus and the physical examination verifies the existence of the drop and studies the characteristics of the shreds in the urine. In the Thompson two-glass test in mild cases the first glass alone may show pus or shreds but in severe cases these elements are in both glasses. For this reason the author's seven-glass test is to be pre- ferred in that it distinguishes the contents of the anterior urethra from those of the posterior urethra and from those of the annexa. In anterior chronic urethritis the Anterior Urethral Glass will contain the contents of the canal and the Control Glass little or nothing. All other glasses are negative. The laboratory recognizes the gonococcus in the drop or shreds and the treatment verifies the other findings. Treatment. — Before the treatment of gonococcal chronic urethritis may be instituted, certain general principles must be laid dowTi and understood. They apply to the subject as a whole independently of whether or not the disease is in the anterior urethra or posterior urethra in its chief lesions. The preventive and abortive treatment are self evidently possible only in the proper management and gentle treatment of every case in prevention with strict cooperation on the part of the patient. It is well known that severe acute infections invariably have a chronic ' stage which is increased in intensity and duration by WTong treatment. Complicated cases are rather essentially chronic in their termina- tion as suitably detailed in Chapter V. Patients who debauch in food, drink and sexuality during treatment invite and induce chronic lesions as well as reinfections grafted on nearly cured conditions. Any infection which has persisted for about four months may be regarded as chronic. Abortive measures in the exact sense do not exist for the posterior urethra. 18 274 CHRONIC URETHRITIS Citratiir 7'/7Yj//??g/?/.— Intelligent application of suitable measures cannot be carried out ■without just knowledge of the needs of each case as embotlied in the indication. Methods of treatment are, as before, two: (1) The conservative or expectant, and (2) the irrigation, both of whose main features in technic are the following, varying with anterior and posterior urethral involvement . Management is the same for both methods of treatment of each portion of the canal and will not be again noted. Cooperation and obedience by the patient are essential. The tendency of the patient to depreciation and discouragement indicates hygiene in fresh air and all effort to a^■oid nervous unrest and indigestion with secondary phosphaturia. Rest in the sexual sense forbids intercourse during regidar treatment and restricts indulgence for a period after treat- ment has ceased, in order to avoid the congestion which excites inflam- mation and relapse. Indirect sexual excitement is very undesirable. Care sunilar to that in chordee will avoid seminal emissions. Bodily rest permits exercise wdthout exhaustion or congestion of the parts, but these restrictions are less definite than in acute disease. No exercise with vibration or great distiubance is advisable and the moderate forms, such as walking, are best. Hygiene must secure absence from the cause of catarrhal inflammation. Therefore alcohol and improper diet are interdicted. Regular habits of life and exercise avoid dissipation of the general health, strength and resistance. Patients with known dyscrasine should receive attention for them. Diet and drinks should be moderate and normal, of the nonirritating and nonconstipating tjT^es. No alcohol or highly spiced stimulating mixtures are allowed. There are, therefore, required relief of the chronic urethral dis- charge, control of the urinary disturbance, quiescence of sexual dis- order and prevention of complications and sequels. One sees three general classes of cases: (1) Intermittent discharge, which is absent during the use of hand injections and restrained habits of life, but present during cessation of home treatment and indulgence in im- proprieties in alcohol, food and sexual relations; (2) continuous dis- charge, which slowdy improves under treatment and usually occurs with anteroposterior lesions; (3) shreds which may be large or small, long or short, light or heavy and contain chiefly pus or little pus mingled with mucus and detritus, or practically pure mucus wdth or without much epithelia. A careful distinction of the bacteriology and source of all three forms of exudate is necessary and readily performed with the aid of the author's seven-glass test as noted under diagnosis. The physical measures include massage, hydrothera])y and electro- therapy. ^Massage is advisable only several weeks after ac'ti\'e symp- toms and is of little avail unless performed with an instrmnent in situ, such as a soft, lead-core dilator, a straight or standard urethral sound or preferably a Bangs syringe sound, because the massage and instillation may be combined at the one sitting. Its object is to GONOCOCCAL CHRONIC URETHRITIS 275 Tig. 64. — Passing a straight sound. "Gravitation" is the only step. The penis is held vertically in the left hand behind the glans while the lubricated instrument is allowed to fall of its own weight as far as the bulb with, only support in the vertical position by the right hand of the urologist. (Original.) Fig. 65. — Massage of chronic folliculitis. The left hand supports the urethra on the stretch, over the straight sound, wliich reaches the bulb. The right hand massages the urethra and its follicles along the instrument. (Original.) 276 CHRONIC URETHRITIS stimulate erosions, ulcerations and <;ranulations, to dissipate soft erosions and to evacuate mucous cry])ts — all ^vith gentleness and without secondary reaction and as preliminary of the instillation or as alternate Avith it e\ery five to seven days. Progressive benefit must follow this treatment as well as other measures or be abandoned. The instrmuent — dilator, straight or standard soiuid, or Bangs 's syringe sound — is passed to the bulb of the urethra ascertained with the finger on the perineinu. Gravity is the only force in passing these instnmients. The urethra is held on the stretch and the massage is gently performed along its coiu-se upon the shaft of the instrument. No pain or unfaAorable reaction should occur but only stimulation of the indolent nuicosa. ^lassage of the lu-ethra may also be performed Fig. 66. — Catheter instillation, supine posture. The Wolbarst basin is placed, the penis draped, the catheter passed and the instillation administered while the forceps holds the catheter under gauze against displacement and spatter. (Original.) with a bougie-a-boule — always the flexible, never the rigid type of instrimient — which is passed into the canal and repeatedly, rapidly but gently manipulated back and forth from meatus to bulb. Its size must not overstretch the canal. Hydrotherapy is of great value in allaying irritation, especially of overtreatment — instrumental, chemical, thermal or electrical. Heat or cold, according to tolerance and response, may be applied to the penis externally best in the form of baths in a large mug or to the urethra internally preferably by means of the syringe-and-catheter irrigations, as these are safest and gentlest. A straight urethral sound chilled in ice-water may be passed into the urethra and left there for five to ten minutes, every five to seven days, associated with other GONOCOCCAL CHRONIC URETHRITIS 277 measures, if found beneficial. Hydrotherapy, except through its heat or cold in irrigations and instillations, is not of great value. In the deeper inflammation, hot sitting baths for twenty to thirty minutes until the skin is red, followed by immediate rest in bed, are good, but must be repeated at least night and morning. Hot or cold rectal irri- gations through the double-current instrument of Kemp, or with two rubber rectal tubes passed, one for several inches into the bowel and the other just within the sphincter beside it, give relief. Normal salt solution is best, and is hot or cold, according to preference and tolerance of the patient and results. Fig. 67. — Various types of urethral sound. From above downward are the olive point, lead-core, woven, lisle-thread dUator; the straight anterior urethral sound; the Chetwood double-taper standard sound ; the author's short beak double-taper irrigating sound with obturator in the canal; the author's standard beak double-taper irrigating sound with the obturator below it; the author's short beak tunnelled and grooved irri- gating sound with the obturator in situ and the standard blunt point Benique sound. (Original.) The heliotherapy fulfils the same functions as hot-water treatment and decongests the parts. It is applied with the standard therapeutic lamp two or three times a day for half-hoiu- sittings until the skin is distinctly redder, as with a poultice, and the comfort of the patient promoted. It is of more service in deep-seated posterior urethritis and its complications, notably prostatitis and seminal vesiculitis, under which heading it is more fully discussed. The medicmal supplies are zinc chloride and copper sulphate solutions from 2 to 5 per cent. 27S ( •llh'OXIC VRF/rH RITIS Tlie fleet rot luM'a])y is i-itlier loeal or systemic. T/Oenl measures are ai)i)lie(l throuj;li tlie urethra or the reetum for germicidal, inhibitory and restorative elleets, and systt^mie tri'atment to the hody at large Fig. 6S. -Portable therapeutic lamp, efficient, convenient and serviceable, consisting of parabolic mirror and 60 c.p. lamp. for its stimulating action. The forms of current and the apparatus for developing and applying them advised by expert electrotherapeu- tists are the following, bearing in mind that much electrical equipment Fig. 69. — Metal and glass rectal electrodes. From above downward are the metal tipped hard rubber handle electrodes, respectively called elongated olive rectal electrode, elongated olive with flat face, seminal vesicular electrode, spoon-shaped prostatic elec- trode, hard rubber with metal face prostatic electrode. Then come the spoon-shaped x-ray vacuum high-tension glass prostatic electrode and the cone pointed instrument of the same type. on the market is so inefficient as to be toys. Failure with such outfits rests with the defects of apparatus and with the inexperience of the operator. GONOCOCCAL CHRONIC URETHRITIS 279 The equipment comprises machines and electrodes with accessories and medicinal supplies. The machines are of five types, developing galvanic, faradic, sinusoidal, static and diathermic (true high-fre- quency current of d'Arsonval) currents, l^^lectrodcs arc designed for the anterior and posterior urethra and the rectum. The anterior urethral instruments are of metal or glass. The metal type must be properly constructed and fully insulated, zinc or copper tipped, as shown in Fig. 70, and paragraphs on Electrolysis of Stricture. The glass type are fully insulated, high-vacuum (for localizing effect) instruments, as shown in Fig. 09. Posterior urethral electrodes are also of metal or glass. The metal forms are preferred and are curved instruments, with metal tips 1 to 2| inches long, of zinc, copper, alumi- num or silver. The glass type must also be curved, and are shown in Fig. 69. Rectal electrodes are made of metal or glass and the Fig. 70. — A and B, short and long curve sounds; C, long curve bougie-a-boule and C", conical points for the same; D, semicurve bougie-S,-boule and D', long cylindrical points for it; E, straight bougie-&,-boule and E', short cylindrical points for the same. former are by choice the elongated olive metal-tip instrument or the flattened olive (spoon-shaped) metal-tip electrode or the elongated olive hard-rubber instrument with a metal face. Glass is made up into the vacuum, fully insulated electrode, with flattened olive tip and exhausted to the .r-ray vacuum degree or into the same type of instru- ment with a conical tip. Of the two terminals used, one is the active electrode, which may be attached to either the positive or the nega- tive pole, according to indications, and the other is the indifferent electrode, most advantageously made of a gauze or sponge covered pad 5 by 8 inches. To ensure good contact it is moistened with warm water. The selection of case is very important. Acute urethritis contra- indicates electrotherapy until the subacute and declining stages are initiated, except perhaps diathermic measures, as stated later. Clironic 2S0 CHRONIC URETHRITIS manifestations invite this treatment, which is independent of idio- syncrasy. Clironic urethritis without infection and with the ordinary lesions present, such as erosions, ulcerations and soft infiltrations, requires the cataphoresis of galvanism. Chronic urethritis with infec- tion, nongonococcal or gonococcal, and any of the foregoing sequels indicates cataphoresis su]i]ileniented with the high-potential \'aeiunn electrodes. Diathermy is a newer doveli)])ment of ap])lying the true high- frequency (d'Arsonval) cm-rent locally for raising the temperature of the organs by closely wrapping them with malleable metal elec- trodes, because imperfect contact produces sparks and blisters. The final results of diathermy in acute cases are still sub jiuJice, but the subject should be mentioned here. General depression of health in indigestion, nervousness and imperfect elimination indicates stimulat- ing measures, as discussed under systemic application below. The piu"poses are, therefore, germicidal, penetration of medication, astringency and tissue massage, and each recpiires particular applica- tion through combination of machine, current and electrode. The local application is urethral or rectal or both. The direct or galvanic current from the street mains or from a large nimiber of batteries (both with j^roper controlling device and a reliable volt- meter and ammeter), is used in the anterior urethra with the metal- tipped electrodes described. By cataphoresis it deposits in the tissues oxychlorid of the metal tips employed so that the electrode is mildly consumed. This action is both germicidal and powerfully astringent. The electrode from the positive pole is passed into the urethra up to the affected points and the indifferent negative electrode is fixed on the abdomen or the back low down. The amount of current is 3 to 5 milliamperes and no more. Any metal astringent previously named under equipment may be soaked into several layers of cotton or gauze wrapped about the metal tip, but if iodin is selected the electrode must have a carbon tip and the negative pole must be within the urethra. The cataphoresis produces deep penetration. The iodin is dissolved in water from 1 in 10 to 1 in 4 parts and the application persists for five to ten minutes and is repeated every five days. Intense actinic or germicidal and mild roentgen-ray effects are produced by the insulated high-vacuum electrodes of glass energized from the nega- tive side of a high-speed static machine, while the positive side is grounded. The tube is applied at the affected points of the urethra in turn, and intensity is measured by a spark gap of from ^ to 1 inch and 0.5 to 1 milliampere of current on a reliable meter in series, with the negative side of the machine. Two to five minutes are the limit of duration, and one visit every five days is the frequency, with longer intervals as improvement occurs, but without change in the intensity and dura- tion of the treatments. The results should never be painful and with reaction of importance. There is no aftertreatment. The systemic application, on the same or different days as the local GONOCOCCAL CHRONIC VRMTIIRITIH, 281 treatment, will benefit the digestive, nervous and eliminating functions. The digestive system, for poor assimiljitioii urid constipation, requires the combined galvanic and faradic siniis(M