Columtjia ®nit)ers;itpi \ mtf)eCitj>of^etD|9orb ^ COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/venerealdiseasesOOhayd VENEREAL DISEASE A MANl Al. FOR STUDENTS AND IMIAOTITIONERS BY JAMES R. HAYDEN, M.D., F.A.C.S. PROFESSOR OF UROLOGY AT THE COLLEGE OF PHYSICIANS AND SURGEONS COLUMBIA UNIVERSITY, NEW YORK; VISITING GENITO-URINARY SURGEON TO BELLEVUE HOSPITAL; CONSULTING GENITO- URINARY SURGEON TO ST. JOSEPH'S HOSPITAL, YONKERS, NEW YORK FOURTH EDITION, THOROUGHLY REVISED ILLUSTRATED WITH 133 ENGRAVINGS LEA & FEBIGER PHILADELPHIA AND NEW YORK 1916 Entered according to the Act of Congress, in the year 1916, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. PREFACE. In the preparation of the fourth edition of thi.s manual, the author has endeavored to emphasize, as before, the practical, clinical aspects of the subjects under discussion. Only those methods of diagnosis and treatment have been included which the personal experience of the writer has proved to be useful and efficient. The number of illustrations has been more than doubled and the vast majority of them are original. The text has been completely revised and the greater part rewritten. The author takes pleasure in acknowledging his indebt- edness to Dr. Rolfe Kingsley, Assistant Chief of Chnic at the Vanderbilt Clinic, for his assistance in the revision of the text. J. R. Haydex. 121 West 55th Street, New York, 1916. CONTENTS CHAPTER I. Gonorrhea 17 CHAPTER II. Acute Gonorrhea 24 CHAPTER III. Treatment of Acute Anterior and Posterior Gonorrhea 32 CHAPTER IV. Complications of Acute Anterior Gonorrhea and Their Treatment 51 CHAPTER V. Complications of Acute Posterior Gonorrhea and Their Treatment 63 CHAPTER VI. Chronic Anterior and Posterior Gonorrhea .... 84 CHAPTER VII. Treatment of Chronic Anterior and Posterior Gonorrhea 89 CHAPTER VIII. Gonorrheal Ophthalmia 104 CHAPTER IX. Gonorrheal Arthritis 107 CHAPTER X. Stricture of the Urethra 115 VI , CONTENTS CHAPTER XI. Symptoms of Stricture 127 CHAPTER XII. Complications of Stricture 130 CHAPTER XIII. Diagnosis of Stricture 138 CHAPTER XIV. Treatment of Stricture 151 CHAPTER XV. Retention of Urine 176 CHAPTER XVI. Urin.vry Fever 185 CHAPTER XVII. Urethral Instruments: Their Care and Use .... 188 CHAPTER XVIII. Common Affections of the Glans and Prepuce .... 198 CHAPTER XIX. The Chancroid 208 CHAPTER XX. Syphilis 221 CHAPTER XXI. The Initial Lesion 228 CHAPTER XXII. The Secondary Period 236 CHAPTER XXIII. Syphilis of the Appendages of the Skin 263 CONTENTS vii CHAPTER XXIV. Syphilis of the Mucous Membranes 2f)7 CHAPTER XXV. Syphilis of the Digestive Organs 200 CHAPTER XXVI. Syphilis of the Respiratory Organs 278 CHAPTER XXVII. Sy'philis of the Organs of Circulation 282 CHAPTER XXVIII. Syphilis of the Genito-urinary Organs 284 CHAPTER XXIX. Syphilis of the Nervous System 288 CHAPTER XXX. Syphilis of the Muscles 296 CHAPTER XXXI. Syphilis of the Bones, Cartilages, and Joints .... 301 CHAPTER XXXII. Syphilis of the Ey^e 306 CHAPTER XXXIII. Syphilis of the Ear 314 CHAPTER XXXIV. Constitutional Treatment of Syphilis 316 CHAPTER XXXV. Hereditary Syphilis 336 CHAPTER XXXVI. Lesions of Hereditary Syphilis 339 VENEREAL DISEASES. CHAPTER I. GONORRHEA. INTRODUCTION. Gonorrhea, or specific urethritis, is a virulent, infectious, and suppurative process, attacking most frequently the mucous membrane of the urethra and the glandular struct- ures in anatomical relation with it. Gonorrheal ophthalmia, or proctitis, may occur during the course of a urethral gonor- rhea, the organism having been deposited upon one of these structures either as the result of accident or of un- natural practises in depraved individuals. Ophthalmia, or proctitis, may also be observed independently of urethral infection in the bearer. Cases of gonorrheal stomatitis and rhinitis have been reported, but as yet lack positive and sufficient proof, and therefore cannot be accepted without much reserve. Specific urethritis is the most common of all the \enereal diseases, is usually sexual in origin, and occurs with the greatest frequency between the twentieth and thirtieth years, although cases of gonorrheal infection are not infre- quently encountered in infants and young children, and the 2 18 GONORRHEA disease is also mot witli in middle-aged, and e\en elderly individuals. An attaek of gonorrhea confers no immunity upon its bearer, reinfection being followed by a reappearance of the disease with all of its symptoms often quite as severe as those of the initial or previous attack. As a rule, the intervening inUd attacks are, in reality, nothing more than a lighting up of an imcured and localized gonorrheal process, either in the in-ethra itself or in some of the glandular structures in relation with it; the exciting causes being alcoholic, dietary, and sexual excesses, non-specific secretions from the female genitalia, concentrated urine, rough instrumentation, irritating in- jections, violent physical exertion, or in fact, anything that in any way causes irritation and congestion of the urethra or its contiguous structures. Infection with the gonococcus may be cither direct or mediate. Direct infection consists in the transference of gonorrheal pus from the genitalia of one person to those of another during coition. This is the usual and most common mode of infection, although it may also result from unnatural sexual practises. Mediate infection may occur when instruments, syringes, towels, dressings, the fingers, or in fact, any articles that have been contaminated with gonorrheal pus are brought into contact with the meatus or urethral mucous membrane. While this method of infection is certainly rare, we should not be so dogmatic and skeptical as to deny its possibility. The author has seen a number of cases which permitted no doubts as to the disease having been acquired in this inno- cent manner. INTROD(/CTION 19 Etiology. — The exciting cause o!' tlic (lisc;is(; is a specific (lil)Ioeoccus discovered by Neisser ;unl luimcd hy liim the gonocoeciis. This organism is the exciting cause of every case of gonorrhea (specific urethritis). Cases of urethritis are ncjt uncommonly encountered, however, in which the gonococcus cannot be found. These infections are spoken of as non- specific or simple catarrhal, the suppuration being due to other microorganisms. The physician should therefore exercise the greatest care and common-sense in every case before giving a final and positive opinion as to its nature, as on his word may rest the honor and loj'alty of wife, husband, or consort. The gonococci are D-shaped organisms, measuring from 0.8 to 1.6 mmm. in length and from O.G to 0.8 mmm. in breadth. As seen under the microscope they occur in pairs, with the flat or inner borders in apposition, like the two halves of a coffee bean (Fig. 1). They multiply very rapidly under favorable circumstances, each pair splitting into four by means of cleavage at right angles to the median fissure. In gonorrheal pus they occur within and upon the phago- cytes and epithelial cells and scattered about between them, grouped in twos, fours, eights, etc., and never arranged in definite chains. They are readily found and recognized in the urethral pus of acute cases; but with increasing difficulty as the gonorrheal process becomes subacute and chronic, when it is then most difficult, and sometimes impossible, to dif- ferentiate them from other diplococci, except by culture experiments, which should always be employed in doubtful cases before giving a final and positive opinion as to the nature of a given diplococcus. 20 GONORRHEA In luakiiiu- a diagnosis by microscopic examination only those organisms which arc hiintccUidur slionid i)o considered. The method of oKtaining and staining the smear should be as follows: The entire glans penis and ])reputial ea\ity should be thoroughly cleansed, and the j)ns at the meatus squeezed Fig. 1. — Gonococci in the acute or suppurative stage. (OriKinal.) out and wiped off with sterile gauze. A sterilized platinum loop is then passed into the lu-ethra to obtain the secretion for examination, or a droj) of pus expressed from the meatus; this is spread in a very thin him on a clean glass slide or cover-glass, allowed to dry in the air, and is then passed through the flame of an alcohol lamp or Bunsen })urner two INTIIODUCTION 21 or three times, l)eiii<;- ciircl'iil to Iuiac llie pus siilc uppciinost. A few drops of a 1 ])cr cent, watery solulion of itietliylene blue are then a])j)lied, left on for a miinite, and then WMslied off with distilled water and the jm-paration (h-ied. The specimen can now be examined by means of ;i oiic-lwiH'lh inch oil-immersion lens, when all of the orfi;anisnis in the field will be seen to have taken on a deep blue c(jlor. Should intracellular organisms of the type described above be found, a second smear should be ol)tained and stained l>y Gram's method, as follows: The specimen having been fixed as before, l)y fhiniing, is stained for two minutes with either carbol- or anilin-water gentian violet; this is then drained off and the smear flooded with Gram's iodin solution for one minute. The specimen is then decolorized in alcohol, washed with distilled water, and counter-stained with 1 per cent, watery Bismarck-brown solution. If the intracellular diplococci in this smear ha^'e given up the gentian violet and are stained brown we can then be reasonably certain that they are gonococci, but the fact should never be forgotten that when the organisms occur only very scantily, or when any other cause for doubt exists, a final diagnosis should never be made without the assistance of cultures. Other diplococci have been found in the normal urethra which bear so striking a resemblance to gonococci as to general appearance and color reactions that in some instances they can only be differentiated by culture experiments; and as these latter are beyond the reach of many physicians, we cannot be too careful and conservative in giving an absolute and positive opinion as to the specific nature of a gi\-en diplococcus. For other methods of staining, and for culture and in- 22 , GONORRHEA noculation exix'rinu'iits witJi the gonococcus, tlic reader is referred to any of the standard works on bacteriology. Pathology. — When infection of the nretln'a by tlie gono- coccns occurs the invasion of the tissues proceeds as follows: The gonococci, having been deposited on the superficial layer of the lips of the meatus or of the fossa navicularis, increase rapidly in numbers and give rise to a scanty, serous discharge, which appears at the meatus and which consists of serum and epithelial cells, u])on and between which gont)cocci are seen in ^•arying numbers. This constitutes the first, prodromal, or serouft stage of the disease. The organisms spread more or less rapidl\' along the urethra by continuity of tissue, and at the end of twelve to twenty-four hours ])enetrate the cement substance between the epithelial cells and pass into the subepithelial connective-tissue layer and the blood^'essels. This stage of invasion is marked by the onset of a ])rofuse, purulent discharge and the destruction and casting-olf of the normal cylindrical epithelium of the urethra, thus giving free access to further gonococcus invasion, and marking the onset of the second, acute, or ■imrident stage. The puru- lent discharge is made up of pus and epithelial cells, serum, and sometimes a few red blood cells; the gonococci being found principally in the pus cells, although some free groups may be seen. After a period varying between ten days to two weeks the character of the discharge begins to change. It is less profuse, and from being thick and creamy becomes muco- purulent and sticky. At the same time the other signs of acute inflammation begin to abate, and the disease enters upon the third, subacute, or declining stage. The conges- tion and edema of the mucous membrane diminish from INTIIOIXJCTION 23 (I;iy to (lay, llic (liscliar<;(: hcromin^r corrcsiMHidiii^ly tliiiiiHT and scantier until tlu; fourth or chronic stage is rcadiffl, which is marked by a sliglit mucoid or serous disdiarj^'c, often visible only in the morning, vvitii a mucous membrane wliich is normal except for isolated spots of c-ongestion, erosion or sui)erficial ulceration, these marking the localities where the gonorrlieal process has become localized. Such areas are most commonly found in the bulbous portion of the canal, whlcli, being of larger caliber, surrouiuleil by erectile tissue, and from its dei)endent position, jxtorly drained, is particularly prone to harbor a chronic inflam- matory process. CHAPTER IT. ACUTE GONORRHEA. Acute gonorrhea is spoken of as })ein<2; either anterior or posterior, aeeording to the portion of the uretJira involved by the infiannnatory ])rocess. If the disease be situated in the anterior urethra — that is, between tlie meatus lu'inarius externus and the anterior layer of the triangular ligament (pendulous and bulbous urethrse) — it is ealled anterior gonorrhea; but if in the posterior urethra, which includes that portion of the canal situated between the anterior layer of the triangular liga- ment and the bladder (membranous and prostatic urethrse), it is called posterior gonorrhea. ^Vhen the entire length of the urethra is involved, as is usually the case, we then speak of it as an anteroposterior gonorrhea; and if the disease has extended into the bladder, in\()l\ing to a limited extent the mucous membrane sur- rounding the vesical orifice and trigone, it is known as a uvctln-ocystitis. ACUTE ANTERIOR GONORRHEA. After a period of incubation varying, in the majority' of cases, from two to seven days, the symptoms of acute anterior gonorrhea make themselves manifest. For clinical purposes the course of the disease is best di\ided into four stages, as follows: the prodromal stage, the acute stage, the stage of decline, and the chronic stage. ACUTE ANTl'naOU aONORRIl/'JA 2.) Ill the prodi'oiiiiil, or first stiii^^c, wliicli iii;iy last from ii few lioiirs to ii (liiy or two, the synii)toiiis iiia\' he (jiiitc severe, or so mild as often to escape notice. TJiey consist of pricking or tickliii}^ sensations in tli(; meatus, which becomes reddened, slightly swollen and glued together, or filled witli a scanty, serous sec;retion. Sometimes decided pain is felt in tlie glans, but in otJier cases jiain is only experienced during and after urination. At the end of a day or two all of the abov^e symjjtoms become more marked. The meatus is pouting in appearance and surrounded by a zone of redness, the secretion is increased in amount and assumes a decidedly i)urulcnt character, the pain is sharper and during urination gives rise to a decided burning sensation in the urethra, which is spoken of as ardor urintc; this may be continuous, or only felt during and after the act. With the onset of the second or acute stage, which usually begins at the end of twent^'-four to forty-eight hours, the discharge becomes profuse, greenish-yellow in color, creamy in consistence, and sometimes tinged with blood, the lips of the meatus and often the entire glans penis are bright red in color, hot and swollen; the edema may extend from the lower angle of the meatus into the frenum and thence into the prepuce, in this way being liable to produce either a phimosis or paraphimosis, according to the conformation of the parts. In se\'ere cases the lymphatics on the dorsum of the penis become swollen and painful, and as they communicate with the inguinal lymph ganglia these latter may become enlarged and tender; but they very rarely suppurate. As the gonorrheal process extends up the urethra it sometimes causes an inflammation of one or more of the periurethral ^6 ACUTE GONORRHEA t'olliclcs. which can he felt beneatli tlie skin as small shot- like botlies. In severe cases the corpus spongiosum becomes hard and i)ainfu], and it' this condition extends to the bulbous portion, patients experience great pain in sitting down and crossing the legs, as pressure is thereby brought directly on this swollen and inflamed mass of erectile tissue. Every act of urination is now accompanied by intiMise suffering as the acid urine forces its way through the urethra, whose caliber has been greatly lessened by the edema of its mucous membrane, from whose congested surface blood is some- times forced by the pressure of the accelerator urinse muscle on the erectile tissue of the bulb at the close of urination. The stream assumes \'arious shapes and sizes, and in severe cases comes only in drops, or there may be complete reten- tion of urine, due to swelling of the mucous membrane and compressor spasm. Painful erections, and in some cases, chordee now come on, especially at night, which rob the patient of his rest, and in this way cause debility and general malaise from loss of sleep, and nervousness. True chordee is due to infiltration of the meshes of the corpus spongiosum with inflammatory material, which prevents its full extension when the corpora cavernosa become erect, thus causing the penis to curve do^^^lward. It is a rare complication of acute gonorrhea, as compared to painful erections, which occur in almost every case. The third or declining stage usually begins at about the end of the second or beginning of the third week and is marked by a general improvement in the patient's condition. Urina- tion becomes less painful, the erections at night disappear, as do also the swelling and soreness along the corpus spon- giosum. The meatus and glans penis begin to assume their normal appearance, and the discharge becomes muco- ACUTE POSTERIOR GONORRHEA 27 purulent, tJiiiiiicr jiihI stickier in cliJiracter, until it is so slight in junount as to cause only a gluing of the lips of the meatus iu tJie morning, from wJiich, when sc^parated, a few- drops of secretion may be pressed. The further vuicorn- plieated course of the disease is indistinguishahic from that of chronic gonorrhea, and will he descrihcd nndcr lli;it head- ing in Chapter VI. Relapses may occur at any time, as the patient, thinking himself about cured, is apt to indulge in overexercise, alcoholics, indiscretions in diet, or sexual intercourse, which indulgence is rapidly followed by the return of many or all of the acute inflammatory symptoms described above. ACUTE POSTERIOR GONORRHEA. When the gonorrheal process passes beyond the anterior layer of the triangular ligament and involves the mem- branous and prostatic portions of the canal (posterior urethra), we speak of it as an acute posterior gonorrhea. In from 90 to 100 per cent, of all cases of acute gonorrhea the disease passes, quite rapidly, up the urethra to the bulb and thence into the posterior portion. Posterior urethritis, therefore, mstead of being a complication, is in reality part of the usual course of the disease in the vast majority of cases. This invasion of the deeper parts of the canal may take place so gradually and with such mild symptoms as to escape detection, unless we are on the lookout for it; but in the majority of cases it is indicated by a sudden and very marked decrease in the amount of discharge at the meatus, accompanied by an increased frequency in urination, with inability to hold the urine when the desire comes on (urgency) , followed bv vesical tenesmus, and in severe cases hx blood ::^8 ACUTE GONORRHEA ill the urine at the end of niieturitidii (terminal heinaturia), wJiieh comes from the eoiiiiested vessels of tlie i)rostatic urotJira, whicli are ruptured by the spasmodic contractions of the prostatic muscuhir fibres, at the close of urination. In sueli cases small, worm-like clots of blood, formed in the urethra during the intervals of voiding, are sometimes passed with the first gush of urine as it washes out the contents of the canal. In some cases the patient has to urinate every few minutes, each act being followed by a few drops of blood and intense pain in the glans penis, perineum, and rectum; in others there is temporary incontinence of urine, due to the extreme irritability of the prostatic mucous membrane, so that when the patient goes to sleep at night, painful pollutions occur that are sometimes blood-stained. Retention of urine may occur at any time from spasm of the compressor urethrse m-uscle brought on by the intense local irritation; we should therefore always be prei)ared to deal promptly with this distressing complication. Vesical tenesmus, if severe, is often accompanied by a temporary albuminuria, which disappears as the tenesmus subsides. In the mild cases our only way of detecting an involve- ment of the posterior urethra is by the frequent employment of Thompson's two-glass test, which is performed in the follow- ing manner: The patient passes the greater part of his urine into one glass cylinder and the remainder into another. If the disease is confined to the anterior urethra, the urine in the first glass will be cloudy, from the pus washed out of the anterior urethra, while that in the second cylinder will be clear, as it consists of normal urine from tlie bladder passed through a now clean urethra. Should the posterior urethra ACUTE POSTERIOR GONORRHEA 29 be involved, Jiowcvcr, tlie pus I'roiii it, escaping backward into the bladder, renders all tin; urine in lliut viscus cloudy; the urine in both eylind(>rs therefore' will be purulent and opaque, tlie first a, trifle more so than the second, as it consists of turbid urine from tJie bliidder ])lus the urethral secretion wfiieh it washes out. For tlie proj)er performance of tJiis test it is essential that the patient have at least 8 to ]() ounces of urine in the bladder, a well-marked urethral discharge, an(f that fie should pass the larger part of his bladder contents into the first glass. Under these conditions the test is of great diagnostic value in acute cases, but it is quite useless in subacute or chronic ones. As tlie opacity in a given urine is not always due to the presence of pus (pyuria), the following table of Ultzmann renders this subject clear in a very concise manner. By gradually lieating the upper lialf of tlie urine (in a test-tube) to boiling, the opacity: Vanishes. Increases. Remains un- changed even after addition of acetic acid. If due to acid urates. If due to earthy jihosphatcs, pus corpuscles. Add one or two drops of acetic carbonates, acid. or The dimming is caused by catarrhal secre- tion, or by bac- teria. Dimness van- ishes with evolution of Dimness van- ishes without evolution of Dimness re- mains un- changed : gas: Carbonates. (Carbonaturia.) gas: Phosphates. (Phosphaturia.) Pus. (Pyuria.) 1 30 ACUTE GONORRHEA The duration of the attack depends hir[>;ely ujjoii the treatment employed and the habits of the patient. Acute posterior gonorrhea is apt to be very severe and rebelhous to treatment in ])ersons who have a previously congested condition of the deej) uretlu'a, prostate, or seminal vesicles, either as the result of sexual abnormalities or ex- cesses, or a previous gonorrheal infection of these structures. Diagnosis. — The diagnosis of acute gonorrhea is, as a rule, readily made from the history of the case, the purulent urethral discharge, which should always be examined microscopically for the gonococcus, the redness and swelling of the meatus and glans, painful urination, and the period of incubation. There are cases, however, in which it must be difl'erentiated from balanitis, balanoposthitis, chancre of the meatus or urethra, and chancroids of the meatus. In balanitis or balanoposthitis, if the ])repuce can be retracted far enough to expose the meatus, the parts should be carefully wiped off and examined, when a correct diagnosis can easily be made, as the pus will be seen to exude, either from the meatus if it be gonorrhea, or from between the prepuce and glans if it be balanitis or balanoposthitis. Chancre of the meatus or within the urethra gives rise to a slight watery, mucous, or mucopurulent discharge, with induration of the lesion and of the inguinal lymphatic glands at the end of about ten days. Endoscopic examination will reveal the lesion if it be situated in the canal. As the indura- tion about the lesion develops, there is increasing difficulty in urination. ^Microscopic, dark-field examination of the discharge will exclude the gonococcus and may reveal tlie presence of the Spirocheta pallida. Chancroids of the meatus cause a purulent discharge ACUTE POSTERIOR GONORRHEA 31 which is auto-iriocuhible. Tlicy may ffivc rise to soino inflammatory thickening of the surrounding tissues, but never to true inchu'ation. The inguinal glands are more or less painful and enlarged, and may even go on to suppuration and abscess formation. Prognosis. — The prognosis of gonorrliea is, as a rule, good, provided the patient is otherwise healthy and is willing to carry out minutely all the details of an intelligent and conservative treatment until he is pronounced cured by his physician. There are cases, however, in which serious and sometimes even fatal complications occur, such as gonorrheal synovitis, tenosynovitis, bursitis, myositis, arthritis, peri- and endo- carditis, peritonitis, meningitis, and pyemia. We must therefore explain to our patients that gonorrhea is at best a grave, persistent, and far-reaching infection, and that treatment must not be relaxed until the urethra and the structures in anatomical relation with it have been returned to their normal condition. If during the course of a case of acute posterior gonorrhea a digital examination of the prostate gland is made by rectum, it will frequently be found swollen, hot, throbbing, and exquisitely tender (acute prostatitis). Occasionally one or even both of the seminal vesicles may be involved, but this complication is rare in comparison with prostatitis, as has been demonstrated by a large number of examinations made by the author during the acute stage of the disease. CHAPTER III. TREATMENT OF ACUTE ANTERIOR AND POSTERIOR GONORRHEA. The treatment of acute anterior gonorrliea (l('])eii(ls entirely upon the stage of the disease at \vhieli the ])atient presents himself to the physician. If in the prepurulent or serous stage, some form of aborti\-e treatment may be employed. If, however, the disease has reached the i)urulent stage, then a milder and more sympt(Mnatic ])laii should })e instituted. Abortive Treatment. — The abortive treatment of acute gonorrhea or specific urethritis should only be employed during the first day or so of the disease, while the diseluirge is still serous in character, and shows under the microscope only epithelial cells and gonococci, but no pus cells, as in this stage the gonococci are situated upon the epithelium of the urethra and are therefore in a ])osition to be destroj'ed by local applications. Unfortunately the vast majority of ])atients do not present themselves until the discharge has become purulent, when it is too late to try any form of abortive treatment, as by that time the gonococci have penetrated the epithelial layer of the urethral mucous membrane and arc therefore to a great extent beyond our reach. It can readily be seen, therefore, that but few patients will seek medical advice early enough to justify our attempting to abort the disease. A HO irn VK TiacA tmhn t 33 However, if after a ciircriil inicroscopie s1ii(l\' of 1 lie di-^cluirjfr-, the abortive treatment has been decided upon, the put lent should always be informed that it is more or less pninlul, apt to fail, and may lead to such {•otii])lieatioiis as periurethral abscess,. posterior urethritis, ei)ididyiiiitis, ])rostatitis, seminal vesiculitis, abscess of tJie i)rostate, and cystitis. The steps in the })rocedure are as follows: Tiic patient having voided his urine, thus washing out any accumulated secretion, lies down. The meatus and glans i)enis are washed with sterile water and a small (10 to 12 French) Fig. 2. — Author's four-ounce bladder syringe and coupler. soft-rubber catheter is passed into the urethra for two or three inches, the patient compressing the canal firmly behind this point to prevent the backward passage of fluids. Through the catheter by means of a four-ounce hand syringe (Fig. 2), the canal is irrigated with warm, sterile water, thrown in slowly and gently, the solution running from be- hind forward, alongside the catheter and escaping at the meatus. After this thorough irrigation of the canal the catheter is very slowly withdrawn while we inject through it, with an instillation syringe (Fig. 3), a drachm or two of a solution of nitrate of silver, 10 to 15 grains to the ounce. 3 34 ACUTE ANTERIOR AND POSTERIOR GONORRHEA The fossa navicularis and adjacent portions of the urethra, which are the seat of tlie disease at this period, are thus thoroughly medicated with the silver solution, and the gonococci, situated upon the surface of the mucous mem- brane, are destroyed. If so desired, we may substitute for the nitrate of silver solution a 10 or even 20 per cent, solution of protargol, which is almost as efficacious and not so irritating. Argyrol and the various other so-called "organic" silver preparations have not proved as efficient in the author's experience. Fig. 3. — Author's instillation sj'ringe. The patient is now instructed to rest as much as possible, put upon a light, non-irritating diet, both as to solids and liquids, and the urine rendered bland by still waters and alkaline mixtures. The bowels are moved freely by means of cathartic pills, and the penis and preputial cavity kept clean by frequent immersions in hot lead-water or hot bichloride solution, 1 to 5000. The silver application is followed in a short time by painful urination and a purulent discharge, which, if the treatment be successful, subsides in a few days, leaving the patient with a slight muco- purulent exudate, which is readily controlled by astringent hand injections. If, on the other liand, the treatment has failed to abort the disease, then the discharge continues, showing under the microscope gonococci and pus cells in ABORTIVE TREATMENT 35 increasiiifi; iiiiiiihci-s, tJic case now presenting llie flinifal ])i('tiiro of tlic acute or sup])urative stage, in wliieli e\cnt all further attempts at abortive treatment siicjuld he ahan- doned. It should not be forgotten that this procedure is exceedingly irritating, and should never be resorted to if there is the slightest indication of the discharge having become purulent. Cases have been reported in which the use of this method, after the onset of the purulent stage, has resulted in more or less sloughing of the mucous membrane of the anterior urethra. The Janet method of aborting and treating acute gonorrhea has been much in vogue, but its popularity at the present writing seems to be decidedly on the wane. Its advocates claim that it will abort the disease in its incipient stage, and cut short the period of acute suppuration if employed at a later date. Ten or twelve treatments are said to be suf- ficient to accomplish a cure. Warm solutions of perman- ganate of potash are used for the irrigations, and vary in strength from 1 to 4000 to 1 to 1000, and even up to 1 to 500 during the declining stage. Janet uses an irrigator or fountain syringe with several feet of rubber tubing, to which is attached a conical glass nozzle; a stopcock on the tubing controls the flow of the fluid. The patient, having urinated, lies on his back or reclines in a chair, and the glass nozzle is inserted snugly into the meatus and the fluid turned on. The irrigator is raised two feet above the level of the patient if the anterior urethra alone is to be treated, but if the posterior uretlira and bladder are to be medicated, it is elevated about five feet or even higher, so as to increase the pressure and force of the flow, which in a few minutes tires out and overcomes 36 ACUTE ANTERIOR AND POSTERIOR GONORRHEA the compressor urethra' muscli' and \ (>si(al sphincter, which, rehixinjj, allow the solution to enter tlie deep urethra and bladder; when the bladder is distended, the irrigation is stopped, and the j)atient, standing, voids the solution by the urethra. These irrigations iwv given onee or twice daily, one pint being used for the anterior nretJn"a and two i)ints when the posterior urethra and bladder are to be medicated. Although this method does cause a rapid cessation of tlie purulent discharge, as is claimed by its advocates, it is liable to cause more or less dilatation of the glandular struct- ures which open into the urethra, and also to leave the canal in a thickened, congested, and irritable condition, which gives rise to a watery or mucoid discharge, very difficult, and in some cases, almost impossible to cure. Spasm of the compressor muscle, and even of the muscular layer of the anterior urethra, is frequently observed following this treatment; as is also an intensely congested, hard, and painful condition of the prostate gland. I have seen a large number of patients suffering from the above conditions as a result of this treatment, all of them informing me that the method was uncleanly and painful, and a few stating that the irrigations caused quite a con- siderable oozing of blood from the meatus. The above facts are not to be wondered at when one considers the force and strength of the solution rushing through and distending such an acutely iiiHanied and delicate canal as the urethra is at this time; also, the injurious effect of overcoming by hydraulic pressure the delicate musculature which guards the deep urethra and bladder, to say nothing of the parts beyond. If so desired, the bladder and urethra may be irrigated with a small soft-rubber catlieter and hand s\'ringe, and TliMATMKNT OF Til/'] A(:iITI<: STAaE :]7 most Siitisl'iictory results ohtiiincd without fiiiisiii|j; f i;iiiiii;i- tism iiiid iiicrciiscd coii'^'cstioii of llic imirous incnihriinc, with injury to tlic {■iit-olV iiiid |)n)stni])('i-atur(' ol" 105'^ to 107° .1''., rclicivcs to a j^rcat extent the feeliii};' ol' soreness and stitt'iiess in the j^roins, jjenis and along the hulh, and may he taken once or twice diiilx . Fig. 9. — Dressing complete. The bowels should be kept freely open, preferably by cathartic pills, as saline purgatives are apt to produce more or less urethral irritation, owing to their content of mag- nesium sulphate. It is extremely important to warn patients of the danger of infecting the eyes, and impress upon them the gravity of such an accident; also the danger of contammating water- 42 ACUTE ANTERIOR AND POSTERIOR GONORRHEA closets, baths, towels, etc., and in this way causing the infection of others. To render the urine l)land and uon-irritatiui;-, the patient should drink freely of any still water, a glassful every hour Fig. 10. — Gauze bag for acute urethriti.s. (luring the day and whenever he wakes at night. He should also be given one of the following alkaline mixtures: I) — Potass, bicarbonat., 5J Tr. hyoscyam., 3ij-iij Aq., ad gviij — M. Sig. — 5ss in water one hour after each meal and at midnight. I^ — Potass, acetat., 5j Syr. anrant. cort., 3ij Aq., ad gviij— M. Sig. — 5ss in water one hour after each meal and at midnight. TItKATMIiNT OF Till': DliCLlNINd STACK 43 l\)V the prevention of i)ainful erections, tlie patient sJiould he instructed to omi)ty his l)]a(l(ler just before retiring, and to sleep on Jiis side on a Jiard mattress, with as hglit covering as possible. If awakened by an erection he can usually o})tjiiii idicf by emptying the bladder and by cold ai)])lic;itions to tlic penis; occasionally, however, heat will be found more beneficial. Internally, we may prescribe monobromide of camphor, potassium bromide, lui)ulin, or medinal. If these drugs do not relieve, we may be compelled to resort to suppositories of opium, or opium and belladonna; but these should never be used unless absolutely necessary, as they may have to be continued for some time, are constipating, and more or less depressing in their after-effects. Treatment of the Declining Stage. — When as a result of the above treatment the very acute inflammatory symptoms begin to subside, as is indicated by a diminution and thin- ning of the urethral discharge, less pain on urination, and a decrease in the redness and swelling of the meatus, it is time to begin the careful and judicious use of bland and non- irritating injections, administered by the patient himself (hand injections) ; or better still, warm medicated irrigations given daily or every other day by the physician. In all cases when a hand injection is ordered, the patient should be told what kind of a syringe to purchase, and how to use it. A good urethral syringe is made of smooth, highly polished hard rubber (Fig. 11), or rubber and glass, with a bluntly conical tip (Fig. 12) ; it holds from two to four drachms, and the plunger should work smoothly and easily. These syringes are sometimes made with soft-rubber 44 ACUTE ANTERIOR AND POSTERIOR GONORRHEA tips, but they possess no praetieal adx ;iiit;i<;'e oNcr the :ill- liard-rubber or ghiss ones, and cannot be kept as clean. A ghiss syringe with conical tip (Fig. 13) is much less expensive than rubl)er, and at the same time quite as good, and can tlu'rcfore be used in hospital and disjx'nsary work, Fic. 11. — Hard-ruhliiT iiii'tliial s.\iingc. Viu. 12. — Haiio\er urethral s>riu^c. Fig. 13. — Glass urethral syriiigo. Fig. 14. — Hard-rulihor syringe for small meatus. where the item of expense is an important one. TJiis syringe is also made with a soft-rubber conical ti]). For patients with a very small meatus a hard-rubber syringe with a small, nipple-shaped point, may be ordered (Fig. 14). Hand injections are given as follows: The patient urinates, TREATMENT OF TIIE DECLININC STAdE lo wijx'S the iiK'Jitiis with a. hit of g;iii/,c, :iii(i stjiiKniifi; ii|) uith the penis on liic stretch niid ;it, right iinfflcs to 1iic t)0(|y, gently inserts tJie nozzle of the eojnijietcly filled syringe into the meatus, the lips of wliicli are lightly pressed together from side to side against the syringe; the solution is then thrown in slowly until there is a feeling of distention, when it may be allowed to escape, or if not too uncomfortable, kept in for a minute or two. While the fluid is being in- jected the patient should contract the compressor urethrse muscle, much as if he were trying to hold back the contents of the bladder, in order to prevent the passage backward of any of the medication into the posterior urethra. Iland injections should be taken two or three times daily, beginning \\\t\\ a warm solution of sodium chloride (1 per cent.), boric acid or lead-water, and after a day or so, with the following formulae used in the order here given: (1) I^ — Zinc, acetat., gr. xij Liq. plumb, subacetat., 3j Aq. destillat., ad gvj Or (2) I^— Zinc, sulphat., Plumb, acetat., aa gr. vj-xij Aq. destillat., ad 5vj Or (3) I^ — Zinc, sulphat., Aluminis, aa gr. vj-xij Aq. destillat., ad gvj and, later (4), potassium permanganate solution, beginning w^th 1 to 8000 and increasing the strength gradually up to 1 to 3000 or even 1 to 2000. The newer silver salts, argyrol, protargol. albargin, etc., have been highly recommended as hand injections, but have 46 ACUTE ANTERIOR AND POSTERIOR GONORRHEA not i)rc)M'(l as effective, in tlie author's experience, as the formula? given above. If the hand injection causes irritation, as it sometimes does, it must be discontinued for a time, until the irritation has abated, and then resumed cautiously, using a weaker c Fig. 15. — Soft-rubber catheters. solution than that employed when the signs of irritation developed. If, however, the patient can come to the surgeon every day during the subacute stage, great benefit will l)e derived from the use of warm and soothing irrigations tin-own into the bulb of the urethra, instead of the hand injections above alluded to. Fig. 16. — Bulbous catheters. These irrigations are gi\'en daily, or every other day, and if properly employed will materially lessen the duration and severity of the attack. The patient, having urinated, stands or reclines, and the operator passes a small soft- rubber or bulbous silk catheter, properly lubricated (Figs. 15 Tlil<:ATMI<:NT OF Till': I>I<:CLININ(1 STAdh: 47 and l(>), into the l)iill), aiid injects I'roni fonr to (rif^ht onnocs of warm medicated fluid, slowly and f^cntly, l)y means of a four-ounce SN'rinf^e and coupler (Fig. 2). In tliis manner the solution waslies out and medicates the entire anterior urethra and escapes at the meatus, where it is caught in a basin (Fig. 17). We may use for this purpose warm solutions of boric acid or lead-water, and later, weak solutions of Fig. 17. — Urethral and bladder irrigation. (.Original.; zinc sulphate, alum, permanganate of potash, and finally nitrate of silver. In the decHning stage great benefit is derived from the intelligent use of the antiblennorrhagics, given in full dose and for a limited period only. They should never be given during the acute or chronic stage of the disease. Of these the pure yellow santal oil is by far the best: it is put up in five- and ten-drop capsules, of which one or two are given an hour after meals. If the santal oil is not obtainable or is not well borne by the stomach we may substitute capsules 48 ACUTE ANTERIOR AND POSTERIOR GONORRHEA of copiiil);!, or a (•oinl)iiiatioii of co]);!!!);! ami culx-hs, wliicli sometimes prove of value, tlioiiuli not as eflic-acioiis as tlie oil of saiidahvood. If, as is sometimes the ease, the antihlciiiKurlia.uics cause gastro-intestinal disturbances, cutaneous rashes, or renal congestion Avith pain and uneasiness in the lumbar region, and even albumin and hyalin casts in the urine, they must be discontinued for a time, and when resumed, taken in smaller quantity. When the discharge decreases in amount and becomes sticky and mucoid in character, it is well to discontinue the use of these remedies, as they are apt, if continued for too long a period, to delay the cure by overstimulation and irritation of the urethral mucous membrane. If the foregoing treatment has been successful, as it usually is in the majority of cases, the patient now has but a trifling urethral discharge, sometimes only seen in the morning, with flakes and shreds and j)erha})s a little free pus and mucus in the lu'ine. The treatment for this condition is so similar to that for chronic gonorrhea or urethritis that the reader is referred to Chapter VII, w^here all the details will be found fully described. TREATMENT OF ACUTE POSTERIOR GONORRHEA. As soon as the symptoms of acute posterior iiuohement develop all injections and other instrumental treatment of the urethra must be suspended. • The i)atient should be ke])t very quiet and, if i)ossil)le, put to bed for a few days, on a light, nutritious diet, with the testicles properly supi)orted. Tlie bowels nnist be kept freely open, as any fecal accumulation in the rectum is TREATMENT OF ACUTE POSTEJUOU. (lONOHKII EA V.) liable to irritate; tlic infhiincd ('|) iin'tlirii ;iii(l |>rostate ji^land. Antihlcnnorrhagics are stopj^ed, iiiid in llicii- ]>lae(; one of the following forniuhe is given: ^ — Potass, citrat., 5J Tinct. hyoscyam., 5ij-iij Fid. ext. kav. kav., 5ss Aq., ad gviij — M. Sig. — 5ss in water one hour after each meal and once during the night. I^ — Fid. ext. trit. repens, Fid. ext. uvae ursi, aa. giss Potass, citrat., 5ss Aq., ad giv — M. Sig. — 3J~iJ in water one hour after each meal and once during the niglit. Still water may be taken in moderation. Hot-water bags over the bladder and on the perineum give relief, as do also rectal injections of hot saline solution at a temperature of 115° to 117° F.; or the hot sitz bath. If these means do not control the frequency in urination, pain, and tenesmus, we may be obliged to resort to opium suppositories in a guarded manner, using just enough of the drug to keep the patient comfortable. If retention of urine occurs, it should be promptly relieved by catheterization with soft-rubber or silk catheters, as described on page 93. When the frequency in urination, vesical tenesmus, and other acute inflammatory symptoms begin to subside, we may then carefully resume local urethral treatment, and allow the patient to be up and about. There are some cases, how^ever, which in spite of the above treatment show no improvement, as to their acute symptoms continue unabated for days and even weeks. In this class of cases great benefit will sometimes be 4 50 ACUTE AXTERIOh' AXD I'OSTEIUOR GONORRHEA derived from the judicious use of small irrigations of warm boric acid or salt solution thrown into the deep urethra and bladder by means of a soft catheter and four-ounce syringe. It is always ad\isable in acute posterior gonorrhea, but especially in the severe cases, to make occasional rectal examinations of the prostate, seminal vesicles and bladder base, as by this exploration we learn their true condition, and are i)repared to treat efficiently and i)ronii)tl>' any \ms- formation that mav occur in or about these structures. CHAPTKR IV. COMPLICATIONS OF ACUTE AXTEIUOK (;().\()li- RIIEA AND THEIR TREATMENT. BALANITIS. Balanitis is an acute or chronic inflammatory process, attacking the mucous membrane of the glans penis, and if accompanied by inflammation of the mucous membrane lining the prepuce, is called balanoposthitis. It is caused by inicleanliness or by allowing smegma or gonorrheal pus to collect beneath the foreskin, where it sets up more or less inflammation. The condition usually occurs in persons with a long, tight prepuce, a condition which prevents retraction and proper cleansing of the parts. The mucous membrane becomes red, thickened, and covered with a thin, purulent, and very offensive secretion; this is followed by swelling of the glans penis, which may be covered with irregular patches of excoriation; these, if untreated, may go on to superficial ulceration. Treatment. — The parts must be kept absolutely clean by washing in hot water, or hot bichloride solution (1 to 5000), and separated by means of absorbent gauze wet in a weak solution of sulphate of zinc, lead-water, or boric acid. (See Figs. 6, 7, 8, and 9 — slit gauze dressing.) When the acute process has subsided the preputial cavity may then be treated by careful cleansing and drying, and the application, night and morning, of a dusting powder composed of equal parts of aristol and powdered boric acid. 52 . COMPLICATIONS OF ANTERIOR GONORRHEA If the i)r(.'i)uct' cannot be retracted, the subpreputial space may be washed out with any of the above solutions, or plain hot water, these being injected with an ordinary hand syringe or irrigator. If there is considerable swelling of the prepuce and glans penis, the patient must be kept on his back, with the penis enveloped in gauze, wet in cold lead-water, bichloride solution (l to 5UU0), or aluminum acetate solution. When, as a result of the above treatment, the parts have returned to a normal condition, circumcision should be strongly advised. PHIMOSIS. Phimosis is that deformity of the prepuce which renders its retraction behind the glans penis impossible (Fig. 18). The condition may be congenital or acquired; the latter results from a balanitis or balanoposthitis, M'hich by its irritation causes edema, redness, and swelling of the j)repuce, this swelling becoming so great as to cause narrowing of the ])reputial orifice. The patient should be kept very quiet, in bed if possible, and the cavity of the prepuce thoroughly irrigated several times daily with hot bichloride solution, 1 to 5000. It is well to keep the penis enveloped in absorbent gauze, which is constantly wet with cold lead-water, mild bichloride solution, boric acid, or aluminum acetate. Congenital phimosis is frequently complicated by bands or adhesions running between the glans and the inner surface of the prepuce, and may or may not give rise to mild or \ery severe attacks of balanoposthitis, with painful and annoying manifestations. (For the further discussion and treatment of this condition see Chapter XVIII.) /'AUAI'If/MOS/S 53 III acqiiii-cd pliiinosis, Jil'ter tin; acute coiKlititdi Im-^ snl)si(]o(l, circiiincisioii should he strongly iulviscd us the only guarantee against ;i ])ossil)le return oF the aft'cetion. (See Chapter XVI II.) Fig. is. — Phimosis. (Author's case.) PARAPHIMOSIS. Paraphimosis is that condition in which the prepuce has been retracted or has slipped behind the corona glandis, and cannot be readily brought forward (Fig. 19). The small preputial orifice, which is now pushed back behind the corona, forms a band of constriction on the dorsal 54 COMPLICATIONS OF ANTERIOR GONORRHEA siirfacr of the poiiis, wliicli, prcxcutinti; I't'tuni circuliition, causes more or less deformity of the orjiaii from edema. This strangulation of tlie penis may develop rai)idly or gradually, and when well established, causes great dis- comfort, and if neglected, may even go on to nlccratiou and gangrene of the prepuce and glans ])enis. Fig. 19. — Paraphimosis. (Author's case.) Treatment. — The first requirement in the treatment of this condition is immediate reduction of the deformity. This can often be accomplished in the following manner: The organ is thoroughly washed and dried, then with the two thumbs pressing on the end of the gland, and the index and ring fingers l)ehind the constriction and corona (Fig. 20), the blood is entirely massaged out of the glans, which, being thus reduced in size and softened, is pushed back through the constricting ring and the prepuce drawn forward. PARA I'll fM()>S/S f)') Should tJiis procedure liiil, owiiii;' to the 1 i;;ht iiess of the coiistrietioii, ii siiiiill, loii^it iidiiiiil incision must he ninde coniplctcly throu^'Ji tJic constrictinj; hiind, on tlic dorsal surrace, after whicJi tlic <^laiis can Ix; reachls- reduced and the i)rei)iice IjrongJit forward, the Htth- woinid heiiif^ dresserl witli sterile g'auze, and the prc])ntial ca\ity ke])t clean. Fig. 20. — Reduction of paraphimosis. As both these procedures are Hable to be more or less painful, it may be necessary in some cases to give the patient a general anesthetic; a few ^yhiffs of gas answering the purpose. Usually, however, a local anesthetic, such as 1 per cent, cocain or novocain, will be all that is necessary. In some cases freezing of the parts with the ethyl chloride spray will answer the purpose perfectly. 50 COMPLICATIONS OF ANTERIOR GONORRHEA PERIURETHRAL ABSCESS. Periurethral abscess occurs on tlie luuler surface of tlie penis, anywliere between tlie frenum and the penoscrotal junction, the region of the freninii being the fa\'orite location. The abscess may be either uni- or bilateral, the latter l)eing especially frequent near the frenum (Fig. 21). Fig. 21. — Pciiiucthral abscess. (Author's case.) This condition occurs as a conii)licati()n of both acute and chronic gonorrhea, and is the result of infection of a peri- urethral follicle, which, as a rule, goes on ra])idl>' to abscess formation. It appears at first as a small, hard mass, but when fully developed it Jias all tlie characteristics of an ordinary acute abscess. If very large, it may impinge on the caliber of the urethra anfl cause more or less obstruction to urination. FOfjjcr/fjTis 57 Treatment. I'iiiiciils siin'('riii<;- IVoiii lliis rdiidii ion -lioiiM l)C kept very quiet oi- |)nt to hcd, uml ;ill injections and instrumental treatment of tJie uretJira st(>j>j)ed for a time. The inflamed parts should be kept at rest and covered with cold lead-water, alum acetate solution, or jtidiloiidc of mercury solution, 1 to r)()()(). In some cases tJiis may lead to a disappearance of the swelling!;, l)ut recurrence is the rule rather than the exce])tion, esj)ccially with ii frcsli in- fection or an exacerbation of the urethritis. If suppuration occurs, the abscess should be laid freely open, swabbed out with pure phenol or tincture of iodin and packed with sterile gauze. It is important to remember that these abscesses should not be opened until suppuration is well advanced, as by that time the urethral orifice of the follicle is closed by a plug of inflammatory material, which prevents the urine from leaking into the abscess cavity, and causing a urinary fistula, which is very difficult to cure in this region. FOLLICULITIS. Folliculitis may occur at any time during the course of a urethral gonorrhea, and is due to infection of one or more of the little follicles which are situated between the layers of the prepuce (Fig. 22), either on its sides or dorsum, opening on its free border or on its mucous surface, or of those on the under surface and near the median line of the penis, even as far back as the scrotum. In the acute stage the tissues about these follicles are acutely inflamed and frequently a small drop of pus exudes or can be pressed from the tiny orifice of the abscess ca^-ity. If neglected, the infection passes into the subacute and then 58 COMPLICATJOXS OF ANTERIOR GOXORRIIEA iutt) the cliniiiit- stagt', and if unrccouiiiziMl or uiitrcati'd, is very liable to lead to the infeetioii of women and to eaiise auto-infeetioii of the bearer. Treatment. — The parts should l)e cleansed in the usual manner, and affected follicles resected under local anesthesia, and a light dressing a]i]ili(>d. Fig. 22. — Preputial loUiculiti.s. (Author's case.) Paraurethral FoUiculitis. — 1 )uring the course of a urethral gonorrhea the follicle in either one or both lips of the meatus may become infected from the urethral discharge, thus giving rise to a small abscess, from the minute orifice of which a little drop of pus escapes or can be pressed. In some cases the follicle forms a sinus, opening on the mucous membrane of the fossa navicularis, thus constituting a true urinary fistula. This form of folliculitis, if uncured, may COWVKIIITIH 59 ciuisc the iiircclioii of vvomcii uiid Miito-iiifcct ion ol' llic in- dividual hiinscir. In many cases ol' jx'riiirctliral al)Sf»'ss, and of paraurctliral folliculitis which \vc have exairiiiied, gonococci have been demonstrated, holh })y niicroscoi>i(; examination and culture experiments, in the abscess and urethral pus. Treatment. — The little abscess must be laid freely open, curetted, and the raw surface touched with ])urc phenol, ji;reat care being taken to avoid cauterization of the ad- joining mucous membrane. COWPERITIS. Cowper's glands, like the urethral follicles, may be the seat of abscess formation, the urethral infection traveling down their ducts, which open on the floor of the bulb, the glands themselves being situated between the anterior and posterior layers of the triangular ligament in the substance of the compressor urethrse muscle. As a rule, but one gland is affected at a time. At first the abscess is situated in the perineum on either side of the median line, but if large it may break through the anterior or posterior layer of the triangular ligament and burrow forward or backward a long distance along the urethra, and by pressure on the canal, interfere markedly with urination, or even cause complete retention (Fig. 23). We have recently seen a case in which the abscess not having been incised, a cyst had formed which resulted in chronic and complete retention lasting nearly two years, necessitating catheterization four times a day during that entire period. Excision of the cyst afforded complete relief. 60 COMPLICATIONS OF ANTERIOR GONORRHEA Treatment. — WIrmicmt ;i cowptTitis develops tlio patient must 1)0 kept in bed, and all urethral instrunu'iitation stopped. If fluctuation cannot ho dotoctod, cold load-wator, aluminum acetate, or bichloride of nurcury solution, applied locally, may cause resohition in some cases; if, on tiio other hand, fluctuation can he j)hiinl> felt, the ])ns must ho im- modiatolv evacuated. Fig. 2.3. — Suppurative" fowporitis, left .side. (Author's cawc.) The patient, having been anesthetized, is properly pre- pared for operation and placed in the lithotomy position. A full-sized sound is then passed to the deep urethra, and held there directly in the median line by an assistant, thus rendering the urethra prominent and preventing it from being cut or injured during the operation, as in many of those ADENITIS 61 cases, after evaciuition of the abscess, the hull) of the nretliru can he (hstiiictly seen haiif^iiig in the wound, and is tlius rendered liable to injury if not made prominent by a sound. The abscess is then freely incised; if burrowing has occurred in any direction, it must be followed up by free incisions which thoroughly efface all blind pockets or cul-de-sacs. The nbscess cavity is then irrigated with bicliloridc; of mercury solution, packed lightly with sterile gauze fto prevent pressure on the urethra, with consequent retention of urine), and covered with a large dressing, held in place by a T-bandage or double spica. LYMPHANGITIS. Inflammation of the lymphatic vessels of the penis may occur during the acute stage of gonorrhea or urethritis. The vessels can be felt as hard and painful cords running along the dorsum of the organ up into the groins, where they empty into the inguinal glands. The penis becomes edematous and enlarged, and the course of the lymphatics is marked by red lines beneath the skin. Suppuration rarely, if ever, occurs. Treatment. — The patient should be kept in bed and the penis enveloped in gauze kept w^et with cold lead-water, aluminum acetate, or bichloride of mercury solution. All intra-urethral treatment should, of course, be suspended for a time. ADENITIS. The inguinal glands frequently become enlarged and tender during an acute gonorrhea, but, fortunately, they very rarely suppurate. 62 COMPLICATIONS OF ANTERIOR GONORRHEA Treatment. — Patients in whom this compHcation occurs should be kept as quiet as possible, or put to bed, and a cold wet dressing of aluminum acetate or bichloride of mercury solution (1 to 500) is applied, over which is placed an ice-cap. If in spite of the above treatment suppuration occurs, the pus must be immediately evacuated by free incision or by puncture followed by irrigation and injection of the abscess cavity with iodoform ointment. (For the details of these measures see page 217.) CHAPTER V. COMPLICATIONS OF ACUTE POSTERIOR (iOXOP.- RHEA AND THEIR TREATMENT. PROSTATITIS, ACUTE AND CHRONIC. Acute prostatitis is a very common complication of acute posterior gonorrhea. The inflammation in the posterior urethra spreads along the prostatic ducts and the gland becomes hyperemic and swollen. This gives rise to a sense of fulness in the perineum and rectum, accompanied by vesical and rectal tenesmus, with more or less pain in the prostate as the fecal masses press upon it as they pass through the rectum. In some cases there is great difficulty in urination, which may go on to complete retention. Frequently there are painful nocturnal pollutions, which are sometimes bloody. Rectal examination shows the gland to be enlarged, hot, and painful; firm and tense in some cases, but soft and boggy in others. The slightest pressure by the examining finger is exceedingly painful and causes an exudation of purulent prostatic fluid from the meatus. As a general rule, the congestion subsides as the urethritis improves, but there are some cases in which the inflammation goes on to abscess formation. This complication, when it does occur, is a very grave and sometimes even fatal one, unless promptly and radically treated. 6-i COMPLICATIONS OF POSTERIOR GONORRHEA There may he one large abscess, situated in either hiteral lobe, or the posterior median })ortion; or se^•eral smaller ones scattered irregularly thrc)Ughout the gland substance. Unless recognized and evacuated, the abscess may rupture either into the bladder, urethra, rectum, peritoneal cavity, or perineum; rupture into the urethra being the most fre- quent. Suppuration is ushered in by an agonizing and constant throbbing pain in the j^rostate, sweating rigors, rise of temperature, and frecjuent and painful djibbling of the urine, which may even go on to complete retention, caused by occlusion of the prostatic urethra and by com- pressor spasm. Rectal examination shows the prostate to be enlarged, hot, exquisitely painful, and throbl)ing. Fluctuation is readily detected if the abscess points toward the rectum, but with more difficulty if in other directions. In some cases the gland is so swollen and tender that only the finger- tip can be introduced into the rectum. If the abscess ruptures into the urethra, as it frequently does, either spontaneously or as the result of catheterization for retention, the patient experiences a sudden sensation as if something had "broken or given way at the neck of the bladder," and immediately passes more or less blood- stained and usually foul-smelling pus and urine by the urethra, following which (rupture of the abscess) there is a sudden cessation of all the above painful and distressing symptoms, with a corres])()n(ling droj) in the temperature. Treatment. — Patients suffering from acute prostatitis should be put to l)ed immediately. All antiblenorrhagics, injec- tions and instrumental treatment must be stopped and the urine rendered bland by copious draughts of water and the use of one of the following formulie: puos'i'A'rri'js, A('uti<: and ciiromc ('..') I^ — Potass, citrat., 5J Tr. hyosi^yami, Sij-i'j Fid. cxt. kiiv. k;i\-., 5.ss Aq., !ui ,', viij — M. Sig. — 5ss ill water oik; hour .■iflcr inr.ils iinil diiriii;.' I he lu'Kht. I^ — Potass, citrat., J,] Tr. hyoscyami, .oij-iij Inf. buchu., ad ^viij — .VI. Sig. — 5ss in water one hour after meals and ;i( ruKht. The bowels should be iiioxcd freely every clay, usiiij^ vegetable catliartics for the purpose. The use of sahnes is inadvisable, owing to their magnesium sulphate content, which renders the urine irritating. Hot-water bags over the bladder and perineum are often useful, ^>ry valuable also are hot rectal irrigations of normal salt solution given daily or twice a day by means of the author's soft-rubber tubes (Fig. 24) in the following maiuier: The patient lies down on his side with the buttocks near the edge of the bed or table. A five-quart douche bag filled with saline solution, at a temperature of 115° to 117° F., is so suspended that its lower end is about a foot above the patient's hips. The author's double tube, thoroughly lubri- cated with vaselin, is now inserted very gently for a distance of about three inches, so that the eye of the inflow tube rests against the gland. The fluid in the bag is now allowed to flow slowly into the rectum through the inflow tube, and out again through the outflow tube, the posterior aspect of the prostate being thus continually bathed with the hot saline solution. Each treatment should last from twenty to thirty minutes. By the use of a bath thermometer in the douche bag and the addition of more hot saline, from time to time, the irrigating fluid can be kept constantly at proper temperature. These irrigations may sometimes result in the develop- 5 ()() COMI'LICATJOXS OF POSTPJRWR dOXOh'UH KA meiit of hemorrhoids, hut we have found that the Hberal use of carbolized vasehn as a hihricaut for the tubes prevents this ct)nipHcation in the vast majority of eases. Sliouhl hemorrhoids develop the irri<;ations are stopped for a few days, and the patient told to use suppositories of tannic acid. INFLOWO ~=^ OUTFLOW Fig. 24. — Author's doublc-currcut, soft-rubber rectal irrigating tubes. After each of these treatments the patient should be directed to rest for a short time, if possible. In addition to the above measures the use of the hot sitz bath taken at bedtime will often prove very beneficial in lessening pelvic congestion. Very rarely suppositories of morphin PROSTATJTfS, ACUTK AND C II HON J C 07 or opium, \\i(li l>cllii(loiiiiii, iiiiiy liiixc to l)c gi\'cii to control the pain and tenesmus. Should retention occur, the urine must })e drawn with a soft-rubber or woven-silk cutlu^ter, and a little warm boric acid solution injected into the bladder and allowed to remain. It is also good practice to gently irrigate the; urethra with the same solution as the catheter is slowly and carefully withdrawn. Catheterization failing, we are then obliged to resort to suprapubic aspiration of the })ladder. (See page 180.) Regular, systematic examination of the prostate, per rectum, will keep us informed as to the condition of the gland and the possibility of abscess formation. Should abscess of the prostate develop, immediate opera- tive treatment is imperative. The pus may be evacuated by either of the following methods : First Method. — ^The perineum having been prepared and draped as usual, the patient, under general anesthesia, is placed in the lithotomy position and a grooved staff is passed to the bladder and held there exactly in the median line by an assistant, who at the same time retracts the scrotum, thus exposing the operative field and rendering the urethra prominent, which prevents its injury during the operation. Great care must also be taken not to wound the rectum, which accident can be prevented by thorough retraction of the wound. A longitudinal incision is then made in the median raphe of the perineum, extending to within half an inch of the anus and carried far enough for- ward to give a good, free wound, at the bottom of which the prostate is found. The abscess is then freely incised, irrigated with hot saline solution, and packed with moist 68 COMPLICATIONS OF POSTERIOR GONORRHEA sterile gauze. An onliimry ,i;;iir/(' drossing is applied and held in place by a T-hanilage. Second Method. — In some eases the abscess is foinid to be difficult of access by this method. Under such circum- stances the urethra .should be opened near the apex of the prostate, using the staff as a guide, as in the operation of external urethrotomy (described on i)age Ki.')). The fore- finger is then introduced into the canal and i)ushed back into the bladder, dilating the pro.static urethra and splitting the lateral lobes of the prostate, thus opening up any abscess cavities in the gland. All partitions between separate cavities should be thoroughly broken down to insure free drainage. A large perineal tuloe is then passed tlirough the perineal wound into the ])ladder, and secured in place by a heavy silk suture; the wound is lightly packed with gauze and a dressing a])plied as above. Chronic Prostatitis. — Chronic prostatitis, as a result of acute or chronic jxjsterior gonorrhea, or urethritis, is of very frequent occurrence, and is often the cause of chronic urethral discharges. It must be remembered that chronic prostatitis may also be the result of posterior urethritis, caused by excessive masturbation in young boys, and by sexual excesses and abnormalities in men of riper years; also, by long-continued and ungratified sexual desire. A chronically congested condition of the prostate is frequently observed following some of the so-called al)()rti\e methods of treating acute gonorrhea, especially the Janet method; and the forcible injection of solutions into the deep urethra and bladder by means of a large hand syringe. Excessive motor-cycling and horseback riding, and especially the all too prevalent "withdrawal" during intercourse, to prevent concei)tion, are also, very i)otent PROSTATITIS, AdUTK AND ClIltONIC iV.) cuiiscs of clii'oiiic posterior iirclliriil coii^csl ion iiiid pros- tatitis. Symptoms. The symptoms of (;liroi)i(; i)rostatitis arc very marked in some cases and j)ra.(;ti('ally absent in others. There may l)e some frequency in urination, increased l)\' sexual and alcohoHc indulgences; nocturnal pollutions and premature and even painful ejaculation may be present, the ejaculate being blood-stained in some instances. Some subjects lose their sexual desire, or may even' become totally impotent. The urine may be clear or more or less cloudy, as a result of the posterior urethritis, which is almost always present in these cases, and which gives rise to a varying amount of urethral discharge. In advanced cases there may be an oozing of prostatic fluid from the meatus after urination and defecation, es- pecially when the bowels are constipated; this greatly alarms nervous and excitable individuals, as they think they are losing their seminal fluid. Some subjects complain of a sensation of fulness and distress in the rectum and perineum, which is greatly in- creased by defecation and coitus, also by long walks, over- exercise, motoring, bic,ycle and horseback riding, and by standing a long time. Catching cold aggravates any or all of the above symptoms. Diagnosis. — The diagnosis of chronic prostatitis can only be arrived at by making a careful rectal examination, when the gland will be felt (Fig. 25), either enlarged, tender, and boggy, or very tense and firm. Digital pressure on the gland will usually cause an oozing from the meatus of prostatic fluid, which should always be collected and ex- amined microscopically. As a general rule, the enlargement is most marked on the left side. 70 COMPLICATIONS OF POSTERIOR GONORRHEA Treatment. — If tlio ^^\ii\u\ is soft aiul l)<).i;gy, it slionld he* massaycd about every five or seven days; hut if firm and tense, very little if any henefit will, as a rule, be derived from this treatment, imless the massage is preceded for a week or ten da\s b\- daiK' rectal irrigations of hot saline solution. Hla.Ulor. AmpuUated ond of vastlcfercns. Sominiil vesicle. Prostatu gland. Fu:. 25. — Photograph of bluddcr baae. (College of Phj-dicians and Surgeons.) which soften the gland and ])erinit the expression of its contents. ^Massage is always contra-indicated when there is a well-marked ])yuria, owing to the danger of setting up an epididymitis. The chronic urethrocystitis, which is found in conjunction El'JDIDYMITIS AND l<:i'l 1)1 l)Y MO OUC II ITl S 71 with this ty|)(; of |)r()stiititis, should be hiiiHllcd in ihc iii;iii- iier dcscrilx'd in the chuptcr devoted to it. fS('e ('hjiptcr \'l Ij Tlie i)atieiit's general condition should he looked into and improved hy general hygienic; measures and tonics. Other local treatment of the prostate, besides massage and hot irrigations, consists in the use of one of the following rectal snppositories, used once or twice daily: I^ — Ung. hydrarg. (50 por cent.), gr. xx Antipyrin, gr. v Ichthyoli, gr. v-x The following formula will also be found of value in some cases of clironic prostatitis: IJ — Ext. bcUadon., gr. \ CoUargol, gr. iij Anesthesin, ■ gr. x 01. theobrom., q. s, M. — Ft. suppos. No. 1. Sig. — Use one suppository at bedtime. Considerable benefit may also be derived from the use of the Oudin high-frequency spark applied to the prostate by means of a rectal electrode (Fig. 26), every week or ten da vs. 137 Fig. 26. — Glass rectal electrode. EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS. Epidid^^mitis is one of the most frequent complications of acute posterior gonorrhea, and consists of an acute in- flammation of the epididymis, which, if it extends to the testicle, is called epididjuio-orchitis. 72 , COMPLICATJOXS OF POSTERIOR GONORRHEA 111 severe cases the \"as det'ereiis is also iiixoKcd in the iiiHaiiiiiiatory jjroeess (aeiite t'unieuHtis), and the cavity of the tunica va<>;inaHs may be more or less distended with serum. This condition is spoken of as acute hydrocele, and may cither disappear spontaneously or remain as a chronic ])r()cess. Epididymitis or epididymo-orchitis may appear during any stajje of a gonorrhea, either spontaneously or as the result of trauma, such as ^■iolent physical exertion, unskilful instrumentation, etc. It is the result of an extension of the inflammatory process from the floor of the posterior urethra into the ejaculatory duct, and thence to the epididymis and testicle. It is uni- lateral in the majority of cases, although l)oth glands may be attacked at the same time, or successively. Symptoms. — The symptoms of epididymitis and epididymo- orchitis will be described together, as they are practically the same. The patient begins to complain of pain in the testicle, and a dragging, aching sensation in the iliac fossa and groin which extends down the cord into the testis. There is a rise in temperature, often accompanied by chilly sensations or a well-marked chill, which is followed by a feeling of general malaise. As the inflammation in the epididymis and testicle increases, all of the above symptoms become more marked, the temperature sometimes going to 105° F. ; the ])ain in the testicle, groin, and lumbar region, which may e\en run up into the kidney, becomes so great that the patient has to lie down, supporting the scrotum with his hand. The intensity of these symptoms varies greatly in different individuals, some being compelled to go to bed, while others are up and about, attending to their ordinarv duties. The scrotum is hot, red, and edema- KI'IDIhYMITlS AND lil'l l>l l)Y MO Oh'CIIITIH tons. 'J'lic epididymis, cilJicr in p;irt or in whole, is enhirj^ed, liiird, und e.\((uisit.ely tender; if I Ik; testicle he in\'ol\-ed, it also is very painful, firm, ;ind eiisory bandage. (See Fig. 28.) The patient is allowed to get up when the local pain and tenderness have disappeared. If there is very marked hydrocele, great relief can often be afforded by aspiration of the fluid, great care being taken not to wound the testicle, or to infect the sac. Of late years some surgeons have advocated the operative treatment of acute epididymitis devised by Hagner. This consists of exposure of the epididymis, by an incision through the overlying scrotum, followed by longitudinal incision through the capsule or by multiple puncture of it with a good-sized straight needle or bistoury. In the author's experience the operation offers no advantage over the treatment outlined above; in a large series of parallel cases the pain and temperature were relie^'ed more rapidly and the time spent in bed was considerably less in those patients that were treated by the more conservative, non- operative method. If true abscess of the epididymis can be demonstrated the pus should be e^'acuated by free incision and the cavity irrigated and drained. The induration in the epididymis, which is the result of the inflammatory process, may sometimes be reduced by the constant use of 20 per cent, ichthyol, compound iodin, or 50 per cent, mercurial ointment. The use of the Oudin high-frequency current, applied to the testis and epididymis will sometimes assist in the absorption of the exudate, which, if left untreated, may result ui partial 7() COMPLICATIONS OF POSTERIOR GONORRHEA and even complete sterilit\', it" both epididynies have been invoK'ed. In tlie hitt(M- case implantation of the \as, cnt through a short distance above the epididymis, directly into the testis itself, as advocated by ]\Iartin, w ill sometimes ])crinit of the ])assage of spermatozoa into the ejacnlate, thus relic\"in<;' the ])atient's sterility. SEMINAL VESICULITIS. By seminal vesiculitis or spermatocystitis is meant an inflammation of the seminal vesicles, which may be either acute or chronic. It may occur at any time during the course of the disease. The inflammation ])asses directly from the floor of the j^osterior urethra through the common ejaculatory duct to either one or both ^'esicles. The symptoms of acute seminal yesiculitis are i)ractically the same as those of acute posterior urethritis or acute pros- tatitis, the patient having frequent and painful urination with vesical and even rectal tenesmus. There may be painful nocturnal pollutions stained with blood. The patients usually' complain of a feeling of fulness just within the anus or in the perineum. In severe cases there is more or less fever, accompanied by a feeling of general malaise. The diagnosis is arrived at by making a rectal examination, when the vesicle or vesicles can be felt as hot, swollen, tender bodies situated jtist beyond the base of the prostate and ruji- ning upward and outward (Fig. 25). For this examination, the patient should be standing up, with the trunk bent at right angles to the thighs, the heels about a foot apart, and the palms of the hands resting on the seat of a chair. The index-finger is used for examination SEMINAL VESICULITIS 11 ;uul slioiild he w(;ll iiiioiiitcd with vasclin iind c(t\crc(l witli a thin rubber fiiif^er-tij) or f^Ioxc. The treatment is the same as that lor acute jn-ostatitis and posterior urethritis, to which the reader is referred. Should the inflammation j^o on to abscess-formation, as is rarely the case, the ])ati('nt must be anesthetized, put in the lithotomy jjosition, and the y)us evacuated by a vertical or semilunar incision tJu-ouf^h the perineum just in front of the anus, and the abscess cavity drained, great care being taken not to wound the urethra or rectum. In a good many cases the process can be relieved b}- massage of the vesicle, by which the pus is expressed into the urethra; operation should not usually be resorted to until this procedure has been given a trial. The steps in the operation are given in the section dealing with the treatment of chronic seminal vesiculitis. Chronic seminal vesiculitis may follow the acute form, or be caused by the extension backward of a chronic posterior urethritis or prostatitis. The symptoms of chronic seminal vesiculitis are varied and differ greatly in different indi\-iduals, some complaining that they are becoming impotent, others that they have nocturnal pollutions and premature ejaculations, both of which may be blood-stained. These conditions may or may not be associated with a mucoid or mucopurulent urethral discharge, which varies greatly at different times. Some complain of a sense of weight and fulness in the rectum and perineum, while others are absolutely free from these sensa- tions, the only symptom of the disease being a cloudy urine with flakes and slight discharge at the meatus. Some patients have constant and greatly increased sexual desire, with perhaps little relief after intercourse. 78 . COMPLICATIONS OF POSTERIOR GONORRHEA Tin- syiiij)t()ins of cliroiiic scniiiial wsiculitis aiv so similar to thoso of chronic i)rostatitis and posterior urethritis that a correct diagnosis can only be arrived at by making a careful rectal examination, as described in the acute form. Wiien diseased, the vesicle or vesicles may often be plainly felt by the finger, running uj) and out from the base of the pros- tate gland. On tJie other Jiand, the ])resence of a chronic gonorrheal arthritis, ^vhich resists all treatment, or the persistence of other symptoms of gonorrhea over long periods of time without improvement are often the only indications on which the diagnosis of chronic vesiculitis may be made. For routine treatment the vesicle or vesicles can ])e thoroughly massaged about once a week, and the patient given the regular treatment for chronic posterior urethritis and prostatitis, the details for which will be found fully described in Chapters V and VII . In a certain number of cases which do not respond to this treatment Fuller and others have resorted to incision and drainage of the vesicles by the perineal route. The technic for approaching the vesicles differs according to the choice of the operator. URETHROCYSTITIS. Urethrocystitis, either acute or chronic, is not an uncom- mon complication of posterior gonorrhea, or urethritis, being caused b}' an extension backward of the inflammatory process from the posterior urethra into the bladder. As a rule, the inflammation is limited to the mucous mem})rane for an inch or so surrounding the vesical orifice of the lu-ethra, as may UUKTII liOCYSTl TIS 70 l)(' seen hy (\ys(<),sc()|)ic cxiiiiiiiijit ion, tlic iiuk'oii , iiiciiilnniic ovc^r the trigone being reddened iiiid ((Iciniiloiis. Il, may extend, however, and involve the ciiliic hhiddcr siirrncc, thus constituting a true cystitis. The symptoms of acute urethrocystitis are rnqiicnt ;iiid painful urination, vesical tenesmus, and in severe f;ases, terminal hematuria. In short, they are practically the same as those of acute posterior gonorrhea or urethritis, except perhaps that they are more persistent and severe in character, the patient also complaining of a constant deep- seated pain over the bladder, which is intensified at the close of micturition. If in these cases we employ the two- or three-glass test, the urine in all of the cylinders will be cloudy from pus and mucus, but especially so in the second or third cylinders, which may also contain blood from the congested mucous membrane of the deep urethra and vesical neck. This hematuria may, occasionally, be so severe that the urine, which is usually acid in these cases, may be rendered neutral, or even alkaline in reaction by the blood and pus. As the inflammation passes into the chronic stage the above sj^mptoms all become much less marked and in some cases even almost disappear. As a general rule, these patients complain of an uncomfortable feeling after urination, as if the bladder were not emptied, and of a disagreeable desire to strain out the last drops of urine; in short, ihev have mild vesical tenesmus. If after urination a soft catheter is passed to the bladder it will draw a drachm or so, or even more, of retained or residual urine, the result of the congested and thickened condition of the mucous membrane about the vesical orifice, which prevents the bladder from emptying itself normally. so COMPLICATIONS OF POSTERIOR COXORRHEA Treatment. — In the acute stage of urethrocystitis tlie patient should he kept very quiet, or in hcd, with hot apjjhcations over the hladder and on the ])erineuni. Hot sitz baths and hot rectal irrigations of saline solution afford great relief. All instrumentation of the urethra must be susi)ended, the patient put on a light, nutritious, and non-irritating diet, and the urine kept bland by means of the following prescription: R — Fid. ext. trit. repens, Fid. ext. uvae ursi., aa 5iss Potass, citrat., .oij-iij Aq., ad 5iv — M. Sig. — 3J in water one hour after meals and during the night. Tenesmus, if severe, may have to be controlled by the judicious use of opium or morphin, either in suppository, internally, or by hypodermic injection. The patient may drink any bland water, liut not in too great quantity. It is very important to keep the bowels nio\ing freely, and for this purpose we may employ a little calomel or any good cathartic pill. When as a result of the above treatment the acute inflam- matory symptoms begin to subside, it is time to commence irrigation of the deep urethra and bladder, using at first warm boracic acid solution, and later permanganate of potash or silver nitrate. The technic for this treatment will be found fully described in the sections devoted to chronic urethritis, and to these the reader is referred. CYSTITIS. Gonorrheal cystitis, by which is meant a suppurati\'e inflammation of the entire vesical mucous membrane, is an CYSTJT/.^ SI extremely nirc coinplicatioii of .'iciih; or clironic |)o.st(;rior gonorrhea. It may l)e eitlicr acut(;, subjiciitc or nlironic in character, and is usually the result of a niixcfl inlcction, in which the gonococcus plays little or no jjart. The symptoms of acute gonorrheal cystitis consist of pain over the bladder and sacrum and increased frequency in urination, which is very painful, especially at its close, and is followed by more or less tenesnnis and sometimes blood. These patients are really sick, having a rise of pulse and temperature and a feeling of general malaise and lassitude. As the process becomes subacute and then chronic, all of the above s,ymptoms lose their severity and intensity', the patient complaining of some pain and urgency in urina- tion, and uneasy sensations in and about the bladder and pelvis. The urine, during the acute stage, is normal in odor and acid, though rendered opaque by pus, tissue elements and bladder epithelium. In a well-established chronic, case, however, it becomes foul and alkaline, with coagidation of the pus into ropy and gelatinous masses, owing to bacterial decomposition. In any stage, if it is passed into three glasses, all will be cloudy with pus and shreds, especially the last. Treatment. — During the acute stage of the disease the patient should be kept in bed, and on a light nutritious diet, avoiding alcohol and coffee, and anything that is highly spiced or seasoned that may in any way irritate the urinary tract. Water may be taken, but not in too large quantities. The bowels must be moved freely once in twenty-four hours by means of any reliable cathartic pill. Hot applications over the bladder and on the perineum give much relief, as do also the hot sitz bath and rectal irrigation of hot 6 82 COMPLICATIONS OF POSTERIOR GONORRHEA saline solution, taken once or twice daily. If the pain and tenesmus are Aery severe, we may hare to resort to the guarded use of opium or morphin, or belladonna, either by suppository, internally, or by liypodermic injection. The urine must be kept bland by the administration of citrate of potasJi, either alone or combined with hyoscyamus, uva ursi, and triticum repens, as given in the formula for acute posterior urethritis and urethrocystitis. As a result of this treatment the majority of cases pass quite rapidly into the subacute and chronic stage, when the patient is allowed to be up and about, and given a more liberal diet. Alkalies can now be discontinued and the l^atient given boric acid in full dose, as in the following formula : IJ — Ac. boric, 3ijss Tr. hyoscyami, 3ij Aq., ad gviij — M. Sig. — ^5ss one hour after meals. If in spite of the above treatment the urine still remains alkaline or neutral in reaction, a normal acidity can usually be obtained by the administration of urotropin or helmitol in full dose. Xow is the time to begin bladder irrigations, given very gently and carefully by means of a small catheter and four- ounce hand syringe in the following manner: The patient urinates and then lies comfortably on his back; the surgeon then passes a small soft-rubber or silk catheter, properly cleaned and lubricated (see Fig. 17), into the bladder, and gently injects a warm and non-irritating medicated solution, until the patient has a desire to m-inate or feels uneasy in any way, when the fluid is innnediately allowed to escape through the catheter. This may be repeated a few URETEIUT/S, l')'MLrr/S, AND I'Y I'lLOM I'U'II lUTI S K\ times, tJu; catheter Ix'in^- fiiuilly witliditiun, leaving sev(;ral ounces of solution in IIk; hhiddcr, wiiieji, as the i)atient voids it, medicates the mucous meml)rane of his prostatic urethra, which was the starting-point and cause of tlie cystitis, so that in tliis manner we treat not only the hladdcT, but also the entire lengtli of tJic urctln-jil canal. As a rule, the irrigations are given once daily, hegiiming with warm boric acid or salt solution, and later zinc sulphate and alum solution (1 to 3000 up to 1 to 1000) followed, still later, by potassium permanganate (1 to 15,000 up to 1 to 2000), and finally by nitrate of silver solution, beginning with 1 to 20,000, and increasing slowly and guardedly up to 1 to 5000 or even stronger. Complicating prostatis, seminal vesiculitis, or stricture should receive appropriate treatment. URETERITIS, PYELITIS, AND PYELONEPHRITIS. Among the very rare and infrequently encountered complications of posterior gonorrhea, or more accurately speaking, of gonorrheal cystitis, may be mentioned ureteritis, pyelitis, or pyelonephritis; the infection traveling upward from the bladder to the kidney by way of the lu-eters; or being carried to these organs through the lymphatics or blood stream. The diagnosis of which kidney is invohed is greatly aided by catheterization of the ureters through the cystoscope. These complications are generally ob- served in persons who have had antecedent vesical disease, or in whom there is some obstruction or hindrance to the free outfloM' of urine from a urethral stricture or prostatic enlargement. As a general rule, but one kidne^' is in\oh-ed. CHAPTER VI. CHRONIC ANTERIOR AND POSTERIOR GONORRHEA. Chronic gonorrhea, also commonly known as gleet, is spoken of as chronic anterior gonorrhea, when the disease is situated scnnewhere in the anterior urethra; as chronic posterior gonorrhea, when in the posterior urethra; as chronic anteroposterior gonorrhea, when the entire length of the urethra is involved; and as chronic urethrocystitis when the disease has invaded the bladder to a limited extent around the urethral orifice. A gonorrhea is called chronic when it has existed for more than eight or ten weeks, and has lost all of its acute inflammatory manifestations. The lesions of chronic gonorrhea consist of a small round- cell infiltration into the submucous connective-tissue layer, and a chronic catarrhal inflammation of the mucous mem- brane itself, whose normal cylindrical epithelium, as a result of the gonorrheal process, has been destroyed in patches, and as healing occurs, replaced by the flat pa^•ement A'ariety, thus leaving the canal in a more or less thickened and rigid condition. The causes of chronic gonorrhea are many, prominent among them being sexual and alcoholic indulgences during the declining stage, patients thinking themselves cured at that time as they see no discharge at the meatus, and therefore stopping treatment et this, the most important period in their disease. CHRONIC ANTERIOR GONORRHEA 85 (lOiiorrlicii. is also a|)1, to run a. clircniic course in dchilitatcd, run-down, and ancniic; subjects, and in tliose wjio will not, or cannot, take sufficient rest or proper treatment in tlie acute inflammatory stage of tJie disease. Tlie numerous so-called abortive methods, with strong injections, retrojections, irrigations, and endoscopic appli- cations during the acute infiainmatory stage, are very liable to leave the patient with a tJiickened urethra, congested prostate, and a clyonic disciuirge tJiat is most rebellious to treatment. Chronic congestion and inflammation of the prostate gland, as a result of gonorrhea and sexual errors and excesses, is a frequent cause of chronic urethral suppuration, and should therefore not be overlooked in the treatment of these cases. Seminal vesiculitis is undoubtedly the etiological factor in some cases of chronic gonorrhea, but is rare, as compared to chronic affections of the prostate. An abnormally small meatus, or a condition of phimosis, associated with balanoposthitis, may, from the irritation they produce, be important factors in the continuation of a chronic urethritis. Uncured preputial, peri- or paraurethral folliculitis, or infection of any of the glands or follicles opening into any part of the urethra (Cowper's glands, the glands of Littre, and the crypts of JNIorgagni), may cause the lightening up, or prolongation of a gonorrhea; therefore these structures should receive due consideration and treatment. Warty and polypoid growths in the urethra may, from the irritation they occasion, keep up a urethral discharge for a long time. They maj^ be diagnosticated by endoscopic examination, which may be employed in chronic and re- bellious cases. 86 CHRONIC ANTERIOR AND POSTERIOR GONORRHEA Urethral stricture, resulting from a previous gonorrhea or a trauniatisni, may sometimes complicate and keep up a chronic urethral discharge, and must therefore not he forgotten in the examination. CHRONIC ANTERIOR GONORRHEA. The symptoms of chronic anterior gonorrhea are \ery \ariahle: In some cases tlie lips of the meatus arc glued together in the morning by the discharge which has accumu- lated in the urethra during the night; in others there is a variable amount of mucopurulent, mucoid, or serous dis- charge at the meatus, which is usually increased after sexual or alcoholic indulgence. In still other cases there is no gluing of the meatus, the only symptom of the chronic inflammation being flakes and shreds in the urine. In the majority of cases there is no visible discharge at the meatus during the day, as the urethra is so frequently flushed out by the stream of urine. Patients often complain of a dribbling of a few drops of urine after each act of urination; this is due to a loss of elasticity of the urethral walls as a result of the chronic catarrhal and exudative inflammation into the submucous connective-tissue layer, which leaves them in a more or less rigid condition, and unable to empty them- selves normally. The Thompson two-glass test, for the differential diagnosis of chronic anterior and chronic posterior gonorrhea, should not be relied on, as it is only applicable to acute cases asso- ciated with much suppuration. The so-called gonorrheal flakes and shreds consist of moist scales made up of pus and epithelial cells, held together by fibrin or mucus; they are situated upon spots of con- CHRONIC POSTERIOR GONORRHEA 87 gestion, erosion, ;iih1 superficial ulceration iilonji; tlic iirctlirnl walls, which mark the localities where the gonorrheal process has become localized. These congested, eroded, or ulcerated patches form the lesions of chronic gonorrhea, and are most commonly found in the bulbous urethra, as this j)()rtion of the canal is large (33 to 36 F.), has no capsule, is sur- rounded by erectile tissue, and being dependent, drains poorly; all of the above conditions greatly favoring a long- continued inflammatory process. When the stream of urine strikes the edges of these moist scales it rolls them up, and they therefore appear as threads or shreds suspended in the urine, which may be either turbid or clear. As healing advances the pus cells disappear, the flocculi being made up entirely of epithelial cells, which, when the case is cured, also vanish, leaving a clear, transparent urine. In a general way it may be stated that the threads or shreds from the anterior urethra are usually long and thread- like in character, while those from the posterior urethra are lumpy and ragged in appearance, although too much reliance must not be placed on these distinctions. iMicroscopically both kinds are found to be composed of the same elements. The presence of spermatozoa, which may sometimes be discovered entangled in their meshes, is an aid in deciding on their place of origin, though not absolutely conclusive. CHRONIC POSTERIOR GONORRHEA. Although chronic posterior gonorrhea may sometimes occur alone, it is accompanied in the vast majority of cases by a chronic bulbous urethritis, as well as bv some chronic 8S CHRONIC AXTERIOR AND POSTERIOR GONORRHEA uri'tlirocystitis, which in turn may he associated with prostatitis, or c\on seniiiial \"csiciiHtis, which conditions iiiiist not he i'orijotten when phinnin<>; treatment. In these cases there is more or less increased frequency of urination with a f(>elinu' of (hscomfort cither at the beginning or termination of the act, and sometimes a ver\' sHght discharge at the meatus, particuhirly in the morning. The urine may he clear, turbid, or cloudy, and contains shreds from the posterior urethra, which, as a rule, sink rapidly to the bottom of the glass. In some cases there are frequent nocturnal ])()llutions which may be bloody; in others premature ejaculation, associated with dull, painful sensa- tions in the region of the prostate and periiieuin. These sexual manifestations are due to the congested and inflamed condition of the posterior urethra, prostate gland, and possibly, of the seminal vesicles. The above symptoms vary widely in different individuals, in some, well-marked and constant, in others, very slight and only brought into activity by alcohf)lic and sexual indul- gences, which cause a congestion of the posterior urethra and prostate, with a lightening up of the dormant inliammation. If, as is usually the case, the patient also has an anterior gonorrhea, a more marked discharge will usually be present at the meatus. CHAPTEll VII. TREATMENT OE C11JK)NJC ANTERIOJi AND POSTERIOR GONORRHEA. Before l)eginning any form of treatment, we should first ascertain tlie number, duration, severity, and complications of the preceding attack or attacks of gonorrhea, as this information will shed much light on the patient's present condition, and also aid greatly in the selection of a proper plan of treatment. In all cases of chronic gonorrhea, the urine should be carefully examined. Its reaction, the amount of pus, epithelial cells, and bacteria, and the composition of the shreds should be ascertained. Any excess of phosphates, carbonates and urates should be noted. If urination is painful the patient should take any of the alkaline mixtures alluded to abo^'e and drink freely of any bland water. Coffee, chocolate and cocoa and alcohol are to be stopped until the case is well under control, when they may be resumed in moderation. The diet should be nutritious, but simple, the patient avoiding all highly spiced and seasoned dishes. As soon as the pain or smarting on urination ceases, great benefit will be derived in many cases from the use of the antiblennorrhagics. All sexual excitement must be strictly guarded against, as it causes urethral and prostatic congestion and thus retards a cure, as does also excessive exercise. 90 CHRONIC ANTERIOR AND POSTERIOR GONORRHEA If the iiriiu' is cloudy from i)iis (pyuria) as \\c'll as gonor- rlieal flakes and threads, it is best to begin with retrojections or irrigations, which consist of throwing into either the anterior or posterior urethra se^•eral t)unces of a warm medicated fluid. If, liowever, the urine is clear, or as a result of the aboNC measures tlie pus disappears and nothing but tln-eads remains in the clear urine, it is tlien time to stop retrojections or irrigations and substitute for them instillations, which consist of a drachm of a concentrated medicated solution, injected into the canal, the technic for which will be described in detail farther on. If chronic gonorrhea is complicated by stricture of the urethra, prostatitis, seminal vesiculitis, an abnormally small meatus, or phimosis associated with balanoposthitis, these conditions should receive appropriate treatment which will be found fully described under these separate headings, to which the reader is referred. TREATMENT OF CHRONIC ANTERIOR GONORRHEA. The general rules just described having been minutely carried out, the anterior urethra is treated in the following manner, either by irrigations or instillations, according to the condition of the urine. Irrigations should be given as follows: The patient passes his urine in order to flush out the canal; then a small, sterile soft-rubber or bulbous \voven-silk catheter (see Figs. 15 and lo), well lubricated, is passed very gently into the bulb of the urethra. , A large hand-syringe (Fig. 2) is then attached to the end of the catheter by means of a coupler (Fig. 2), and the warm medicated fluid injected slowly and gently into the bulb of the urethra, beyond TliEATMKNT OF CJIIlONlC ANTERIOR GONORRIINA 01 whicli it (Iocs not. pjiss on ;i,ccotiiil, of jJic compressor iii-<;t licic muscle, bill flows I'orw ;i,i(l iiiul escapes ;it the iii(;atns. In this iiiiumer all ol" the diseased areas in tlie anterior portion of tlu; canal are brought into direct contact with the medicated sohition. The irrigations may he given daily or every other day, according to the results obtained, which can be ascertained by the patient's symptoms and sensations, and also the cond|ition of the urine, which should be examined before each treatment. On the alternate days the patient can use an ordinary hand-injection, if so desired, provided it does not cause irritation, which it sometimes does. The amount of solution used at each sitting varies from four to eight ounces, the fluid should always be warm, and thrown in with the utmost care and gentleness. For irrigation solutions we use the following stock formulae in the order given and manner described: Solution I. I^ — Alum, crud., Zinc, sulphat., aa 1.00 Aq. destillat., 500.00 — M. Sig.^-Add one-half (^) of an ounce of this solution to seven and a half {7\) ounces of warm boiled water, and inject. Increase strength from day to day until equal parts of solution and water are used, or even stronger, if so desired. Solution II. I^ — Potass, permanganat., 1.00 Aq. destillat., .500.00 — M. Sig. — Add one-quarter (J) of an ounce of this solution, to seven and three- quarters (7J) ounces of warm, boiled water, and give an irrigation every day or every other day, increasing the strength slowly up to 1 to 1000 (1 to 16,000 to 1 to 1000). Solution III. ^ — Argent, nitrat., 1.00 Aq. destillat., 500.00 — M. Sig. — Use in precisely the same manner as the second solution, increasing the strength very slowly, as the silver nitrate is liable to cause severe pain and irritation if used too strong (1 to 16,000 to 1 to 1000). 92 CURONIC ANTERIOR AND POSTERIOR GONORRHEA Tlie i'ollowinji; t;il)lc' will l)i' t'oiiiul \-en- ('onvciiicnt in makiiiu' ii]) tlu' i)rnnan'i;inatt" or siKcr solutions: //( an S (iz. (jraduaie: sfoch sal. (/ to 500). 3ij of solution equals 1 to 10,000 3ss of solution equals 1 to S.OOO 5j of solution equals 1 to 4,000 5ij of solution equals 1 to 2,000 3iij of solution equals 1 to 1,300 5iv of solution equals 1 to 1,000 If, at about the end of the tenth or tweU'th week of tlie disease, the patient still complains of a dribbling of urine from the meatus after urination, good results will often be obtained by the judicious use of warm, medium-sized steel sounds passed to the triangular ligament a})out once a week, and left in the uretlira for about a minute; the pressure which the sound exerts helps to restore the lost elasticity of the urethral walls, and in that way cures this troublesome and disagreeable symi)t()m. In the author's experience sounds are greatly to be preferred to any of the \arious dilators in use. If, after using the abo\e irrigations in the manner described the urine is rendered clear but still contains shreds and flakes, it is advisable to give the patient instillations of nitrate of silver in the anterior urethra. This method is fully described in the next section. TREATMENT OF CHRONIC POSTERIOR GONORRHEA. Before proceeding to discuss the treatment of chronic posterior f/onorrhea it will he well to emphasize the fact that in the vast majority of cases of (/onorrhcal infection the entire length of the urethra and the bladder base become involved in the TREATMENT OF CIIIIONIC POSTEHIOR GONORRHEA O.'i yroccsa. Under these circumstances, of course, Ixdli. the ante- rior and 'posterior urethras must be treated in order /o ohtaiu a cure. Great care must therefore he taken in malciiKj a diafjnosis of anterior Involvement only. The general lines of treatment described on page 80 having been instituted, the posterior urethra and a limited area of the bladder should be irrigated by retrojection. The patient, having urinated in order to cleanse the canal, lies down, with head and shoulders elevated and muscles relaxed, and a small, sterile, soft-rubber catheter, properly lubricated, is gently passed, so that its eye lies just within the bladder, which will be shown to be the case by the escape of a drachm or so of retained urine. In some exceptional cases it will be found impossible to pass a soft-rubber catheter beyond the compressor urethrae muscle. For these cases we can substitute a No. 10 French woven-silk instrument, which, although more rigid than the rubber one, is flexible and less liable to cause irritation and compressor spasm than the metal instruments whicJi are sometimes recom- mended for this purpose. The much-talked-of and over- estimated spasm of the compressor urethra muscle is, as a rule, caused by rough, rapid, and unskilful instrumentation, and will rarely, if ever, be encountered, provided the surgeon is gentle and uses flexible catheters in preference to metal ones. A four-ounce syringe (Fig. 2) is attached to the catheter by means of a coupler with stopcock, and the warm medicated fluid thrown slowly and gently into the bladder. When the syringe is empty the stopcock is turned off, the syringe uncoupled, refilled, and more fluid injected until the bladder feels full, or the patient complains of a desire to urinate, when the catheter is slowlv withdrawn into the bulbous 94 CHRONIC ANTERIOR AND POSTERIOR GONORRHEA portion and the entire anterior urethra irrigated. The jiatient now stands up and passes the medicated fluid, which, having already acted on the base of the bhidder, washes out the posterior lu'ethra, and flowing through the anterior urethra, distends it as it rushes out, and in this manner medicates all of the congested, eroded, or ulcerated spots and patches along the canal. The solutions used must always be warm and increased very slowlj' in strength, especially the permanganate of potash and nitrate of silver solution, which, if too strong, will set up intense vesical and rectal tenesmus, which may last for several hours. The fluid should always be injected with a f(,ur-ounce hand-syringe, as with it we know the exact amount of solution thrown in, the resistance off'ered by the bladder, and the force used; whereas, if an irrigator or fountain syringe were employed, none of the above valuable information could be obtained, and more or less damage might be done. The amount of fluid used at each sitting A-aries, a good average being about eight ounces, although many bladders will not hold more than from one to four oimces at flrst; this is due to irritability of the posterior urethra, with more or less contraction of the bladder, which has been produced by the frequent calls to expel the urine during the acute attack; this irritability subsides rapidly under the treatment, and patients frequently speak of the comfort they experience after the first few irrigations. If, in spite of the above treatment, carefully carried out, the urine does not clear up promptly, then the prostate, semi- nal ^•esicles, and ampullated ends of the vasa deferentia must be examined per rectum, and if found affected, treated as described in the sections devoted to these subjects. TREATMENT OF CHRONIC I'OSTEIUOJl (lONORRJIEA 05 If, after having used the irrigations or retrojectioiis, the urine clears up, but still contains gonorrheal threads and tissue elements, it is advisable to change our plan of treat- ment by using small amounts of concentrated sohitions; these are called instillations, and are given in the following manner (Fig. 29): The patient, having urinated, lies (hnvn or stands before the surgeon, who passes a small, sterile, soft-rubber or silk catheter, as before, into the posterior Fig. 29. — Urethral instillation. (Original.) urethra, if posterior urethritis or urethrocystitis exists, or into the bulb of the urethra, if there is only an anterior urethritis to deal with, and by means of the author's instillation syringe (Fig. 3), throws in about a drachm of a solution of nitrate of silver. When the posterior urethra is involved, half the syringeful is injected into it and the rest into the anterior urethra as the catheter is withdrawn. Before inject- ing the solution, any urine retained in the bladder must first be drawn off, in order not to decompose the medication. 90 CHEOXIC ANTERIOR AND POSTERIOR GONORRHEA The strength of the nitrate of silver sokitions used should run from 1 to 10,000 for tlie first injcctidii, up to 1 to 1000 or 1 to 500, or even stronger. These instillations should be repeated daily or every other day, according to the results obtained and the strength of the solution used. In some rebellious cases we may be comi)elled to increase the strength of the silver solution up to 1 to 250, or even 1 to 100; this should be done very slowly and carefully, and the instillations given at longer intervals; our guide in these cases being the condition of the urine, which should be examined at each ^'isit. In the same manner we may sometimes advantageously use o to G per cent, sulphate of thallin solution; as a rule, howe\er, nitrate Fig. 30. — Silk bulbous instillation catheter. of silver is the most efficacious of all, and if intelligently used will produce a cure. In some cases, where unusual thickening and edema of the mucous membrane makes a certain amount of pressure on the tissues and dilatation desirable, we may substitute for the ordinary rubber or silk catheter a bulbous silk catheter, as shown in Fig. 30. The specially constructed metal instruments or drop catheters, which are sometimes recommended for instillations, should never be employed on account of the irritation and trauniatisni that they are liable to produce, even in skilful hands. If the surgeon fails to enter the deep urethra with soft-rub})er and silk catheters it is ])roof ])ositi\e that he is either very unskilful, or that the parts are in a far too irritable TREATMENT OF J'llUONK! I'O^TKIilOll (lONOIiUII EA \)1 and sensitive eondition lor any l\iiHl of local nntliral iiicdi* a- tion. 'I'lie rit/iiiaiiii (Iroj) catheter, wliicli consists of a tlnck-vvallcd silvcT catlictcr with capillary horc, and a ^lass and hard-rubber syringe, is the histrument usually employed by those who are opposed to soft-rubber instruments for urethral medication. The use of the endoscope (urethroscope) in the treatment of chronic gonorrhea is frequently of service in those cases which have resisted the different forms of treatment already described. The endoscope can only be employed to ad\aiitage in certain selected cases in the chronic stage of the disease, and by one who is accustomed to the appearance of the urethral walls, both in their normal and diseased states. By its aid we can examine with the eye the entire length of the anterior urethra, recognize polypoid or warty growths, areas of infiltration, congestion and erosion, diseased follicles, false passages, stricture, impacted stones, etc., and treat them locally by topical applications of various kinds. It must be remembered, however, that the endoscope is an instrument of reserve, and should never be employed in a routine or careless manner, as its frequent passage through the urethral canal causes more or less irritation, distention, and congestion of this sensitive and highly vascular mucous membrane. It should never be used in the prostatic portion of the urethra, where its relatively sharp edge, by pressure on the verumontanum and the orifices of the ejaculatory and prostatic ducts, causes more or less trauma and bleeding, as a result of which the author has not infrequently seen epididymitis, prostatitis, and even abscess of the prostate. Should we desire to examine this region visually, the close- 98 CHRONIC ANTERIOR AND POSTERIOR GONORRHEA vision urethrocystoscope is the instrument of choice, for with it we can not only reduce trauma to a minimum but also get a much clearer and less distorted ^■iew of tlie struct- ures in the posterior urethra. For general endoscopic work the most useful ty])es of instrument are those constructed on the principle of the Luy urethroscope and the instrument devised by the author. In the Luy instrument the light consists of a small, "cold" lamp, carried on a staf}' of such length that the Fig. 31. — Liiy's urethroscope. lamp rests just within the distal end of the endoscopic tube (Fig. 31). This instrument gives an excellent view of the urethral walls, as the tube is slowly withdrawn, but lias the disadvantage tliat the lamp may easily become covered with secretion or blood, thus cutting ofl' the illumina- tion, and that the lamp is somewhat in the way of applicators and other instruments. To obviate these objections and to supply an instrument with unobstructed field, in which the operator can see the lesions while treating them, I have devised the present TREATMENT OF CIIIIONK' I'OSTIiinOlt COSOUHII ICA 00 urethroscope, wliicli cuii he used eitlier in the aiiLfTior c>r posterior urethra, and even in the bladder, where the ureteral orifices can he found and cathetcrizcd, small stones or foreign bodies removed, and the nmcous mcinhrane clearly seen. Fig. 32.— Author's operating and examining urethroscope. The tubes for the anterior urethra are 5 inches long and those for the posterior urethra 6f inches, but can be length- ened or shortened according to the requirements of the case, and made in any caliber. The proximal ends of the obtu- rators and tubes are milled so as to give the operator a 100 CHRONIC ANTERIOR AND POSTERIOR GONORRHEA firm hold, and flattened above and below to prevent their rolling when laid down. The little lamp consists of a carbon filament in front of which is a planoconvex "collecting" lens, which gathers and projects the rays to the distal end of the tnbe where the field is seen in brilliant illumination. The lamp is held in a metal collar outside of the tube so that it does not encroach on the field, is not in the way ^=^g^ .^^m=. @= WAPPLER E. M. CO. INC NEW YORK Fig. 33. — Instruments for operating endoscope. of applicators, examining or operating instruments, and cannot be soiled and obscured by blood, secretions, or the lubricant. If air distention is required, an air-tight cap with magnifying lens is slipped over the proximal end of the collar and the urethra gently and carefully dilated by slowly compressing the little bulb, which forces air down the tube, where it can be retained by shutting off the stopcock. Water distention may also be used, if so desired. For simple WHEN IS aONORRIIEA dUliKI) 101 examination, treatment., or " liil^nralion," a manjm'fyiii^ lens is attached to tlie collar hy a slender rod w liieli allows of the use of appHcators and any kind of instrnments under din-et visual inspection. The method of usinu; the instrument is as follows: 'J'he patient, having emptied his bladder, lies down on the operating table, his thighs supported 1)\' proper foot-rests or two ordinary stools. The largest tube that will enter the meatus with ease is then selected, cleansed, and lubricated and passed slowly and gently into the bulb of the urethra (in rare cases into the prostatic urethra), the obturator carefully withdrawn, and the light turned on; the urethral walls are then seen bulging into the lumen of the tube, which being slowly withdrawn, gives a clear and distinct picture of the entire canal from behind forward. As diseased areas are discovered they may be touched wdth concentrated solutions of silver nitrate or copper sulphate by means of wooden applicators wrapped with absorbent cotton, which has been dipped in the medicated solution. Polypoid and warty growths can be easily removed by means of a delicate snare used through the tube or by fulguration with the Oudin or d'Arsonval high-frequency spark. WHEN IS GONORRHEA CURED? Having considered the treatment of gonorrhea and its complications, the important question now arises: When is the disease cured, or at what time does the patient cease to be infectious? In order to answer these questions intelli- gently we must examine the patient's morning urine, passed in our presence, for several successive mornings, and if it is clear and contains neither pus nor gonorrheal shreds; that is, 1(V2 CHROXIC ANTERIOR AND POSTERIOR GONORRHEA if if he pcrfirtli/ iioninil mi rcpralcd in'icruscopic ('X(uii'niat'n)US, we know that the urt'tlitTal lesions, at least, have been cured. If, on the other hand, there are shreds, which under the microscope are found to consist of pus and e])ithehal cells, whether they contain gonococci or not, we know that the urethral lesions are still uncured, and that the secretion may be infectious. If the shreds consist of epithelial cells alone, they, of course, in themselves, may not be dangerous; but even these patients must be warned not to have sexual relations, and adN'ised to take a proper course of local treat- ment. In order to ascertain that there is no lurking trouble in the })rostate gland, seminal vesicles, or ampullated ends of the vasa deferentia, as a result of posterior gonorrhea, the patient should pass all of his urine, and then have 8 to 10 ounces of warm, sterile water injected into his bladder. The prostate, vesicles, and vasa deferentia are then examined and massaged by a finger in the rectum. The material appearing at the meatus is ^ecei^'ed in a sterile glass graduate and kept for examination; the patient now passes the fluid in his bladder, which washes out any remaining secretion that has been expressed into the urethra; the sediment from this fluid and the material caught at the meatus are examined microscopically and cultures taken, and if the findings show disease, this must be treated as already described imder urethritis, prostatitis, and seminal vesic- ulitis. The examiner must be familiar Avitli the normal secretions of the prostate, vesicles, and ampulla", so as not to err in his microscopic fintlings. One cannot be too guarded in giving an opinion on this subject, and should therefore make the above examinations in a most thorough, con- scientious, and careful manner, an() warn })atients against matrimony or sexual relations until they are absolutely cured. WHEN IS CONOR nil MA CURED 10.'^) The follicles in tlu; iiit(;;(! ol" sounds, urethroscopes or v\g\i\ iiistruuient.T in the acute stiiji;e of the disease, and the use of unnecessarily strong and irritatinnt to bed, and the inflamed joints immobilized by appropriate splints; the use of cold wet dressings of aluminum acetate, bichloride of mercury, or a solution of lead subacetate, in conjunction with an ice-bag, is indicated for the relief of pain and swelling. Internal medication with the salicylates, aspirin, pyramidon, etc., is sometimes useful in alleviating the pain, but these drugs have absolutely no specific action whatsoever. When the process has reached the subacute or chronic stage it is time to begin the use of measures designed to restore the mobility of the joint and to pre^'ent the formation of adhesions. Massage, passive and active mo\ements, the use of superheated dry air, baking the part at a temperature of 250° to 350° F., the therapeutic incandescent lamp, and the Oudin high-frequency electric current are all very useful at this time. Some benefit may also be derived from local applications of ichthyol, methyl salicylate, or compoinid iodin ointments, and a firm pressure bandage. Of utmost importance in this stage of the disease is the use of gonococcic vaccines and sera. These should be autogenous whene^•er possible, but very satisfactory results can also be obtained from the use of the usual stock preparations. 114 GONORRHEAL ARTHRITIS TJie dosage sliould begin with about 25,000,000 organisms, and tlie injections be repeated, Avitli constantly increasing doses, every three to six days, according to the reaction and the results obtained. Antigonococcus serum has not yielded as good results, in my hands, as vaccine, but it is occasionally very beneficial, and should therefore not be forgotten. The large number of cases of gonorrhea in which the seminal vesicles have apparently acted as the local foci of infection has led Fuller and others to resort to perineal incision and drainage of these structures. Some very brilliant residts have been reported following this procedure but the operation should never be advised until the above methods of treatment ha\'e been given a fair and sufficient trial, as the exposure and drainage of the vesicles is, at best, an operation of some magnitude. The use of Bier's hyperemia is sometimes of service in chronic and subacute cases, but in the author's experience it has proved of doubtful value. Occasionally in rebellious cases of hydrarthrosis which have resisted strapping and the other measures described above, it may be necessary to resort to aspiration of the joint under the most rigid aseptic precautions. In the rare cases in which the arthritis goes on to sup- puration, immediate arthrotomy and drainage is imperative, but the prompt and intelligent application of the methods of treatment outlined above will, as a rule, render the adoption of tliis measure unnecessary. CHAPTER X. STUKTURK OF THE UU>7JMIKA. In order that the reader may clearly understand what stricture is, and how to detect and treat it properly, it is necessary at this point to devote a few lines to the anatomy, length, shape, and so-called "caliber" of the urethra. The male urethra is a collapsed canal or a continuous closed valve, whose surfaces or walls are always in contact, except during urination, ejaculation, and the passage of instruments. It extends from the meatus urinarius externus to the bladder, which it joins at a right angle. It is made up of three layers, an internal or mucous layer, a middle or submucous connective-tissue layer, and an external or muscular layer, which in turn consists of circular and longitudinal fibers running from the bladder to the meatus, the circular or ring-shaped fibers being situated outside of the longitudinal ones. In overdistention of the canal with examining instruments the circular fibers may be, and have been, frequently mistaken for true stricture, and the patient subjected to much harmful and unnecessary treatment. The mucous membrane of the urethra is shining in appear- ance, yellowish-pink in color, arranged in longitudinal and small transverse folds, and covered with flat pavement- epithelium for about the first quarter of an inch to one inch of its length, beyond which it is of the columnar variety as far as the bladder. 116 STRICri'RE OF THE URETHRA The portion of the canal which is contained in the cori)us spongiosum extends from the meatus urinarius externus to the penoscrotal junction, where it joins the bulbous portion; it is known as the penile or pendulous urethra. On the roof or upper surface of the penile urethra, about one-half to three- quarters of an inch from the meatus, is the lacuna magna, into the orifice of which, although bounded by valve-like reduplications of the mucous membrane, the tips of whale- bone filiform bougies are apt to pass during urethral exami- nations. Situated principally in the roof or upper surface, but also in the floor or lower surface of the canal for about the first three or four inches of its length, are the mucous follicles or glands of the urethra, with their orifices opening directly toward the meatus; these, if dilated, may also engage the tips of small examining instruments. The bulbous portion of the canal extends from the peno- scrotal junction to the anterior layer of the triangular liga- ment, and is surrounded bj^ the erectile tissue of the bulb of the corpus spongiosum and the accelerator urina^ muscle. Opening directly on its floor are the two orifices of Cowper's ducts, the glands themselves being situated between the anterior and posterior layers of the triangular ligament, and in the substance of the compressor urethra? muscle. We next come to the meml)ranous or fixed portion of the canal, which is surrounded by the compressor urethrae muscle and limited in extent by the anterior and posterior layers of the triangular ligament. The prostatic portion, situated as it is in the prostate gland, and extending from its apex to its base, presents the following structures upon its floor: Running longitudinally in the median line is the verumontanum or caput gallinaginis, STRICTURE OF THE URETHRA 117 coiitiiiiiiiiK on its smiiiiiit (lie Drilicc of tlic uterus riiusciilimis, on cacli side of which is the opening of the common ejaciilatory duct. '^I'hc i)rostatic ducts open into the prostatic sinuses, which arc situated on each side of the vcruniontatunn. It will therefore l)e seen tluit the seniiual vesicles, testicles, and prostate gland are in direct communication with \\\\< portion of the urethra by means of their ducts. The total length of the urethra varies in different indi- viduals and under different conditions, the average being from about seven to eight and one-half inches (17.5 to 21.5 cm.); this is somewhat increased in hyi)ertroi)hy of the prostate gland. The penile and bulbous portions together measure a})out six and one-half (65) inches (16.5 cm.); the membranous about three-quarters (f) of an inch (2 cm.); and the pros- tatic portion one and one-quarter (Ij) inches (3.25 cm.). Being a collapsed canal, and in no sense of the term a tube, the urethra has, strictly' speaking, no caliber, l)ut merely a degree of dilatability which varies greatly in different individuals and in different portions of the same urethra, there being certain points of physiological contrac- tion and dilatation, which points are well shown in Fig. 34, which was drawn from a plaster cast of the normal urethra. Therefore, in examining a patient for stricture of the urethra, the surgeon must bear in mind the fact that the meatus urinarius, the middle of the pendulous portion, and the membranous portion are normally narrower than the rest of the urethra, and also that the fossa navicularis, the bulb, and the middle of the prostatic portion are larger and more dilatable; and that if the urethra is overdistended with examining instruments, these physiological contrac- tions are verv liable to be mistaken for strictured areas. 118 STRICTURE OF THE URETHRA Tlir sliajK' of the iirothra varies greatly in the ditlVrcnt regions of the canal, being vertical at the meatus and through- out the fossa na\icularis, transverse in the penile or i)en(lu- Idus urethra, and like an inverted Y in the middle of the prostatic portion, thus A; this formation is due to the jutting uj) of the \eruni()ntanum from the floor of the pros- tatic urethra. Fig. 34. — Showing points of contraction and dilatation in a normal urethra. (Thompson.) 1. Meatus urinarius 21 to 28 French. 2. Fossa na%'icularis 30 to 33 3. Middle of pendulous portion . . 27 to 30 4. Bulbous portion 33 to 36 5. Membranous portion 27 0. Apex of prostatic portion .... 30 7. Middle of prostatic portion .... 45 8. Base of prostatic portion 33 9. Indentation caused by verumontauum. Etiology of Stricture. — The \Rst majority of cases of urethral stricture are due to gonorrheal urethritis. Traumatism is the etiological factor in a small percentage of cases. Congenital stricture is occasionally, though cjuite rarely, encountered. Traumatic stricture is usually single, and may occur in any portion of the urethra, depending on the seat of injury. In the pendulous urethra it usually follows injury of this portion of the penis from various causes. In the vast HTlUCTUItK OF Tflf'J UliKTIIUA H) majority of cases it is roniid in the hiilhoiis or iiiciiiKniiiDu,-, portions or at the hulhonicinhranons jnnctioii; in tlic^c regions it follows falls, kicks or blows upon tli(' perineum, causing i)artial or complete rupture of the un^tlira, either with or without fracture of the pelvis. It may also result from caustic injections into the urethra, in which case the region of the fossa navicularis is the most usual site of the constriction. At the time of the injury these patients have more or less difficulty in urination, or even complete retention of urine, with extravasation of blood and urine into the surrounding '>X% ins. i 2' o to 3 ins. I 2;^ ins. Fig. 35. — Showing division of urethra into regions. (Thompson.) tissues. Bleeding from the meatus may be either scanty or free, depending upon the severity and extent of the uretlu-al traumatism. For a description of urinary extravasation and its treat- ment the reader is referred to page 132. Congenital stricture is occasionally observed. It may occur in any portion of the uretlira, but especially at the meatus, or just beyond it in the fossa navicularis. For conciseness and clearness of description in regard to the location or seat of gonorrheal stricture we will follow the plan of Sir Henry Thompson, who di\-ides the urethra into three regions as follows (Fig. 35) : 120 STRICTURE OF THE URETHRA Region I iiu-huk's all nf tlu' nu'iuhraiious, and one inch of the bulbous uretlira, and is thcrctnrc al)()ut one and three- quarters (If) mclies iu length. Recjion II extends from tin- anterior hinit of Kej^ion I, to within two and a half (2|) inches of the meatus, its length varying from two and a half to three (2| to 3) inches. Rc(/i(»i III includes the first two and a half (2-2) inches of the canal from the meatus. Thompson found that the vast majority- of gonorrheal strictures were located in the bulbous urethra, and at the bulbomembranous junction, or Region I; next in the region of the fossa navicularis, or Region III; and least frequent! \- in the middle of the jjendulous urethra, or Region IT. Primary gonorrheal stricture of the prostatic urethra has never been found, the changes in this portion of the canal being due to submucous cell-infiltration, which does not go on to true stricture-formation. The reason for the so frequent occurrence of gonorrheal stricture in the bulb of the urethra and fossa na\icularis is the fact that in these regions the mucous membrane is lax and surrounded by a large amount of erectile and vascular tissue, an arrangement that tends to prolong a gonorrheal inflammation which has settled there, which naturally results in more or less cicatricial contraction. In the majority of cases gonorrheal stricture is single, although sometimes there may be two, three, or even foiu' well-marked contractions in the same case. This, however, is not at all common, and when found is in all probability due to a continuation of the same pathological process, either from the l)ulb forward, or vice versa, and con- stitutes what is known as a tortuous stricture, which may invt)lve the canal for an inch or so; or even for its entire ST III CT I J UK OF TIIK URETHRA 121 l('iij;'tJ), t.lius coiixcrf iii' fonn bcliiiid tiie stricture, (origi- nating in inflamed urethral follicles or ulcerated spots into which the urine escapes, and finally burrows in fistulous tracts, which may open in the perineum, on the buttocks, the scrotum, or the abdomen (Fig. 40). In some severe cases abscesses of Cowper's glands or of the prostate occur, which, if untreated, may rupture either into the urethra, bladder, peritoneal cavity, perineum, or rectum. Fig. 41. — Cystoscopic photograph of diverticulum of bladder. (Author's case.) DIVERTICULA OF BLADDER. The bladder walls become greatly thickened from hyper- trophy of the muscular layer, which causes trabeculie of muscular tissue to project into the viscus; between these ridges the bladder wall may become very thin and dilated, going on to the formation of sacculi and diverticula (Fig. 41), which may in time rupture and allow" the contents of the 132 COMPLICATIONS OF STRICTURE l)l:i(l(ler to cscaj)c' iiit(» tUv peritoneal Ciivity. Vesical calculi may also be foiiiul lying in these diverticula or embedded in the recesses between the trabecule. URETERS. Follo\\ ing these (haunt's in tlie bladder, the ureters become dilated, as do tlie ])('l\(>s of the kidneys, the secreting por- tions being pushed out and compressed by the accunndated urine. The inflammation ascending from the bladder through the ureters finally enters the pelves of the kidneys, causing pyelitis or pyelonephritis on one or both sides, Avith all of their concomitant symptoms. EXTRAVASATION OF URINE. The urethra behind the stricture having become thin and weakened may, as the result of violent straining, or without any apparent cause, give way and allow the urine to escape into the surrounding tissues in greater or less amount. Extravasation of urine also occurs in partial or complete rupture of the urethra from falls, blows and kicks on the perineum, either with or without fracture of the pelvis. The urethra may gi\e way or be ruptured in any of the fol- lowing regions, depending, of course, upon the site of the stricture or the point of injury: 1. Between the meatus and the penoscrotal junction. 2. Between the penoscrotal junction and the anterior layer of the triangular ligament. 3. In the membranous urethra; that is, between the anterior and posterior layers of the triangular ligament. 4. Behind the posterior layer of the triangular ligament. EXTRAVASATION OF URINE 1.''.3 It is, of course, possible iind not iiiicoiniiioii for two of i\\c^c regions to be iiicliidcd l)\' tlic nij)tiirc of the iirctlirjil wall at the same tiiiic. The constitutional symptoms of extravasation are as fol- lows: The patient sometimes experiences a sudden sensation, as if something had given way in some part of the urethra; this is followed by a feeling of momentary relief, speedily accompanied by swelling of the penis, hypogastrium, scrotum, or perineum, according to the locality of the rupture. The patient at this time has fever, with chilly sensations or well- marked chills and a feeling of general malaise, and if not radically and speedily treated by operation, passes into a condition of extreme shock, and finally dies of a general septicemia. The skin over the swelling, which at first is very tense, bright red in color, and shining in appearance, soon becomes gangrenous, sloughing, and em.physematous from the pres- ence of the gases situated beneath it, which are produced by the purulent, decomposing, and sometimes ammoniacal urine extravasated through the tissues (Figs. 42, 43, 44, and 45). It is an established fact that normal (sterile) urine does not cause gangrene or destruction of the tissues even when injected beneath the integument in considerable quantities. The situation of the swelling varies according to the point of rupture and the time that has elapsed since the injury or accident. When the opening in the urethra occurs between the meatus and the penoscrotal junction the extravasation takes place into the tissues of the corpus spongiosum, pushing for- ward into the glans penis and causing great swelling of that organ. When the rupture occurs between the penoscrotal junction 134 COMPLICATIONS OF STRICTURE Fui. 42. — Extnivasatiou of urine into penis, scrotum, and y\<^\ii buttocl (Author's case.) Fig. 43.— E.\trava.sation of urine iulu scrotum. (Author's case.) EXTRAVASATION OF IJIiINK ] ?,: Fig. 44. — Extravasation of urine into scrotum and over symphysis. (Author's case.) Fig. 45. — Extravasation of urine, with gangrene and sloughing of scrotum. (Author's case.) 130 COMPLICATIONS OF STRICTURE and the anterior layer of the trian, the best instru- ment to use is the flexible bougie a boule (Fig. 50) selecting one that will readily enter the meatus. The penis is held at right angles to the body by means of the thumb and index- finger of the left liand, which grasps it in the sulcus behind the corona. As the bougie, properly cleansed and lul)ricated and held lightly between the right thumb and forefinger, sHdes slowly and gently down the canal it imparts to the examiner an accurate idea of the condition of the uretlu-al walls: whether they are inelastic and rigid, soft and pliable, or the seat of stricture, in which last case it will slij) througli the contraction with a jerk, especially as it is being drawn out. A steel sound, or olivary bougie, is not suitable for this examination, as these instruments are conical and liable to dilate a soft strictiu'e, and not detect it, and in this way give the examiner a faulty idea as to the real condition of the canal. After the stricture has been located with the bougie a boule we may obtain additional information with regard to its size, the location of its orifice, wliether central or eccen- tric, the condition of the mucous membrane, etc., by exami- nation of the face of the contraction with the urethroscope. Great care must be taken to avoid trauma, how^ever, and it may often be advisable to postpone this procedure to a later occasion. Method of Passing a Sound. — An instrument is selected that enters the meatus with ease; it is properly cleansed and lubricated, and passed slowly and with the utmost care and gentleness in the following manner: DIAGNOSIS OF STiaCTIIUK 145 The ()j)orut()r stiuuls on the left side of I lie |);iti(iit, lioMiiifr tlic iKMiis ill the coroiiiil sulcus, l)etw(!('ii the thiiinl) ;iiiil iiKJcx- fiiiger of the left liiuid; in this wny th(! penis is put on the stretch at right angles to, and in tJic median line of, tlic body; thus eflaeing the first curve of the nretJira. 'I'he sonnrl is held lightly between the thumb and first two fingers of the right hand, which rests on the median line of the abdominal Fig. 52. — Sound entering meatus. (Original.) wall, and the tip of the instrument is gently inserted into the meatus (Fig. 52). The hand, still resting on the abdominal wall, urges the sound gently into the urethra, the penis at the same time being drawn upward, so that the sm'geon's hands approach each other (Fig. 53). At this time the tip of the sound is just entering the bulb. The left hand now drops the 10 146 DIAGNOSIS OF STRICTURE penis, wliich is swept slowly dowiiwarfl and at right angles to the body by the sonnd, whose tip now rests against the opening in the triangular ligament, and its convexity in the bulb of tlie urethra (Fig. 5-4). In order to reach the prostatic portion, the handle of the instrument is gently depressed, it being now held in the left hand (Fig. 55). The patient usually complains at this Fig. 53. — Tip of sound entering hulljous urethra. (Original.) time of a desire to urinate, owing to the pressure of the instrument on the mucous membrane of the prostatic urethra, which is extremely sensitive, even in health. If the bladder is to be explored, the handle of the sound is depressed still farther between the thighs and pushed gently upward, when it will be felt to glide easily into the bladder (Fig. 50). DIACNOSfS OF STRICTURE 147 Fig. 54. — Tip of sound resting against anterior surface of compressor urethra; muscle (membranous urethra). (Original.) Fig. 55. — Convexity of sound resting on the floor of the prostatic urethra. (Original.) 148 DIAGNOSIS OF STRICTURE Kn(loscoi)ic tubes, cyst().st'()])es, iiivthrocystosc'ojK's, stone- sea rcliers, lithotrites, evacuating tubes, and in fact, all instrinnents used in the tleep urethra and bladder are introduced in the same maimer as above describeti, always rememberino; to employ tlie utmost care and gentleness, when, as a rule, the instrument will find its way into the deeji urethra and bladder, with only a reasonable amount Fig. 56. — Tip of the sound iu the bladder. (Original.) of assistance from the surgeon. Quick, rough, and unskilful instrumentation invariably leads to muscular spasm, which in turn means difficult or even impossible instrumentation, and may result in a prostatitis or even ])rostatic abscess. In examining old men tJie tip of the instrument will some- sometimes catch or hitch in the bulb, as in these cases it is often in a more or less relaxed and sacculated condition, DIACNOSfS OF STincriHiK 149 find is ciisily cjirricd on llic lip of llic :^i»iiii(| lor ;i -.liort. (list.llicc ii|)\v;ir(i ;uhI l)ciic;itli llic iii(iiil»r;iiioiis lirctlini. TJiis (lifUciilty can be easily oKviatcd hy kccijiii^ tlic tip of the instrument in close contact with the rooi' of the ciinal; a j)oint wi)ich a])i)lics e(juall\' well 1o cases of [)o>1crior median liyjxM-trophy of the j)rostate ^hiiid. If the flexible bouf?ie a boule deteets a strietiire, we must then ascertain its exact distance from the meatus and its caliber. The bougie having been j^asscd down to the ob- struction, the distance down is noted by holding the thumb and finger on the shaft of the instrument at the meatus; it is then withdrawn, when the distance between the finger and thumb and the bulb of the instrument is measured, which gives the exact depth of the contraction in inches. Smaller bougies a boule are tried until one finally passes the obstruction, which, of course, gives its caliber or size. If the stricture is so tight that it will not admit our smallest olivary bougie, or bougie a boule, we then employ whalebone filiform bougies. In passing filiforms it is best to keep the penis on the stretch and at right angles to the body, and try to avoid the lacuna magna on its roof, in which these little instruments sometimes catch. The tip of the instrument may be left straight, or turned and twisted in various ways and shapes, as already shown. The urethra having been injected with a solution of adrenalin chloride 1 to 1000, to reduce the congestion of the mucous membrane o^•er the face of the stricture, the canal is then fully distended and lubricated with warm, sterile olive oil, and a filiform is passed down to the face of the contraction, and rotated slowly and care- fully until it engages in the opening of the stricture; if this does not occur we pass another filiform alongside the first, 150 , DIAGNOSIS OF STRICTURE and so on, until one finally enters the opening in the con- traction and passes through, when it is left in situ and the others removed. If tliis is impossible, we speak of it as an im])assable stricture; that is, im})assable to instruments, altliough even yet the urine can often be voided in drops or even in a fair-sized stream. If the patient has such an abnormally small meatus (IC to 18 French) that it will not admit bougies or sounds of a suffi- cent size to examine the urethra properly, and if it is not thought wise to enlarge the meatus at the time by meatotomy, then we may employ for exploratory purposes the Otis urethrometer in the following manner: It is cleansed, lubricated, gently passed into the bulb, and screwed up to about No. 28 or 30 of the French scale. As the instrument is slowly and gently withdrawn the stenosed areas or spots of thickening are noted, great care being taken not to diag- nose physiological contractions and the circular muscular fibers of the urethra as strictures, which mistake can easily be made if the examiner o\'erexpands the bulb of the instru- ment, or if he is unfamiliar with the anatomy of the canal. CHAPTER XIV. TREATMENT OF STRICTURE. The treatment of stricture depends entirely ii})oi) its cause, situation, and extent, and whether it be soft and yielding, or dense and fibrous in character. As a broad, general rule, however, it may be stated that the best routine treatment for the majority of cases of gonorrheal stricture is gradual dilatation with bougies and sounds combined with local urethral applications and internal medication. If these methods fail or cannot be employed, we are then compelled to resort to one of the cutting operations about to be de- scribed. Traumatic and congenital strictures, being fibrous from their incipiency, do not yield to dilatation, and must therefore be treated by meatotomy, urethrotomy, or perineal section, according to their location. The urine should be carefully examined in order to ascer- tain the condition of the kidneys, and the extent and severity of the urethral and bladder inflammation, if these conditions are present. If any complications exist, they must be treated in the manner already given for such aflPections, to which the reader is referred. Kidney disorders are to be handled on general medical and surgical principles. The reaction of the urine must be modified either by the administration of urotropin or helmitol, as indicated, and the patient's diet l.")!' Th'KATMKXr OF STRICT CRK c-aivt'ullx' rcjiulatc'd, x) tliat \vc may render the urine as hland and noii-irritatiiiu' as ])ossil)le. Strictures of or Near the Meatus. Strietures in this situa- tion do not yield to dihitation and nuist therefore l)e eut (meatotomy). The normal meatus \aries from No. 21 to 2S French, and should ne\er he interfered with unless ahsolutely necessary, as overzealous cutting of tliis part of the canal leads to a flat, spluttering stream that cannot be thrown any distance from the body, and a disagreeable dribbling of urine after each act of urination, also a feeble and unsatisfactory ejaculation, of which some patients complain bitterly. If the meatus is so small that normal urination is interfered with, or that proper treatment cannot be applied to the parts beyond, then it may be cut up to No. 28 or even 32 of the French scale, according to the requirements of each individual case. Strictures of the Penile Urethra. — Strictures of the penile or pendulous urethra include all of those contractions which are situated between the meatus and the j miction of the penis with the scrotum. If these contractions are soft and yielding, gradual dilatation should be tried with filiform or olivary bougies or the steel sound. If dilatation causes such pain or irritation that it is found impracticable, it should be stopped and the stricture cut (internal urethrotomy), either with a straight, blunt bistoury, if near enough to the meatus, or with a urethrotome, if further down the canal. For a description of this operation the reader is referred to page 158. Strictures beyond the Penoscrotal Junction. — For strictures situated in the bulbous ])()rtion of the urethra, or at the bulbomembranous junction, that are soft or even semi- fibrous, we should always try gradual dilatation and local urethral medication before resorting to any cutting operation. INSTRUMENT.'^ 153 Should (liliitiil ion Ijiil, (he slrieliuc Is llicii cwi l)_\' cxtcni.tl urethrotomy. Gradual Dilatation. By ,t;Ta(hial (hlatation is iiicaiit the ^•('iitlc |)assa<;(' of Mhronii bougies, ohvary hoiiji;i('s, or steel soiiiids throiif^h the stricture, the seleetioii of the (hhitiiij^ instrument dependiiif^ ui)oii the size or ealilxr of the eori- traetion, which was ascertained and noted at the time of examination. Instruments. — If the stricture is under IS I^Vench, we should use filiform or olivary bou<^ies, hut if IS hVcnch or over, steel sounds should be employed. Gradual dilatation is performed every fifth or seventh day, depending upon the reaction and results obtained; these can be noted by the patient's sensations, and the appearance of the urine, which should be examined at each visit. The dilating instrument should be warm, well lubricated, passed slowly and gently, and left in the urethra for a minute or so, in this manner exerting pressure on the thick- ened and infiltrated urethral walls, which in many cases resume their normal consistency as the result of the absorp- tion of the inflammatory material. The size of the bougies or sounds must be increased slowly and guardedly in the following manner: If a stricture takes a No. 15 French at the first visit, the surgeon should pass at the second ^'isit a No. 15 and 16, and even higher numbers, provided they do not cause too much pain or bleeding, and so on until he has reached No. 28 or 32 of the French scale, according to the requirements of the case. By the careful employment of gradual dilatation combined with local urethral medication, many cases of even filiform stricture may be dilated up to No. 30 French and over, as the case may require, and be kept so for the remainder of 154 TREATMENT OF STRICTURE the patient's life, provided he will have a sound passed a few times during the year, \\'hile the stricture is being dilated, the urine must be kept bland by a carefully regulated diet, and, if necessary, the internal administration of urotropin in full doses, with l)l(>nt\- of still water. Alcohol in all forms must be prohibited, and si'xual relations refrained from, if followed by irritation. Complications.^ — If the surgeon is hasty, unskilful, or uncleanly in his urethral manipulations, he may cause such complications as urethritis, urethrocystitis, epididy- mitis, prostatitis, abscess of the prostate, false passages, laceration of the urethra, with urinary extravasation, urethral chills and fever, or retention of urine from swelling of the urethral mucous membrane and spasm of the compressor muscle. If, after a fair trial, gradual dilatation fails, we shall then have to resort to urethrotomy, either external, internal, or a combination of both, depending on the seat and extent of the strietured area. Continuous Dilatation. — By continuous dilatation is meant the retention in the urethra for several hours of the bougie or filiform that has been passed through the stricture. As a result of the long-continued pressure of the retained instru- ment some strictures yield sufficiently to allow of the volun- tary passage of urine, and also of larger dilating instruments. It is a useful method in certain selected cases of tight, but soft and yielding stricture, if the patient can be kept in bed and be carefully watched. Rapid Dilatation. — If the stricture will only admit a filiform bougie, it may be left in place and used as a guide for a small tunnelled sound (Fig. 57), which consists of a grooved, conical steel sound, the groove terminating in a canal or kAPIJ) DILATATION W, tunnel at its vesical (extremity, tlirongh which the filiform guide piisses. 'J'hese sounds shoiil. Fig. 57. — Gouley's tunnelled sound and filiform in place. Fig. 5S. — Kollman straight dilator. Fig. 59. — Kollman curved dilator. 150 TREATMENT OF STRICTURE tt) In Fri'iicli. iiiclii>i\ c, ;iiiil nuist \)v well iniidc, so that the edges of the tuiiiiel will not cut the hlit'orin hoiiu'ic, which should pass easily through it, as such an acci(hMit may result iu the loss of the distal fraguient of the filiforui iu the posterior urethra or bladder. The sound is ])assed over the filiform guide and through tlu> stricture, which can in this nianuer be dilated through seAeral sizes at oue sitting, ])ro- vided it is soft and yielding, the subsequent dilatation being carried out with bougies and sounds. This method of rapid dilatation is in reality a form of divulsion, and is attended with more or less risk, even in the most skilful hands, and is therefore not to be employed except in an emergency, and unless the i)atient can remain in ])ed, with ])roper constitutional and local treatment. Divulsion. — The treatment of stricture of the urethra by divulsion with si)ecially constructed straight or curved instruments (dilators) (Figs. 58 and 59) is dangerous, inexact, and rough, as compared with gradual dilatation and the various forms of urethrotomy, and sliould therefore never be employed, on account of the traiunatism inflicted on the delicate urethral and periurethral tissues which, in realitv', are lacerated and torn, with the subsequent formation of additional cicatricial tissue. Electrolysis. — As electrolysis is only of questionable serAice in strictures of the "soft" variety, it is merely mentioned to be emphatically condemned, as in this ^■ariety most brilliant results are obtained by gradual dilatation, and instillations of silver Jiitrate. It has no effect whatsoever upon fibrous or innodular strictures, which demand free incision, either from within or without, de])ending upon their situation in the canal. MKATOTOMY 157 Urethrectomy. I'>y iirctlirccloiiiy is iiic;iiit, citlici- tlu; partial or comijlete resection of nil of tlic stricture; tissue at the time of an external urctlirotoiii\ or perineal section, and the hnildin^- up of a new urethra, sutured nhout a retainerl soft-rul)her catheter or tiihc. (.See discussion of external ur(>throtoiny, i)aj;e 1(17.) Meatotomy. — Hefore jx-rfoi-niint;' nieatotoniy llic patient urinates, in order to flush out the canal, and lies on his back; the external genitals are cleansed, as is also the urethra, by irrigations of warm boric acid solution, and the parts surrounded with sterile towels. Local anesthesia may be caused by injecting a little 2 per cent, novocain or alypin solution into the urethra, which produces its full effect in about ten minutes; or by infiltrating, by hypodermic injection, the region to be incised with a few drops of one of these solutions. The prepuce is retracted and the penis grasped in the sulcus behind the corona; then, with a straight, blunt bistoury, the meatus is slow^ly incised downward on its floor and directly in the median line up to about No. 28 to 32 of the French scale. Contractions just beyond are dealt with in the same manner, except that a little cutting may have to be done in the median line of the roof of the urethra; this fact having been ascertained at the time of the first examination. A full-sized meatus sound (Fig. 60) is then passed through the meatus to see that all is clear, and the passage repeated daily to prevent contraction of the little wound, until healing is complete. Fic 60. — Meatus sound. 158 TREATMENT OF STRICTURE If l)k'C(liiig occurs, it can be readily controlled by pressure witli a plug of gauze and a light gauze dressing. Internal Urethrotomy. — This operation consists of the divi- sion of the stricture within the lU'ethra, the incision being made on the roof of the canal and directly in the median line, either from before backward, or from behind forward, depending upon the kind of urethrotome employed, thus producing a linear wound. When the operation is properly performed there will be little or no danger of wounding either of the corpora cavernosa, as the cut is situated below and between them, in the base of the septum pectiniforme. As a rule, internal urethrotomy should be limited to undilatable strictures situated in the pendulous urethra and not farther down the canal than the penoscrotal junction, unless it is combined with external urethrotomy for the purpose of properly draining the bulb. Instruments for Internal Urethrotomy. — Instruments for this purpose are called urethrotomes, of which there are many forms and ^'arieties. The surgeon shoukl always ha\e two or three of these instruments, as no single one is adapted to all cases. If the stricture is near the meatus, it may be nicely cut with a straight, blunt bistourj' or a Gouley beaked knife (Fig. 61). ]\laisonneuve's urethrotome (Fig. 62) consists of a small groo\-ed shaft with a short curve. The groove carries the blade, and is situated on the concave surface of the staff, stopping at the point where the curve begins. The distal end of the staff has a screw tip, to which may be attached a filiform guide; or it may have a tunnelled, or a solid tip. The blade, fastened to a long stylet, is triangular in shape, sharp in front and behind, l)ut blunt at its apex, so as not to cut the health V urethra. INTERNAL URETHROTOMY 159 Fig. 61. — Gouley's beaked bistoury. Fig. 62. — Maisonneuve's urethrotome. f £ D Fig. 63.— Fluhrer urethrotome. 160 TREATMENT OF STRICTURE Thv instriimcnt is iisod as follows: Thi" stall', with its solid ti]), is i)assc'(l into the hladdcr and lirld Hrnily in the median line of the i)enis, wJiich is j)ulled forward on the streteh; the blade is then slipped into the groove and pushed down, eiitting the contractions before it; it is then with- drawn, the j)enis and staff being held in exactly the same position. If the staff cannot be introduced alone, it can be screwed to the filiform, wliich it will follow; or it may be passed oxer a long whalebone filiform lx)iigie threaded through the eye in the tunnelled tip. The Fluhrer urethrotome (Fig. (53) con- sists of a straight Xo. 12 French grooved stafi", the groove for the knife being situated on the ui)per surface of the in- strument and terminating m a tunnelled ti]), which is slightly cu^rved upward. The blade is like the Maisonneuve and cuts to about Xo. 24 French. A whale- bone filiform bougie is passed into the l)ladder and its end slipped through the tumielled urethrotome, which is intro- duced over it through the stricture. The penis is held on the stretch in the median line, the knife pushed down the groove, and the stricture cut from before backward. The Otis urethrotome (Fig. (')4) is a dilating and cutting instrument combined. It consists of two steel shafts, wliich, when closed, are a})out Xo. 16 French; these shafts are connected by short bars, 1 ke Tiu. 04. — Otis lire thro tome. INTKUNAL iih'i<:'riii,'()'r()Mv nil a pariillcl nilcr, wliicli ciiii he opciicd ov closed \)\ iiiciiii-.ot ;i screw at the llJilidlc of llic iiish-iiiiiciit , w liirli ;it the >;ili)<' time indicates on m little index the caliber to wliicli tliey ;ire opened. 'i'Jie blade running in a f^roove in tJie upper bar becomes concealed in a slot when it reaches its extremity. The instrument, with binde concealed in its tip, is jnissed just beyond the stricture and gently and slowly dilated until the stricture feels slightly tense, when the blade is drawn out, cutting through the stricture on the roof of tlu' can;d and exactly in the median line, and from behind forward. The blade is then pushed back and concealed, the shafts partially approximated, and the instrument withdrawn. This urethrotome is a most serviceable instrument, provided the urethra is not overdilated and unnecessarily incised. Internal urethrotomy having been decided on, the urine must be examined in order to ascertain the condition of the kidneys and whether the bladder or urethra is the seat of inflammation. If diseased conditions exist, they must be treated on the lines already laid down. The patient is kept very quiet in the house for twenty-four hours before the operation and his general condition carefully attended to in every detail. Alcohol in all forms must be stopped and the urine rendered bland by a light, nutritious, and non- irritating diet, and proper internal medication, including urotropin and plenty of water. The bowels should be freely opened before the operation and kept so afterward. If the kidneys will not allow of ether, the urethra may be anesthetized with a little 2 per cent, alypin solution, or general anesthesia may be induced by nitrous oxide and oxygen. The patient having urinated, is prepared as usual. If 11 162 . TREATMENT OF STRICTURE possible, the urethra and bhulcler are thoroughly irrigated with warm boric acid solution by means of a four-ounce hand-syringe and catheter, and the cutting performed either with a straight, blunt bistoury, if near enough to the meatus, or with a urethrotome, if further down the canal. The incision with the bistoury is made directly in the median line and on the roof of the urethra. A No. 28 to 32 French steel sound is then passed, and the (li^•ided con- traction kept open by passing sounds every other day until the wound is healed, when the inter\als ])etween instru- mentations can be made nuich longer. If the stricture is any distance from the meatus, it should be divided with one of the urethrotomes just described, and which is most suitable to the case. As a general rule, it is safe to say that the ]\Iaisonneuve and Fluhrer ure- throtomes are the best instruments for strictures of small cali})er, while the Otis instrument is serviceable for the larger ones. The stricture having been cut, the urethrotome is taken out and a full-sized bougie a boule, or steel sound, should be passed, to see that no bands or constrictions are left, after which the urethra and bladder are again irrigated with warm boric acid solution, several ounces of which are left in the bladder with the idea of diluting the urine and rendering it less irritating as it is voided over the wound in the urethral wall after the operation. The operation being completed and bleeding controlled, the patient is put to bed, with a light sterile gauze dressing around the penis. The stricture, having been cut up to No. 28 or 32 French, is kept open by dilatation, which, with urethral and possibly vesical irrigation, is begun on about the second day after the EXTERNAL URETII UOTOMY \^')A oijcratioii, uiul continued, us already described, (jaily or every other day. If internal urethrotomy is performed in this manner, we will not have such unnecessary complications as s(;vcre, and sometimes even fatal, hemorrhage, urethral chills and fever, permanent curvature of the penis, etc. In this opera- tion, no matter wdiat instrument is employed, it should always be held firmly in the median line; and the penis pulled out over it, and put well on the stretch by an assistant so that the incision will be as nearly as possible in the median line of the roof, thus avoiding injury of the corpora cavernosa, with subsequent and sometimes profuse hemorrhage. External Urethrotomy. — For strictures situated in the bulbous, the bulbomembranous, or membranous portion, we should perform external urethrotomy or perineal section; the object of the external cut being to drain the bladder and the bulb through the perineum, and in this manner prevent the accumulation and absorption of any irritating or infectious secretion that might occur (urinary fever). The following perineal operations are for bladder-drainage and for the relief of strictures of the bulbous, the bulbo- membranous, and membranous portions. The preparation of the patient and the instruments for all of these operations are the same, and to prevent repetition will be described here, and not with each special operation. The condition of the kidneys must be carefully looked into, by uranalysis of the twenty-four-hour specimen, and disease, if it exists, must be treated on the usual medical or surgical lines. The patient is kept very quiet in bed for a day or so before the operation, and his general health is put in as good condition as possible by a light diet and rest. Alcohol must be stopped and the urme rendered bland and 164 TREATMENT OF STRICTURE non-irritatini]; by the administration of urinary antiscjitios. The liberal use of any pure water is also advisable before these operations. If possible, the bladder and urethra should be irrif^Mted Fig. 65. — Lithotomy position for external urethrotomy — scrotum re- tracted to expose operative field — staff renders urethra prominfiit. (.\uthor's case.) daily with warm boric acid or salt solution for several days before the operation. The bowels should be freely moved with calomel the day prior to the operation, just before which the rectum is cleansed with a hot saline enema. KXTFJiNA L VlfETIIh'OTOMY H)o The piiticiit, hciii-,^ aiicstlicti/cd, is jjhifcd Jn il,,. \\\\mAu\i\\ position on the cxtrcinc end of tlie table, on a Kelly pad (Fig. (if)). 'i'he patient nuist he in a good light, and held there flat on his back and exaetly in the median line by leg-holders. All asejitic ])reeantions are obserxcd, as in any operation. Kxtemal Urethrotomy icith a Guide. The patient being prepared for opera- tion and anesthetized as already de- scribed, the anterior urethra is injected with a drachm or two of (1 to lOOO) adrenalin chloride and then distended with warm, sterile olive oil. Then a whalebone filiform bougie is passerl through the stricture into the bladder. The author's tunnelled staff (Fig. 6(3) is then passed over the filiform to the anterior face of the stricture and held there exactly in the median line by an assistant, who, pressing the instrument downward, renders the perineum tense and at the same time retracts the scrotum, thus exposing the operative field (Fig. 65). The operator then cuts down on the groove on the convex surface of the staff, being careful not to cut the filiform guide as it emerges from the tip of the staff. The urethra is opened grooved and tunnelled by a single clean incision, which thus piace"""^ ^^'^°™ '° 160 . TREATMENT OF STRICTURE exposes tlie stall', ami the lilit'orm bougie entering the stricture (Fig. 67). The staff is now withdrawn and the filiform drawn down throu,i,^li tlie penis and out of the perineal wound, its distal Fig. 67. — Tip of staff in contact with anterior face of stricture and filiform passing through it into bladder. (Schematic drawing.) (Original.) end remaining in the bladder through the opening in the stricture. An Arnott grooved director (Fig. 68) is now passed into the bladder by the side of the retained filiform, which is then removed. EXTERNA L f/Rf'JTffROTOM V ](i7 The director Ix-in^ firinl.y held in the mediiiii line, with its groove (hrectcd upwiird, ;i })e;iked })i.stoiiry (Fig. 01) is passed in its groove, and the stricture cut on the roof of the urethra; the bistoury is tlien withdrawn, the probe inverted so that its groove looks downward, and the stricture incised on the floor of the urethra in the same manner as on the rf)of. Fig. 68. — Arnott's grooved director. A gorget (Fig. 69) is now passed through the thoroughly divided stricture into the bladder, from which the urine flows. The index-finger is now passed through the perineum into the bladder to see that all stricture tissue is thoroughly Fig. 69. — Teale's gorget. incised and to dilate the prostatic sphincter and thus prevent postoperative spasm. In some cases of extensive traumatic stricture in which there is a very dense form of scar tissue, it may be necessary at this point to resort to urethrectomy, ?'. e., the partial or complete excision of all the stricture tissue, with the 1.08 TREATMENT OF smiCTrRE huildiiii;- up oi a iirw urethra l)y suturiii.u- toijjether the divideil ends of the eaiial al)()iit a retained soft-rubber catheter. Fig. 71 Fk;. 70 Fk;. 72 Fig. 70. — Four calculi removed from pendulous urethra with urethroscope. Actual size. (Author's case.) Fig. 71. — Two calculi removed from bulbous urethra by external urethrot- omy. Weight, 17 grains. (Author's case.) Fig. 72. — Calculus removed from bulbous urethra by external urethrot- omy. Weight, 49 grains. (Author's case.) Fig. 73 Fig. 75 Fig. 73. — Calculus removed from bulbous urethra by external urethrot- omy. Weight, 15 grains. (Author's case.) Fig. 74. — Calculus removed from bulbous urethra by external urethrot- Weight, 26 grains. (Author's case.) Fig. 75. — Calculus removed from bulbous urethra by external urethrot- omy. Weight, 11 grains. (Author's case.) omy. The deep urethra and liladder shf)uld ahva\'s ])e explored \)\ the index-finger, as in these cases small calculi or con- cretions are sometimes found in the prostatic urethra or J'JXTl'JRNAL l/h-l'yi'/lh'O'l'OM)- Mi!) hl;i(l(l(T (I^'ij^'s. 70 to 7")); Ix-sidcs wliicli, tlic fiii^^cr pn^M'd into the l)l;i(l(l(T dilates tlic prostatic iintlira, uliidi i^ usually contracted in these eases, tini> prcx cntiim in i< great measure postoperative teiiesniiis, and al-^o detects any stricture tissue tliat has not \h-c]i |)rop(rly (h\ ided on the roof of the canal. If the caliber of the stricture is sufliciently lar;,^' to permit of the passage of the tunnelled staff' through it into the bladder, the use of the filiform bougie will not be necessary, ■ the steps in the operation, with this exception, liowever, being the same as those outlined abo\(>. The finger having been passed into the bladder, a perineal tube of about No. 30 to 35 French (Fig. 70) is passed over Fig. 76. — Otis's perineal drainage tube. it and held in the bladder by means of a silk suture, wliich, being passed through both edges of the wound and the tube, is securely tied. The bladder is irrigated with warm boric acid or salt sohition, which is thrown in by means of a hand-syringe or irrigator through the perineal drain, which, when the bladder is partially filled with warm solution, should be clamped, to retain a few ounces of fluid in the bladder until drainage is established. Bleeding-points are caught and ligated, the wound packed with sterile gauze, and the dressing held in place by a firm T-bandage. When the patient is put to bed the clamp is taken off" and the perineal tube is attached to a piece of rubber tubing by means of a glass coupler through which we can see whether the 170 TREATMENT OF STRICTURE bladder is tlraiiiiiig properly or not. The tiihiiig terminates in a bottle under the bed (Fig. 77), wliich is one-quarter filled with 1 to 1000 bichloride solution; this keeps the urine which runs into it sweet, and prevents the entrance of air into the bladder. If the tube fails to drain, it may be due Fig. 77. — Perineal drainage of bladder. (Original.) to the plugging of the eyes with clots, which can be dis- lodged by injecting the tube with boric acid solution by means of a large hand-syringe. The perineal tube is left in place for forty-eight hours, during which time the bladder may be irrigated through it, once or twice a day, with warm boric acid solution. The anterior urethra should EXTERNAL URETHROTOMY 171 receive similar irri^Htioiis, \(\vvm i\\vin\\L\\ ;i siiimII sol't-ruMicr catheter. After tlie tube is removed, lull-sized s(juiids mu.^L be passed daily, at first, and then every other day, followed by bladder and urethral irrigations, the j)atient being allf)\ved to be up and about. When the perineal wound is cicatrized the interval between sounds is made longer and the chronic urethritis is treated, as already described, until rnrcd. Even then these patients should be examined, at intervals of a few months, for several years after all symptoms have disappeared, to forestall any contraction of scar tissue and recurrence of the stricture. ■External Zh-ethrotomy without a Guide. — This operation is employed in cases that will not admit of the passage of an}^ instrument through the stricture. The patient is prepared and placed on the operating table, as above described, and a last attempt made to enter the bladder under general anesthesia. This failing, a Hayden staff is passed down to the anterior face of the stricture, with its groove toward the perineum, and held there by an assistant, who at the same time retracts the scrotum. The operator cuts down on the staff, through the perineum, opening the urethra, on the groove of the instrimient, just in front of the stricture; the cut edges of the urethral wound are then retracted by Allis's clamps (Fig. 78). The staff is now withdrawn and the divided urethra held well open with the clamps. The operator now has a clear view of the anterior face of the stricture. This is carefully examined for its opening by means of a whalebone filiform or Arnott's grooved director, which, if possible, is passed through it into the bladder. 172 TREATMENT OF STRICTURE The strictiiiH' is (li\i(UMl with (imilcys ht'jiked bistoury on the director, as described in the previous operation, and the index-fiujjer is ])assed to the bladder for dilatation of the prostatic urethra, ex|)loration of the i)lad(ler, and to ascertain if all of the stricture tissue has been c()nii)letely dix'ided. A full-sizetl sound is now passed from the meatus to the bladder to see that no contraction has been left. The drainage, dressing, irrigation, and ])Ostoperative dilatation are the same as in the ])erineal oj)eration above detailed. Fig. 78. — AUis's clamp. If the opening in the stricture cannot be found, the surgeon will then huxe to complete the operation without a guide, cutting through the stricture slowly and carefully in the median line, with perhaps the index-finger of the left hand in the rectum, which, i)ressing uj) against the membranous urethra, keeps the operator informed as to the proximity of the rectum and the position of the apex of the prostate gland, both of which are valuable landmarks. This part of the operation will be much simjjlified by keeping the operative field thoroughly .sponged, and the urethral wound well retracted, so that the surgeon can see the ])rogress he makes. The application of a solution of adrenalin (1 to ]()()()) is often useful to prevent obsciu'ing i<:xTi<:i{NAL ('u/'j'nih'o'i'oM ) 17:'. of tilt' opcrjil i\(' field \>\ oo/.iii;^' of Mood. Tlic .^1 lining iiiih-oii~, membrane of the roof of the iirethr;i is also a s(T\iee;d)le guide, as it can he plaiiil.N- seen ;ind fell. Perineal Section, '{lu^. operation is |jerl'ornie(| in those exceptional cases which will not admit of the passage of any instrnnient throngh the anterior nrethra. It is there- fore done without a guide, and is, at best, a \-ery difheiilt and oftentimes tedious procedure. The usual preparations for perineal operation> ha\ii)g been made, the surgeon makes a last attempt to jjass a filiform guide under ether, which, if accomplished, con- verts the difficult perineal section into a simple external urethrotomy. The steps in the operation are as follows: The index- finger of the left hand is introduced into the rectum, and its tip kept in contact with the apex of the prostate gland. A free incision is made, layer by layer, in the median line of the perineum, down toward the anus, in the endeavor to open the urethra just at the apex of the prostate; or the operator can cut down to the urethra by careful dissection, as in an ordinary external urethrotomy. The urethra having been found and opened, a fine, probe- pointed director is now passed through the perineal wound into the bladder, which should be explored by the index- finger, and all of the stricture tissue thoroughly divided, not only on the floor, but also on the roof of the canal, as in an ordinary external urethrotomy. The drainage and the subsequent treatment are precisely the same as described in the other perineal operations. The anterior stricture or strictures are di\ided by imme- diate internal urethrotom\-. 174 . TREATMENT OF STRICTURE Rcirofiradr Cathctcrhai'wn.- — If it is impossible, as it very rarely should be, to find the urethra and to enter the bladder by the perineal route, then the surgeon may i)erform supra- pubic cystotomy, and, guided by the index-finger in the Fig. 79. — Urethroperineal fistula. (Author's case.) bladder, pass a silk bougie through the siuall sui)rapubic incision into the vesical orifice of the urethra, down through its prostatic portion, and out into the j)erineal wound, thus locating the proximal end of the canal. This method may have to be employed in some old and EXTKUNAL U h'l<:Tll h'OTOMY lib neglected cases of stricture, iji wliidi the urethra is con- verted into a fil)r()us cord, llie urine escaping by fistulous tracts which open on the scrotum, f)Uttocks, a})fJornen, or thighs (Fig. 79), also, in cases of extensive laceration or rupture of the urethra, caused by blows or falls on the perineum, either with or without fracture of the pelvis. In these traumatic cases the tissues are sometimes so lacerated and filled with ])looasses the stricture and enters the bladder; this one is always left in and the others removed. The filiform that has entered the bladder ean be retained by tying it in with a pieee of strong waxed A Q Fig. S3. — Filiform liougie tied in the urethra. (Original.) thread or silk (Fig. S3), which is first tied securely about the filiform as it emerges from the meatus (.4), then knotted about an inch from this point {B), and the two long ends brought around in the sulcus behind the corona, and tied in a bow knot on the dorsum {C)\ if the penis becomes erect the knot can be loosened. In a short time, as a result of this continuous dilatation, the urine may begin to drilible out along the side of the retained filiform, but this is not always the case. Using this filiform as a guide, we may pass either a tunnelled silver catheter (Fig. 84) over it and draw some of the urine, or several sizes of tunnelled sounds, and 180 . RETENTION OF URINE in this manner dilate the stricture rapidly. If deemed advisable at this time, the surgeon should perform external or internal urethrotomy, or a combination of both, depending on the site of the stricture and the requirements of the case, using the filiform as a guide, and in this maiuier relieving the retention and cutting the stricture at one sitting. Occasionally it may be possible to pass a filiform through the stricture, even when the method described above has failed, by passing an endoscopic tube down to the face of the contraction. This procedure, by dilating the urethra and smoothing out the folds over the face of the stricture-, permits the operator to locate visually the opening in the contraction and to introduce the filiform guide through it. G. TieMA/VN & CO. Fig. 8-i.- — Gouley's tunnelled catheter and guide. If this plan also fails, and the case demands it, we must then resort to suprapubic aspiration of the bladder, passing the needle through the space of Retzius and anterior bladder wall, which, fortunately, is not covered by peritoneum when that viscus is distended with urme. Aspiration is performed as follows: The patient is placed on his back and the operative field shaved, rendered sur- gically clean, and surrounded with sterile towels; a few drops of a 1 per cent, solution of noA'ocain or cocain are then injected beneath the skin, directly in the median line and just above the symphysis; the integument over this TREATMENT 181 spot is incised for ahoiit, ii- ([uartcr of ;iii iiH'li, the jmtlior's trocar and cannula (Fig. 85) thrust downward througli the little incision into the bladder and part of tlu; urine drawn, after which a little warm boric acid solution should be thrown into the bladder through the outflow tube of the cannula by means of a hand-syringe and rubber coupler, so as not to relieve the pressure too suddenly, by completely emptying the viscus. The cannula is then removed, and the little puncture covered with a pad of sterile gauze. If the retention is due to prostatic hypertrophy and the patient is not in too much distress, we should first try hot sitz baths and rectal irrigations, as already described, Fig. 85. — Author's trocar and aspiration cannula. especially if it is the first attack the patient has ever had, as in such cases the urine is usually clear, instruments never having been passed, and infection is therefore very liable to occur from traumatism of the congested prostatic urethra and bladder base. These means failing, we may then resort to careful catheterization under aseptic precautions, as before described; we may use olivary or plain silk or rubber coude catheters (Figs. 86 and 87), or silk bicoude catheters (Fig. 88). The angle in these instruments enables them to rise over the bar or posterior median enlargement of the prostate, which is situated on the floor of the vesical orifice of the urethra. It is alwavs best in these cases to 182 RETENTION OF URINE Fig. SG. — Olivary pointed silk coude catheter. Fig. 87. — Soft- rubber coude cathe- ter. Fig. 88. — Silk bi- coudc catheter. ri{i<:.\TMi<:NT 183 try llic sot't-nihhcr iiislriinicnls first, ;is tlicy iirc less liiiMc to produce trauinatisiii, wliicli is the first step toward urinary infection witli its trjiin of distressing anrl dangerous sequela'. If the hiadder cannot he entered with any rjf the above instruments, then a siilver catheter with jirostatic curve (Fig. 89) may be employed, the surgeon always bearing in mind the traumatism that this rigid and unyielding instrument is liable to produce even in trained hands. If catheterization is impossible, the patient must })e aspirated above the pubes as already descril)ed. Fig. 89. — -Silver catheter with prostatic curve. In all cases of retention of urine, but especially in those due to hypertrophy of the prostate gland and old and tight urethral stricture, great care should be taken never to draw all of the urine, as the sudden and complete evacuation of the bladder, especially in prostatics, is very liable to be followed by severe shock and suppression, or by brisk hemorrhage in the kidneys, bladder, or both, owing to the sudden removal of pressure from the kidneys and bladder wall. If by some mistake the bladder has been completely emptied, then several ounces of a warm, sterile, boric acid or salt solution should be thrown into the bladder through the catheter or cannula and left there. As the urine is 184 RETENTION OF URINE slowly withdrawn it must he partially replaced by a warm, sterile, and non-irritating solution. In any case of retention, no matter what the cause may be, all instrimicntation of the urethra should cease as soon as there is nuicli bleeding from the meattis, as this shows that the mucous membrane has been damaged and false passages ])robably i)roduced; catheterization at this time is futile, and should therefore be abandoned for the hot bath, aspira- tion, and rest in the recumbent position, or, this failing, immediate perineal or suprapubic drainage. Should the patient's general condition warrant it, a prostatectomy or urethrotomy may be ])erf()rmcd at this time, as indicated, although in the majority of cases these operations should be deferred imtil drainage has ])een established for some time and the functionating powers of the kidneys ascer- tained. CHAPTER XVI. URINARY FEVER. Urinary fever, also known as catheter fever, urethral fever, urinary poisoning, and urinary infoftiou, may follow any of the various operations or instrumental procedures on the urethra and bladder, especially in those cases in which the mucous membrane is lacerated, the urine septic, and the kidneys damaged. Patients are occasionally met with in whom the easy and gentle passage of clean urethral instruments is followed by pallor, faintness, and even complete loss of consciousness; this is merely a reflex nervous phenomenon which is in no way connected with true urethral infection. There are two main varieties of urethral fever, as follows: In the first variety there is a slight rise in temperature, coming on after urethral operation or instrumentation, and preceded or accompanied by chilly sensations or a decided chill. These patients feel hot, uncomfortable, and restless for a short time, after which they are perfectly well. The second variety is more severe; the chill is sudden, well marked, and prolonged, followed by a rise in tem- perature (sometimes as high as 105° F. or over), profuse sweating, and general depression of the vital forces. This severe form may recur with each attempt at urethral in- strumentation, and is often accompanied by partial or even total suppression of urine. These patients are in a .186 URINARY FEVER critical condition, as their kidneys arc, as a rule, more or less iliseased. The etiology of tirinary i'e\cr is hactcrial infection, the most common orjianisnis being the colon bacillus, staphyl- ococcus, and stri'ptococcus. It is therefore more apt to occur and to be more severe in i)atients with daman'cd kidneys, septic urine and lacerated bladder and urethral mucous membrane, from which septic absorption can take place. In order to gtiard against urethral fever we must be absolutely aseptic in all of our operative procedures and instrumental examinations on the gcnito-urinary tract, and endeavor not to produce lacerations or al)rasions of the bladder or urethral mucous membrane by overzealous and rough instrumentation. Urotropin in full dose should always be administered before and after instrumentation, with copious draughts of water. Treatment. — The patient is kei)t in bed and the bowels freely moved with calomel and saline in liberal dose. Alcohol baths will add to the patient's comfort. Cardiac stimulants and tonics, such as quinin and strychnin, are administered if indicated. Should there be any sign of suppression of urine we must immediately order dry cups over the kidneys and hot-air liaths, or hot packs, with diuretin, or caffein- sodium-salicylate, tincture of digitalis, sweet spirits of nitre, and liberal amounts of water. Hot normal salt solution is of great ser^•ice in some of these cases, and may be ad- ministered either by infusion into the median basilic vein, subcutaneously with a small aspirating-needle (hypo- dermoclysis), or injected into the recttnn. If there are any operative wounds of the urethra, they must be kept clean by irrigation with sterile boric acid solution, and the urine TREATMENT 187 drawn with sterile e;illie1ers, or I he Madder dniined l»y perineal or sti])rii|)iil)ie ineisioii, or the retained or iiiflwellin^ catheter. liorie acid, heii/,oat(! of so(hi, iirotropiii, or liel- niitol, fi;iv('ii internally and in I'nII dose, lia\(' marked eflV'ct on tlie urine, and should therel'ore he employed. CHAPTER XVII. T'lIKTIIlJAL INSTUrMENTS: T1IKI1{ CAIIK AND USE. Before taking uj), in detail, tlic discussion of the prepara- tion and nianipnlation of the various in(hvi(hial instruments used in urologieal work, we must consider, for a moment, the general principles which go\'ern their use. It must be remembered that in the great majority of cases demanding urethral examination and treatment the mucous membrane is congested and more or less irritated and infected. It is imperative, therefore, that all instruments coming in contact with it be absolutely sterile, and that their surfaces be smooth, highly polished, and non-irritating. Also that the surgeon be so careful, gentle, and skilful in his instrumental manipulations that he does not cause contusions, abrasions, or lacerations of the mucous membrane, over which purulent urine subsequently flows, the septic material from which, being absorbed by the wounded mucous membrane, is very apt to give rise to alarming and even fatal mani- festations; this point is of paramount importance and is not always sufficiently appreciated. We should always remember that traumatism is the first step in urinary infection. The examiner must never forget that extreme gentleness is of as much importance as the proper cleansing of his instruments, and that many of the methods advocated for this latter purpose with formalin, formaldehyde, etc., are SILK OJJVAItY BOUGIES AND BOUdIKH A BOIILE ISO liable to render the surface of flexiMc instminents so rotif^li and irritating to the urethral mucous inenihrane that they are really unfit for practical use, although from a laboratory standpoint they may be absolutely sterile anrl harmless. If instruments have been sterilized in this nijiinicr, they should always be dipped in a sterile boric acid solution and their surfaces tested prior to use, in order to prevent urethral and bladder irritation. Sounds should be kept separate from each other to prevent scratching or denting of their nickel-plated surfaces, whic-h ought always to be intact, smooth, and highly polished. When passed on a patient they should be washed with soap and hot water, dried on sterile gauze, and dipped up to the handle in alcohol, which is then lighted and allowed to burn off; or after washing, the sound may be boiled for a few minutes in a 2 per cent, carbonate of soda solution (to pre- vent rusting), or plain water, if this method be preferred to the flaming process. The sound can now be cooled, if so desired, by dipping it in cold sterile water or boric acid solution. Tunnelled sounds are prepared in the same manner as ordinary sounds, great care being taken to render the tunnelled portion and groove clean, with a stiff nail-brush and plenty of soap and hot water, before the instrument is subjected to the flaming or boiling process. Endoscopic tubes must be very carefully washed inside and outside with hot soapsuds, dried on gauze, and then flamed oft' with alcohol; or boiled in soda solution; their obturators are cleansed in a similar manner. Silk Olivary Bougies and Bougies a Boule. — These instru- ments should be soft and flexible, with smooth and highly polished surfaces. They can be boiled in plain water for a 190 URETHRAL INSTRUMENTS tVw iiumieiits, and tlu'ii })lacc(l in cold Uoric acid s(tluti()ii. When not in use tliey should l)c laid away straiulit, and separate from each other. Before usint;; these instruments we should always test their strength, as they deteriorate with age, and may become so weakened as to break ofl^' in the canal and slij) into the bladder (see Fi^. !)1 ). Whalebone Filiforms. — Filiforms must be kept straight, as coiling or bending roughens and si)lits their surface, thus rendering them unfit for use. It is well to keep tliein in tightly covered metal cases, as they are liable to be attacked by a parasite, which renders them brittle and useless. They should be washed in soap and cold water, dipped in alcohol, and dried on sterile gauze, after wliicli they can be placed in cold sterile water or boric acid solution. All this should be done only a few minutes before they are to be used, as long immersion in watery solutions renders them too soft and pliable to pass through tight strictures. Urethrotomes. — These instruments are difficult to clean, and tluTcfore require a thorough and careful scrubbing with a stiff brush and plent\' of soap and hot water, especially in their grooved and jointed j)ortions. They are then dried with absorbent gauze, boiled for a few minutes in 2 per cent, carbonate of soda solution to prevent rusting, or flamed with alcohol. The blades should not be boiled or flamed, even for a short time, as it destroys their keen edge; they are, therefore, first washed in soap and hot water, wij)ed with sterile gauze, and then laid in alcohol, from which they are taken for use. Lithotrites. — These instruments are taken a])art, and sterilized in the same manner as just described for the urethrotome. The handle of the Bigelow instrument must not be boilcfl. SOFT-RUBBER CATII f'JT/'JUS 191 Silver catheters with tlicir ohtiiriitors or st\ lets jin- \v;isli(;y means of tlu; author's tirctliral forceps (V'\i^. 92); or, this failing, through a small jx-rincal or sui)rapuhic cystotomy incision. They should l)e laid away straight and not in contact with each other. 'JgffLU A M^^lUli{W^^^^^ Na«» "Fig. 92. — Author's urethnil forceps. During the heat of summer soft-rubber and flexible instru- ments, unless in daily use, should be lightly dusted with French chalk to prevent them from sticking together, \\hich destroys their delicate and highly polished surfaces. For transportation in a sterile condition these and the silk catheters can be placed in a glass catheter-carrier, (Fig. 93), which, together with the catheters, can be placed in a sterilizer and boiled. Fig. 93. — Glass catheter-carrier. Syringes. — The large metal and glass syringes, for bladder and urethral irrigation, can be taken apart, washed and boiled for a few moments. Cystoscopes- should be carefully washed in soap and water, and their irrigatmg and catheter channels injected 13 194 URETHRAL INSTRUMENTS with ak'oliol, aftrr which llu-y arc rinsed oil' in sterile water, dried on sterile gauze, and i)iac'ed in a Sciiering formalin sterilizer, in which formaldehyde gas is produced from the vaporization of ))araform pastils. In phice of this they may he laid in sohitions of formahn, '2 per cent., or oxycyaiiide of mercury (1 to oOOO) for ten or fifteen minutes before use. In any case they are dipped in a sterile solution of boric acid just before use, to guard against irritation of the mucous membranes by the sterilizing agent. They cannot he boiled on account of the cement around the lenses. Urethral Catheters. — These httle catheters are made of woven silk, and have delicate and highly polished surfaces, which must always be intact. They are washed in soap and hot water, carefully injected, dried on sterile gauze, and then subjected to formaldeliyde gas in the sterilizer above mentioned, or boiled for not more than two minutes. Just before use they are dipped in a sterile boric ackl solution. LUBRICANTS. These substances must be smooth and sterile, and ab- solutely non-irritating to the urethral and bladder mucous membrane. If instrumentation is to l)e followed by urethral or bladder medication, the surgeon must use a lubricant that is soluble in water, otherwise the mucous membrane will l)e covered with a non-soluble coating, which prevents the medicated fluid from acting upon the urethral walls. Of the soluble lubricants, that made according to the following formula has pro\'e -' ■"f Fig. 96. — Hard vegetations (warts). (Author's case.) As hard warts are always prone to undergo malignant degeneration, the surgeon should remember this fact, especially in middle-aged and elderly men, and always have an immediate microscopic examination made of the deeper portion of the new growth, which, if found to be malignant in character, should always be promptly and .204 AFFECTIONS OF THE GLANS AND PREPUCE radically removed, eithor l)y amputation or total extirpation of the penis; together with, if indicated, the removal of the inguinal lymph ganglia. Treatment. — The warts themsehes and the surrountHug parts are carefully cleansed and surrounded with sterile towels, and then, under local (cocain or novocain) or general anesthesia, all of the vegetations are thoroughly removed with curved scissors, close to the mucous membrane or integument. Fig.- 97. — Hard vegetations (warts). (Author's ca.se) The parts are then cleansed, lightly wiped with moist sterile gauze, and dressed with dry gauze and an\' good dusting powder, such as boric acid or aristol. If not too numerous the warts can be fulgurated with the Oudin high- frequency current. CIRCUMCISION 205 ir llic wiirts iirc sitiialcd ;il)oii1 the meatus, fare imist he taken not to cut its lips, us healing of the little wounds will bo followed more or less by eieatrieial eontraetioii, with a resulting stenosis of this portion of the canal. Warts in the urethra proper are best removed through a large endoscopic tube, by fulguration witli the Oudiii high- frequency spark. If the patient has a long foreskin, circumcision should be performed when the warts are removed, or at a later date if deemed more advisable. CONGENITAL PHIMOSIS. Congenital phimosis is caused by stich a degree of narrow- ing of the preputial orifice that the foreskin cannot be retracted beyond the glans; it is frequently complicated by bands or adhesions running between the glans and the inner snrface of the prepuce, and may or may not give rise to mild or very severe attacks of balanoposthitis, with painful and annoying manifestations. Treatment. — The palliative treatment consists in keeping the parts as clean and dry as possible, but circumcision should be strongly advised as the only cure for this condition. CIRCUMCISION. The external genitals are shaved and rendered surgically clean in the usual manner^ the patient urmating just before the operation, which is done under general or local anesthesia in the following manner: The prepuce is dra\^^l well forward, and a circumcision clamp (Fig. 98) applied in such a manner that its blades are exactly parallel with the corona (Fig. 99) ; 206 AFFECTIONS OF THE GLANS AND PREPUCE this u'i\"cs tlifiii ail (il)li(iiic |)((^iti(l!l,as shown iii the liiiurt.'; thr foreskin is now ahhitcd with a pair of iicaxy curxcd scissors or a straight knife, eiittini;' close to the distal siih- Hnmmmy"!!!! iir^^jiw -j i i - — — I'r;. 'J.s.--( 'ircuiiK-isinn chiiiii). of the ehmi]), ^\■hi{•h is now renio\'ed, when the iiitei;imieiit retracts to the coronal sulctis and lca\es the external or raw surface of the mucous layer of the pre})uce exposed. The clamp is now applied to this layer and the cutting done Fig. 99. — Clamp applied to foreskin. in exactly the same inanner as above described, which leaves the frenum intact and also plenty of mucous membrane. Bleeding-points are caught and ligated with fine gut, and cntaiiMdisioN 207 the wouikI closed with hhick-silk intcrnipfcd iiliirc plnccd about ouc-qiiiirtcr incli Ji])iirt. A inoist birhloridc dn^ssiii^ is then ii])phed, and the j)atieiit ke])t on his haek, or xv.vy quiet, for a (h\.\ or so. If the operation is done under noxoeain or eoejdn anes- tliesia, the solution (0.5 to 1 })er cent.) shoukl he injected hypoderiuically between the two layers of the foreskin after the clainp has been applied, and alktwcd (i\c to ten minutes to act before cutting is comrneueed; when the tegumentary layer has been removed, a little of the solution may be dropped on the raw surface of the mucous layer. Local cocainization produced in this manner renders the operation comparatively painless. If the prepuce can be retracted it is well to do so and to wrap the glans and retracted prepuce with gauze soaked in 2 per cent, cocain for a few minutes before applying the clamps. Should retraction be impossible, the preputial cavity may be dis- tended with the solution, injected by means of a hand- syringe. In either case the mucous membrane of the pre- putial cavity is anesthetized, thus adding greatly to the patient's comfort during the rest of the operation. Patients must be told not to soil the dressing while urinating. CHAPTER XIX. THE CHANCROID. The chancroid, or soft chancre (also called the simple and non-infecting chancre, or the local, contagions nicer of the genitals), is an acute inflammatory and destructive lesion, whose action is purely local in character and limited to the parts upon which it is situated, and to the lymphatic vessels and glands in anatomical relation with those ])arts. Chancroidal infection may be either direct or mediate. Direct infection is caused by the transferrence of the secre- tion from the genitals of one person to those of another during coitus or unnatural practises. ]\Iediate infection is that mode in which the jjus is trans- ferred upon any article to a healthy individual, the agents of transfer being surgical instruments, dressings, towels, or the fingers. Although this manner of chancroidal infection is quite rare, it does sometimes occur. Chancroid of the anus is occasionally met with, the infection being due to unnatural practises or to accidental contamination. The lesion may also be accidentally trans- ferred to other parts of the body. The chancroid is in reality a form of infected or septic wound or ulcer of the genitals. It is caused by the secretion of a chancroid, a chancroidal adenitis, or Ij'mphangitis. It may also originate from any form of pus containing pyogenic microbes, as is well illustrated in those cases where THE CHANCIiOIlJ 209 men derive cluiiuToids from woiiicii, who on f;ircl'iil cxunii- nation reveal iiotliiiig but a purulent discharge, vvliieli, ciitcr- iiig a hair I'olliele, chafe, or ahrasion on the male genitals, produces a typical cliiUKroid. Cliiiiicroids also originate dc novo in subjects who }ia\'e not had sexuid relations for many months |)revious to tin; appearance of the ulcer; these cases are sonictiincs followed by suppurative adenitis in either one or both groins. The infecting agent or cause of these chancroids is some form of pyogenic organism, which gains access to the tissues through a ruptured herpetic \'esicle, or in fact, any lesion which leaves a raw and absorbing surface. Such instances are frequently met with in patients with long foreskins who suffer from balanitis or herpetic vesicles, which if kept clean promptly heal, but if neglected may become infected and thus converted into typical chancroids, which are sometimes complicated by suppurating inguinal adenitis. Ducrey describes a rod-shaped bacillus with rounded ends which he always finds in the chancroidal secretions, and claims, therefore, that it is the specific organism in all cases of chancroid. Up to the present time, however, he has not made satisfactory and convincing culture and inocu- lation experiments, and therefore no absolute conclusions or assertions in regard to the specific nature of the chancroid can be made. The chancroid has no fixed period of incubation, usually making itself manifest in a day or so after infection, its rapidity of development depending on the resistance of the tissues upon which it is situated; thus chancroids develop much more rapidly on mucous membranes and raw surfaces than they do upon the integinnent. which offers more obstruction to the invasion of the pyogenic microbes. 14 210 THE CHANCROID Tlu' chaiKToid usually hi-giiis as a siiuill pustule, the mucous nicuibrane or iutcgunicut surrouuding which is bright red in color, which is due to the acute inflammatory and destructive nature of the lesion. The pustule soon rup- tures, leaving a round or irregular ulcer, with sharply cut edges, undermined walls, "worm-eaten," rough, and yellow floor, which gives rise to a brownish, purulent, and auto- inoculable secretion. There is a varj'ing amount of inflam- matory edema or thickening of the tissues around and beneath the sore, W'hich shades oft" gradually into the surrounding parts, thus dift'ering from the induration of the chancre (initial lesion of syphilis), which is hard, firm, and sharply limited. The duration of the chancroid varies greatly in difl'erent cases and depends upon its extent, situation, and the treat- ment employed. Chancroids of the meatus are usually fol- lowed by more or less cicatricial stenosis of the canal at this point, while those situated on the free edge of the prepuce may lead to phimosis, from cicatricial contraction of the preputial orifice. Chancroids are most commonly found upon the genital organs of either sex, but may occur on the head, face, and finger, usually from auto-inoculation. They may be situated either on the free border or inner surface of the prepuce, upon the penis, at or within the meatus, on the glans, corona glandis, or in the sulcus behind the glans. When occurring on the scrotum, pubes, thighs, or anus, they are ordinarily due to auto-inoculation. As the result of unnatural practises. we sometimes find chancroids situated at the anus, within the rectum, and on the ])erineum. Varieties of Chancroid. — Follicular or Acneform Chancroid. — This form of chancroid begins in hair or sebaceous follicles, COMPLICATIONS OF CIIANCUOU) 211 and is situjitcd iit tlic junction of integument iind niiH-ou-, meinbriuie. It orij^iinates as ii, small j)nstnle, vvliicli is soon eonverted into a deep, ragged ulcer, whose secretion is very destruetive in eliaraeter. Ecfliyniatous Chancroid. — The eethymatous ehaneroid is usually found ui)on those parts of the integument of the genitals which are dry and are not in contact with opposing surfaces. It begins as a little red spot, which is finally con- verted into a pustule with an area of redness around it; the pustule increases in size and dries up into a blackish-green crust, beneath which is a typical chancroid. If phagedena attacks a chancroidal ulcer, as it rarely does nowadays, the lesion is then called a phagedenic chancroid. This serious complication occurs in persons who are insuffi- ciently nourished and alcoholic, and in whom the original lesion was vigorously cauterized, and not kept m a cleanly condition. The infected lesion now has a foul, purulent secretion, a sloughing and gangrenous floor, and is surrounded by edematous tissues, which are purplish-red in color. It de- stroys the soft parts by extending both in depth and at its periphery. When a chancroid becomes really phagedenic, the bearer has a brisk rise of temperature, sometimes to 105° F., with a corresponding pulse increase, chilly sensations, or even well-marked chills, which are followed by sweating and a feeling of general malaise and discomfort, with loss of appe- tite and strength; the aboA'e conditions being due to the absorption of septic material from the lesion. Complications of Chancroid. — Lymphangitis. — In chancroid of the penis or prepuce the lymphatic vessels may become enlarged, hot, red in color, and very painful from absorp- 212 THE CHANCROID tioii of the fliaiRToidal secretions. This iiinainination may either subside or go on to suppuration, with the fornuitioii of abscesses and chanfroichil ukrrs along the course of the lymphatic vessels. Adeiiitis. — ('hancroithil a(h'nitis is caused by the passage of septic material from the sore to the glands in the groin, by means of the lymphatic vessels of the penis. The glands in either one or both groins become enlarged, matted together, and very painful, while at the same time the skin over them assumes a red and brawny appearance. Supj)uration of the glandular mass soon begins and con\erts it into a large abscess ca^'ity, which, if not incised, ruptures spontaneously, leaving a deep, sloughing pocket, with under- mined and broken-down edges, thus constituting a typical chancroidal "bubo." Different Diagnosis. — The chancroid may be mistaken for many lesions occurring on the penis, the most i)rominent among them being the hard chancre (initial lesion of syj)hilis), ruptured herpetic vesicles, abrasions, chafes, fissures, and exulcerated balanitis. The hard chancre has a definite period of incubation, usually from two to three weeks, and becomes typically indurated, as do the glands in anatomical relation with it; its secretion is serous, and its fioor smooth, red, and shining in appearance. Herpetic vesicles coalesce, and are not, as a rule, so deeply ulcerated as chancroids, unless they become infected. The previous history of the formation of the vesicles associated with local pain and itching is of great aid in making a fliagnosis. In exulcerated balanitis the lesion is large and sn|)erficial, with smooth floor, and no undermining of the edges, as occurs in chancroid. TREATMENT OF ('II A SCIiOl I) AND rOMPLK'ATfONS 213 Ahnisioiis, cliiilVs, iind fissures, unless iileerjit.ed, ;ir(; readily recogiiizt^d, as uikIct appropriate treatment tliey lieal rapidly, and leave no tliiekeiiin*^ of the tissues u])(m ^vllielI they were situated. In diaii;nosin<;' any lesion of the ])enis the physieian nnist always use the lifa- tions and told to refrain from sexual relations. The examination of smears from the lesion, by means of the dark-field microscope, will also greatly assist in the diagnosis. In connection with this it must not be forgotten that at the time the chancroidal inoculation takes place there may also occur infection with the spirochetse of syphilis. In such a case the ulcer may appear to be a simple chan- croid, at first, only to develop later into the initial lesion of syphilis, after the typical longer incubation period of the latter has passed. Under these circumstances, the lesion is spoken of as a "mixed sore." Prognosis. — The prognosis of chancroid is always favorable, provided the sore can be kept clean, separated from opposing surfaces, and the parts put at rest. Chancroids of the meatus or urethra, and those complicated by a long, tight prepuce, are more difficult to keep clean, and therefore the prog- nosis as to a speedy cure is not so favorable as when the sore is more readily accessible. Treatment of the Chancroid and its Complications. — The Chancroid. — General ■ Treatment. — Patients suffering from chancroid must be kept as quiet as possible, and told to abstain from alcohol and sexual relations. 214 THE CHANCROID Tlu' trcaliiu'iit 1)1' tlic loioii (K-pciids soincwhat upon its situation, tlu- important ])oints l)cinj;' to kvv\) it absolutely clean, free from all irritation, sei)arat('(l from hcaltliy tissues, and never to cauterize it. The ulcer and surrounding parts should Ix- thoroughly irrigated or washed in h(^t bichloride of mercury solution (1 to .3(100), morning and evening, or more frequently if possible, and dried, the lesion itself being kept coN-ered with wet dressings of zinc sulphate, lead subacetate, aluminum acetate, or bichloride of mercury solution (1 to 3000 to 1 to 5000), which shoukl be renewed every few hours. All the dressings used upon or about the sore must l)e destroyed as soon as removed, and the patient told to wash his hands, ^■ery carefully, immediately after the dressing is completed. In all cases cauterization is absolutely unnecessary and e\en harmful, and should therefore ne\er be employed. If, however, in spite of cleanliness and proper local treat- ment, the lesion extends and threatens the destruction of the surrounding parts, as it very rarely, if ever, does, then we may be compelled to resort to applications of tincture of iodin by means of swabs of absorbent cotton wrapped on a small wooden appUcator. Care must be taken to apply the tincture of iodin to the floor of the lesion and its under- mined walls and edges, but not to the surrounding healthy tissues. A cold bichloride dressing is then applied to allay the pain and inflammation following this application, and the patient told to keep very quiet. Chancroids of the fossa navicularis require the following special treatment: The patient having urinated, the prepuce is retracted and the parts washed with l)ichloride solution. A small soft-rubber catheter, properly lubricated, is then TREA TMKNT OF ClfA NCIIOI I) A Nl) COM I'LICA T/O.S'S '1 1 .'> piissccl ii|) llic iircllirii hcyoiid llic lesions, and hot, horic acid solution is injected l)y means of a large hand-syringe or irrigator. In this inainier the canal is washed out from behind forward, the solution esca})ing at the; meatus. This procedure should be repeated three or four tiin(!S a day. Should the lesion prove resistant, we may supi)lement these irrigations by the application of solutions of zinc sulf)liate or alum (1 or 2 per cent.), or of tincture of iodin, ajjjilicd through an endoscopic tube, by means of absorbent cotton swabs. Fig. 100. — Phimosis scissors. (Taylor.) Chancroids situated beneath a long, tight prepuce, which cannot be retracted, require frequent subpreputial injections or irrigations of hot bichloride of mercury solution. A better plan, however, is to make two lateral incisions through the foreskin and expose the parts for inspection and local treatment, thus preventing sloughing, with more or less destruction of the glans and surrounding tissues. This operation is performed in the following manner: The patient having been anesthetized, the parts are shaved and rendered surgically clean in the usual manner, and with heavy phimosis scissors (Fig. 100) or a scalpel and grooved director, a lateral cut is made through each side of 210 THIi CHANCROID tlu' j)i-('i)iicc tVoin its free cdu'c, well down into tlic coronal sulcus, tlius t'oi'minu' an ui)pc'r and lower (lap, wliicli, when retracted, exjxjse tJie entire glans j)enis and tJie inner surface of the foreskin (Viii;. 101), wliich is not tlie case when tlie dorsal incision is made. The parts are kept constantly Fici. 101. — Lateral infisioiis. (Papier mar-hc model by Dr. Roynold.s.) irrifjated durinii; the operation witli hot bichloride solution. The chancroids are then treated as already described, and the raw edges of the wounds protected from infection by frequent dressings and irrigations with very hot bichloride solution. The liemorrhage, which is quite free, is readily ADh'NfT/S 217 controlled l)y llu- pccssiirc of the (li-cs,siii\ a simple j)lii.stie o|)era,tioii the flaps iiiay l)C triiiiiiied oil', if iie(;(;.ssary, and the edges sutured, at a later date, vvJieii tJic infection has subsided and tJie wounds have healed. Adenitis. — If during the course of chancroids the inguinal glands become enlarged and painful, the patient should be kept very quiet or put to bed. A cold, wet bichloride or alummum acetate dressing is often followed by favorable results in this condition. Dressings of 20 per cent, ichthyol or of compound iodin ointment are also useful in some cases. If in spite of the treatment above given the glands fuse together, break down, and suppurate, thus forming an abscess, they must be promptly treated either by evacuation of the pus and injection of iodoform ointment, or by free incision with removal of the infected glands. First Method. — This method, which was advocated by Helm, and which I have somewhat modified, should be tried in all suitable cases of suppurative adenitis, as it leaves no scar, nor is it necessary for the patient to take an anesthetic, remain in bed, or be subjected to a more or less painful and tedious convalescence. The steps in the procedure are as follows : 1. The operative field and genitals are shaved and rendered surgically clean in the usual manner and the penis bandaged with sterile gauze. 2. A few drops of a 1 per cent, solution of cocain or novocain are injected beneath the skin where the puncture is to be made. 3. A straight, sharp-pointed bistoury is then thrust well into the most prominent part of the tumor until pus flows. 4. All of the pus is forced out through this opening by firm but gentle pressure, as this procedure is, as a rule, painful. 218 THE CHANCROID 5. Tlie abscess Ciuity is irrigated \vitli peroxide of Jiydro- gen until the return is practically clear. 6. It is then irrigated with a 1 to 5000 biclih^ride of mercury or salt solution, all of which is carefully squeezed out. 7. The now thoroughly cleansed abscess cavity is com- pletely filled, but not painfullj'^ distended, with 10 per cent, iodoform ointment, by means of an ordinary ccMiical glass syringe pre\iously warmed in hot water. 8. A cold, wet bichloride dressing is applied with a fairly firm spica bandage, the cold congealing the ointment at the wound and thus preventing its escape into the dressing. The patient should be kept verj^ quiet for the first twenty-four to forty-eight hours, rest in bed being prefer- able, althougli not absolutely necessary. The dressing is remo^•ed at the end of the third or fourth day and the parts examined. If i)us has reaccumulated, a second injection may be made. If, on the other hand, all looks well, the first dressing is replaced by a gauze pad and spica bandage, and the patient told to report in two or three days for examination. In order to secure the most favorable results from this method, it should only be employed when the glands are thoroughly broken down, fluctuation well marked, and the integument thinned over the most prominent part of the tumor so that the iodoform may come in direct contact with all of the infected tissues. If, after one, two, or even three injections, this method fails to produce the desired result, an incision may then be made and the contents of the abscess removed, the previous treatment not having interfered in any way with this operation. Second Method. — The patient having been anesthetized and prepared as usual, a long incision is then made over tlie most ADEN IT I H 210 prominent ]);iH. of \\\v. iiiiiss jiihI |);ii-iillcl witli tlic iiiKninul fold, tlius exposing tlic hrokcii-dovvii, suppunitiiig, and infected glands, wliieli mnst l)e tJiorouglily removed, great care being exercised not to wound the femoral vessels or their branches. Bleeding-points are caught and ligated, and the abscess cavity thoroughly irrigated with ])cn)\idc f)f Fig. 102. — Chronic edema of penis and scrotum follo^dng complete extir- pation of the right inguinal glands. (Author's case.) hydrogen and hot bichloride of mercury solution (1 to 2000). The now clean and dry wound is packed with moist sterile gauze, over which is placed the usual sterilized gauze and cotton dressing, which is held in position by a firm spica bandage. No attempt at suturing should be made in these cases on account of the inflamed and infiltrated condition 220 TIJE CHANCROID of the tissues, wliicli, if left fi-cr tn dfalii, will, under tlio jji'oper treatment, granulate (piite I'apidly IVom tlie hottoni, and not be followed by sinuses, as is so freciuently the ease wlien the wound has been sutured, and primary union obtained at only a few points. In severe cases, where the pus has burrowed downward to the thigh and up on the abdominal wall, it is well to eombine a vertical with the transverse incision for purpose of better and freer drainage. It must not be forgotten that the too radical removal of the inguinal lymphatics is sometimes followed by edema of the lower extremity, or the penis and scrotum, which is severe in character, chronic in course, and very rebellious to treatment (Fig. 102). CHArTKR XX. SYPHILIS. Syphilis is a cJironic, infectious, and constitutional disease, always beginning in a local lesion called the initial lesion or chancre, which, in acquired syphilis, invari- ably marks the point of entry of the syphilitic \irus (or spirocheta). Entering the system by means of the blood- vessels, lymphatics, and perivascular lymph spaces, it attacks primarily the connective tissue, and in its course may affect every tissue and organ in the body. The disease is characterized by an increase of the con- nective-tissue cells and by the development of a new tissue, called granulation or gummatous tissue, composed of small round cells resembling somewhat white blood corpuscles, in which are found the spirochete in varying numbers. Etiology. — The microorganism which is the cause of the disease is a flagellate protozoon discovered in 1905 by Schaudinn, and named by him the Spirocheta pallida (Treponema pallidum) (Fig. 103). It is found in all the lesions of the disease, including general paresis and tabes dorsalis, though its detection in these last "is so very difficult that it has only recently been accomplished. The spirocheta varies from 4 to 14 mmm. in length, with a breadth of from ^ to I mmm. The number of turns of the spiral is from 8 to 26, the turns being narrow and corkscrew-like. The organ- isms mav be found in smears stained hv Giemsa's stain; the 222 SYPHILIS examination of the infected secretion by dark-fic'ld illumina- tion (the best method), and by flooding the smear with Cliincse ink, when they will appear as bright spirals shining against a dark background, provided too much ink is not Spirochpta refringens. Spiroclu'ta pallida. Fig. 103. — Spircjclicta pallichi and Spiroclu'tii rofriii^cii.s. used. The smears should not be made from the surface secretion of the lesion but from the exudation obtained by gently scraping the ulcer until a colorless serum exudes. For further details the reader is referred to the standard works on bacteriology. ET1()L0<;y 223 There are two forms of sypliilis: the acquircfl form ;ind the hereditary form; both are due to tl)e saiin; orgjuiisrn, but differ in tlieir course and manifestations. Acquired syphilis is communicated by a syphiHtic pcrscm to one free from tlie disease, tlie point of inoculation being always marked by the initial lesion or chancre. Hereditary syphilis is transmitted in utero from citiicr one or both parents, and in this form there is no initial lesion; the onset of the disease being marked by general manifestations. As a general rule, syphilis occurs but once in the same individual, although reinfection may take place both in the acquired and the hereditary forms, as a number of cases have been reported in which reinfection has occurred after treatment, with mercury and salvarsan, of the initial attack. The course of syphilis is best divided into three stages: the primary, the secondary, and the tertiary; but it must not be forgotten that in a certain number of cases tertiary lesions may occur in the secondary stage, or vice versa, or that lesions of these different stages may be present at the same time, thus showing that the disease does not invariably follow these sharply defined periods. Primary Stage. — The primary stage of syphilis consists of two periods of incubation. The first period of incubation exists from the time of infection to the appearance of the initial lesion, and, as a rule, lasts from fourteen to twenty- one days; but may be as short as ten or as long as seventy days. This is immediately followed by the second period of incubation, which dates from the formation of the initial lesion to the development of constitutional manifestations, and usually occupies forty to forty-five days, but may be prolonged to sixty, seventy, or even ninety days. 224 SYPHILIS These two periods of incubation make up the primary stage of SNpliiHs, the duration of wliich is from fifty to eighty days. The lesions of tlie primary sta'.\ by ii ciciitrix, hut hy ;i pnrplisJi s|)()t, wliicli in tiinc fades to wliito. If, Jiowevcr, the cliaiicre was infected and suppurat- ing, then there may he more or less of a depression or sear left as a, result of the local tissue destruction. The diagnosis should he made on tJie i)eri'>ains in the bones, joints, tendons, and muscles, which become worse at night, are very common at this period (^f the disease, esi)eciall>' in those who have previously sufi'ered from similar non-specific afi'ections. riff': HYi'iiiiJDKH 237 Iiisoiiiniii, jiccoiiipiiiiicd l)\ \;iri<)Us tible to irritation and inflammation, as may frequently be observed in the slow healing of wounds and scratches, in untreated syphilitic subjects. Syphilitic disturbances of sensation occur in l)oth men and women, but most frequently in tlic latter sex. In some cases anesthesia extends over the entire body, while in others it is restricted to certain regions, its favorite localities being the dorsal surfaces of the forearms, the hands, the ankles, and the feet. Icterus is sometimes observed during the secondary stage, and is caused by congestion and edema of the mucous membrane of the common bile duct. THE SYPHILIDES. The syphilides constitute the various lesions of the skin and mucous membranes which may appear at any time during the course of the disease, in improperly treated cases, and are caused by a localized hyperemia and a varying amount of cell-infiltration. The hyperemic or erythematous syphilides are peculiar to the early stages, while those due to cell-infiltration appear later. The infiltrating cells are small, round, granular, nucleated bodies, resembling somewhat white blood corpuscles, and very similar to the cells found in the initial lesion and the later gummatous tumors. 238 THE SECONDARY PERIOD Tlio course of the syphilides is chronic, and marked by the absence of acute inflammatory symptoms. As a rule, there is no pain or itching except Avhen the lesions degenerate or are situated on the scalp, when they may then cause more or less irritation. Sometimes several varieties of lesions are present at the same time; this occurrence is due to faulty treatment. Their color, which is at first pinkish red, finally fades to a brownish red or copper color; these pigmentary changes being due to a deposit of the coloring matter of the blood in the affected spots. In the following descriptions of the various syphilitic eruptions involving the skin and mucous membranes, the reader must bear in mind and clearly understand that, as a general rule, the roseola or macular syphilide is the first and only eruption commonly seen in otherwise healthy subjects who undergo a proper treatment, and that papules, pustules, gummatous infiltrations, etc., are, in reality, due to tardy, improper and insufficient treatment, or to some intercurrent disease, habit, or condition which undermines the patient's health and vitality, thus rendering his tissues more vulnerable to the action of the spirochetfp. It must also be remembered that, with our modern methods of early diagnosis and more rapidly efficient treatment, not even the macular syphilide or roseola will appear, in the vast majority of cases, provided the patient is seen early enough in the disease. The Erythematous Syphilide. — The erythematous syph- ilide, also called syphilitic erythema, syphilitic roseola, or macular syphilide, is the first eruption to appear, and marks the commencement of the secondary period of the disease (forty-fifth to the ninetieth day). It exists in all TIIIC SYI'UIIJDICS 289 untreated cases of syj)Iiilis, hut may he sf> faint and scanty in some as to escape ol)ser\'atioii. The lesion (joiisists of rouiuh oval, or irrc|(iilar spots of hyperemia with a (Hameter of from one Hue to half an inch. Their color varies from a delicate pink to a decided red or even purple hue. In some cases there is only a mottling of the skin, or the eruption is so faint as to be invisible except Fig. 109. — Diffuse scaling erythematous sj-philide. (Author's case.) on careful examination. Exposure to cold brings the spots prominently into view, which can be accomplished by apply- ing alcohol to the surface or having the patient undress in a cool room. i\.s a rule, the eruption appears first near the umbilicus, then spreads over the trunk and extremities, especially on their flexor aspects; the dorsal surfaces of the hands and 240 THE SECONDAin' PERIOD tVct arc rari'ly imadrd, Imt the spots an- \(.'ry persistent on the ])alins and soles, where they nia\ form seaHng patches (Fig. l(H)j. On the hack tiie eruj)tion i'oUows the obUquity of the ribs, from the mechan hne ontward. When it occurs on the scalj) it is usually aceomi)anied hy alopecia. On the nftiiSi^ ■ ^ ^ t V * iH i^ ^^^B ■^ fl -« a ■ km 1 Fl(i. 110. — f'ondvloiiiata lata. genitals of either sex the macules may hypertrophy, and thus form condylomata lata; the same is true if they are situated al)out the anus, tlie umbilicus, the nose, the mouth, or in the folds beneath and between the l)reasts, or where surfaces of skin are in contact (Fig. 110). If the face be involved, Till'] SYl'IIIIJDh'S 241 tlie eruption is most inurkcd about the nose, nioiitli, diiii, •dud especially on the forehead, at the honlcr of the scalp. The eruption ou the face is generally covered hy fine scales of epidermis or yellowish-white crusts. The Papular Syphilides. -The lesion of the ])apular syphilides consists of circumscribed cell-infiltration into the integument. There are two varieties of the papular syphilide: the conical or miliary papular syphilide, and the lenticular or Hat papular syphilide. The Conical or Miliary Papular Syphilide. — This syphilide has two varieties: the large conical or miliary pajjular syphilide, composed of large papules, and the small conical or miliary syphilide, composed of small piapules. The large miliary papular syphilide is less common than the small variety, and is frequently associated with it. The papules are conical, red m color at first, but finally assume a coppery hue. They rarely appear in large numbers, and are generally scattered over the body. The papules are most profuse on the back and buttocks, the front of the thighs, the face, and the back of the neck. If untreated they are very prone to pustulate and degenerate into ulcers. In the small miliary papular syphilide the papules are about the size of a pinhead, round or conical, sometimes umbilicated, and of a deep pinkish-red color. They are grouped either in the form of circles, segments of circles, or like the letter S or figure 8. The eruption begins about the face, and thence in\-ades the entire body. Some of the papules may be converted into \'esicles or pustules by the formation of serum or pus on their apices. 16 242 , THE SECONDARY PERIOD The Lenticular or Flat Papular Syphilide. 'I'Iutc arc two varieties t)f this syphilide: the small leiitieiilar or flat i)apuhir syphilide, eonijxist-d of small papules, and the lari^e lentieular or fiat i)apular syphilide, eomi)ose(l of lar<;'e papules. Small Lcnticiilar ar flat Pdpiihir Sj/plillidr. — lu this form the papules begin as little red sjjots, and rapidlx' increase in size to one-eighth or even one-quarter of an inch in (Hanieter. They are round or oval, with flat surfaces and sharply limited margins. The papules first appear about the shoulders, the back of the neck, or the sides of the thorax, and are rapidly followed by others on the face and the front of the neck; the trunk and body generally are then in\aded, and on the back the eruption follows the course of the ribs. They are espe- cially numerous on the flexor aspects of the extremities and near joints. The supra- and infraclavicular regions are not invaded. They are more numerous on the palmar than on the dorsal surfaces of the hands. If the papules extend below the knees they are sparingly distributed on the inner surfaces of the legs, and sometimes on the soles. This syphilide frequently spares the face, l)ut not invariably. The scales on the papules are small, adherent, and yellow'- ish white in color. Under proper constitutional treatment this eruption disappears rapidly. A relapse of this syphilide may occur at any time, in improperly treated cases, and the papules then tend to form circles, or segments of circles, on the elbow's and knees, and may be accompanied b}' papules on the shoulders and trunk. Larf/e Lenikidar or Flat Pajndar Syphilide. — Commencing as small spots, the papules increase rapidly in size; they are elevated, sharply defined, and co\ered with small scales; in diameter they vary from three-eighths of an inch to one inch 77//'; SYI'IIILIDKS 243 (Figs. Ill, 112, 1111(1 I i;!). Tlic (-(tlor, wliidi is at first rerJ, soon becomes ('()])|)ery. 'riicir course is ciiroiiic, iiiiless checked hy ;ii)i)r()i)ri;ite treatment. Tliis sypliilide really Fig. 111. — Maculopapular syphilidc. (.Author's case.) 244 THE SECONDARY PERIOD belongs to the middle and late periods of the seeondary stage. The ernption consists of a large number of papules scat- tered irregularly over the body. Upon moist, warm, and Fig. 112. — Muculoijapular syphilido. (Author's case.) unclean surfaces papules, either large or small, become excoriated and transformed into condylomata lata, with a foul and infectious secretion. This occurs most frequently between the toes, around the umbilicus, at the margin of the THE SYI'IIILIDES 245 nostril, on tin; perineum, iihout, the genitals, and Ix'tween tlu; tliiglis and serotinn. Scaling Papular Syphilide of the Palms and Soles. Sealing papular syphilide of thte palms and soles may oceur at any time during the secondary period or with tertiary lesions. Fig. 113. — Maculopapular syphilide. (Author's case.) Their course is chronic, painless, and unaccompanied by itching. The well-marked scaling syphilide of the palms and soles may appear as early as the third month or much later. At first the papules are elevated, sharply defined, and of a deep red color; they increase in size, fuse together, and form irregular spots and patches (see Figs. 114, 115, 116, and 117). 24(1 Till-: SECONDAUY I'Kh'/oi) Fig. 114. — Cirouinsciibcd .scaling papular syphilidc. (Author's case.) Fig. 11.5. — Diffuse scaling papular syphilidc. (Author's case.) Till': svriii LI i>Ks 247 Fig. IIG. — ("ircuinscrilHil -r.iliiMj^ iiapiilar syphilide of sole. Fig. 117.— Scaling papular syphilide. 248 THE SECONDARY PERIOD There is a general thickening of the epidermis, with scaHng and redness of the snrface; in severe cases the furrows of the hand may be converted into painful fissures, wliich are liable to last for months or even years, in improperly treated cases. This affection may extend along the fingers to the nails, whicli tluni become brittle and thickened (syphilitic onj'chia). The Pustular Syphilides. — These syphilides may appear at any time during the secondary stage, or even as late as the tertiary period. The pustules vary in size, from that of a pinhead to that of a ten-cent piece; are round or oval, and surrounded by a coppery zone. They may begin as papules or pustules. In some cases they cover the entire body, while in others they are limited to special regions. The crusts of the small pustules are greenish brown in color; while those of the larger and later ones are greenish black, and somewhat adherent. Beneath the small crusts there is little if any suppuration, but under the larger ones there are well-marked ulcers. The Small Pustular or Acneform Syphilide. — This is a papuiopustular syphilide and attacks the sebaceous and hair follicles. It consists of small, conical, or slightly rounded pustules. The appearance of this eruption is usually attended by more or less fever, which may last for some days, the tem- perature varying from 99° to 100° F., or over. In some cases the pustules are transformed into small ulcers; in others they run together, forming complete or partial rings. The eruption usually begins about the face, the scalp, the back of the neck, and the shoulders, and may then invade the entire body, but is most marked upon the scapular, THE HYJ'IIILIDKH 240 steriiJiI, iuid }irts, soon l)cc;ome transformed into mucous patches or condylomata. 'J'lic lesions may also occur about the anus in the form of tubercular syphilidcs. In the rectum itself the most frequent syphilitic lesion is the se(;()n(lary ulcer. The ulcers may be single or nnilti[)le; they arc "punched-out," with sharply defined, indurated edges, and, at first, involve only the mucous membrane and submucosa. In their later stages they extend deeper, with marked destruction of tissue, and give rise to a foul, offensive and higlily infectious discharge. The sacral lymph nodes are markedly enlarged and the wall of the rectum in tin; neighlwrhood of the ulcers is tough and indurated. Healing, in this stage, is very liable to be followed by stricture of the rectum, owing to the extensive formation of fibrous tissue which occurs. The tertiary manifestations include gumma, which may be single or multiple, and a peculiar slow, productive inflam- mation, with extensive connective-tissue production. The gummata may break down and ulcerate, in which case stricture is liable to occur, and this is even more fre- quently the case after the form of proliferative proctitis described above. Cases of gummatous infiltration and ulceration have been mistaken for carcinoma, and the patient subjected to extir- pation of the rectum, a fact which must not be forgotten by the surgeon when examining these cases. THE LIVER. The liver is invaded by syphilis more frequently than any other abdominal organ. Congestion of the liver sometimes occurs in the secondary 270 SYPHILIS OF THE DIGEST I VE ORGANS stage ot" the disease, and is usually associated with a eutaiu'ous eruption; it may last for from one to sexeral weeks in untreated cases. The symptoms are icterus, gastric disturbances, and febrile reaction, the organ being sensitive on ])ressure. This condition is j)ro])ably due to the extension of a specific catarrh of the intestine to the liver, by way of the common bile duct. The tertiary forms of syphilitic affections of the liver are: amyloid degeneration, perihepatitis, and hejiatitis, of which there are two forms, the diffuse and the gummatous. The symptoms of hepatic gunmia are often obscure; the organ may be increased in size and nodules felt upon its surface. Pain may })e present or absent. The functions of the organ are not interfered with unless the tumors are numerous or large. In severe cases there may be icterus, gastro-intestinal disturbance, and clay-colored stools, flue to obstruction of the gall ducts by pressure from the tumor. Without the assistance of the Wassermann reaction the differential diagnosis from carcinoma may be very difficult, even after an exploratory laparotomy. The diffuse variety is clinically indistinguishable from other forms of hepatic cirrhosis. THE SPLEEN. In rare cases enlargement of the spleen occurs early in the course of sj'philis. The swelling is quite rapid, usually painless, l)ut may give rise to a feeling of weight in the left hypochondrium. It generally subsides in three or four weeks, but may remain several months, if treatment is 77/ A' PANCREAS 277 withheld or is iiiii(l<'(|ii!itr. it iii;i\ occur ;it ;iiiy time (hiriiif^ the secondary period. Gummata of tlie sj^leen arc citiier siiif^lc or iiiiilti]jlc, and vary in size from that of a millet-seed to a walnnt; they may be deeply seated or sit ii;it cd ii|)()ii tlic pcriplicry of tli<; organ. THE PANCREAS. Specific affections of the pancreas are very rare, bnt it cannot be denied that, like the other viscera, it is subject to the diffuse and circumscribed lesions of syphilis. CHAPTER XXVI. SYPHILIS OF THE RESPIRATORY ORGANS. THE NOSE. The mucous membrane lining the nose may be the seat of erythema, mucous patches, and ulcerations, as can be readily demonstrated by examination with the nasal speculum. The symptoms of these lesions resemble those of ordinary catarrhal rhinitis. In the later stage of syphilis deeper ulcerations may occur, which originate in gummatous infiltration of the submucous tissue, and may finally involve the adjacent cartilages and bones, thus leading to serious deformity of the organ from destruction of its framework (saddle-nose). THE LARYNX. Laryngeal lesions are very variable as regards their time of appearance and the severity of their symptoms. The invasion is usually insidious, and the course chronic and painless. The secondary or superficial lesions consist of erythema, mucous patches, superficial ulcerations, chronic inflamma- tions, and vegetations. Erythema of the larynx causes some huskiness of the voice and slight catarrh. It may occur during the course of the THE LARYNX 279 early skin eruptions, and is either difluse or cirenniscribcfl; superficial erosions soni(;tiiTies develo]). Sui)eriicial ulcerations involve only tlie mucous incnihrane. Their margins are shari)ly defined, regular, and slightly elevated, and the floor is covered by a tenacious secretion. They may interfere with phonation to a more or less marked degree. Mucous patches may be situated upon any portion of the mucous membrai>e. If exposed to irritation during respiration or phonation they become prominent, with ragged margins. Chronic inflammation may appear early or late in'^the disease. It is a very persistent affection, and usually leads to a thickening of the mucous membrane. Chronic ulcers are always associated with this condition. Vegetations may spring from the margin of an ulcer or from the mucous membrane itself. The tertiary lesions comprise deep ulcerations, gummata, inflammation, and necrosis of the cartilages. Deep ulcerations occur, and generally begin, in degener- ated gummata. Extensive regions may be destroyed in this manner. Gummata of the larynx may be either single and large or multiple and small. The deposit sometimes undergoes absorption, but without treatment it usually degenerates, forming deep, ragged ulcers, W'hich may attack the framework of the larynx and produce p,ermanent deformity. These lesions are liable to cause an impediment to respira- tion, either from their size or from causing acute edema of the larynx. Perichondritis is usualh' caused bv an extension outward .280 svrfin.is OF THE hksp/ratory organs of ail iiidamniatory or iilccratixc process troiii the imicous or sul)imicoiis tissue. The eartilai;es themselves may be nivaded by the process and partiall.x or totally destroyed. Necrosis occurs in those cases in whicli tiie (•artilaf>;es are ossified and is a very late manifestation. It follows ])erichon(lritis. THE TRACHEA AND BRONCHI. Syphilitic lesions of the trachea and bronchi are rare, but may be similar to those which attack the larynx. Ulcerative processes, following gummatous infiltration, are the most common and sometimes result in stricture, from the contraction of their cicatrices. The principal symptoms of tracheal syphilis are cough, purulent expectoration, and dyspnea. If stenosis of the tube occurs, its most common seat is just above the bifurcation. THE LUNGS. Pulmonary lesions due to syphilis are of rare occurrence. They include syphilitic sclerosis, or induration, and gummata. Syphilitic sclerosis aft'ects a variable extent of the middle or lower lobes but rarely involves an entire lobe; it may be disseminated at \'arious points. The diseased portion of lung becomes firm, elastic, and furrowed, while the con- tained bronchi are flattened and the surrounding pleura more or less thickened. Gummatous tumors may be single or multiple, and resemble those situated in other organs. They are not at all common, but occur more frequently than syphilitic induration. They THE riJcvuA 281 undergo {legenerutioii \vi\\\\ I lie ccnln' oiitwjinl, lc;i\iiig cavities witJi wliite, fibrous vvulls. Ill some cases sy])liilitic lesions ol' the lungs cause no syiiip- toms; in others tJiere is more or U'ss (listnr})ance of res})ira- tiou, and in yet otJiers there are cougli, pain, expectoration, and all the symptoms of pulmonary tuberculosis. The temperature rarely goes above 101° F. The diagnosis depends on the presence of a positive Wassermann reaction and the absence, on repeated examination, r)f tubercle bacilli from tlie sputum. THE PLEURA. During the secondary stage of syphilis patients may complain of pain in the chest, which is associated with more or less rise of temperature and a moderate amount of effusion into the pleural cavity. CHAPTER XXVII. SYPlllLlS OF THE ORGANS OF CIRCULATION. THE HEART. Tertiary syphilis may attack the Jicart in citlier of two ways: (1) as a chronic inflammation (myocarditis), and (2) as gummatous tumors. Endocarditis occurs about the end of the second year, and is usually associated with myocarditis; most frequently it attacks the left ventricle at the apex or base of the organ. Gummatous endocarditis attacks any and all parts of the heart, giving rise to tumors of various sizes. Pericarditis usually follows myocarditis, and attacks either the visceral layer or the entire pericardium. Gummatous tumors of the pericardium are very rare, and usually follow myocarditis. The symptoms of cardiac syphilis are absent in many cases and very obscure in others. The action of the heart may become irregular and feeble, and the patient suffer from palpitation, dyspnea, cyanosis, and ])ain o^'cr the precordium. The diagnosis is rarely made except by tlie disappearance of the symptoms after antisyphilitic treatment administered for some other manifestation of the disease. 77/7'; BLOODVIC^HML^ 283 THE BLOODVESSELS. Syphilitic alTcctioiis of the veins }iik1 «ii)ill;irics arc very rarely encountered. , The arteries may be attacked primarily or secondarily to specific disease of the surrounding tissues. Primary lesions generally occur in the small arteries of the brain. In the large arteries gummatous foci sometimes appear, which may break down and perforate the vessel wall, with resulting hemorrhage into the surrounding tissue or body ca^dties. In affections of the smaller arteries the caliber of the vessel is reduced, and sometimes occluded, by a new, dense, cellular formation in the internal coat, which resembles granulation tissue, and finally becomes organized (endarteritis obliter- ans). This new formation involves the entire circumference of the vessel, and extends outward as well as inward, invad- ing both the middle and external coats. It occurs in patches, which are generally single; a thrombus may form on the patch, become organized, and thus obstruct the lumen of the vessel; or it may become detached, with a resulting embolism. In some instances the changes in the artery are xevy slight, the process being limited to the internal coat; in others the vessel is thickened, rigid, and nodulated in appearance. The disease most frequently affects the carotid and its branches, especially the middle cerebral; syphilitic aortitis is also quite frequently encountered. These lesions may occur as early as the first year or as late as the twentieth, but, as a rule, appear about the third year after infection, in untreated or improperly cared-for cases. As can readily be seen from the above, the symptoms will depend entirely on the location of the lesions. c H A p T i: n X X ^■ 1 1 1 . SYPIIILTS OF THE (IKNITOrPvIXAUY OlUiAXS. EPIDIDYMITIS. Syimiilitic epididymitis may occur as early as tlic second month or as late as the fifth year, but generally de\el()ps within the first six months of the disease, in insufficiently treated cases. It is more commonly unilateral and, as a rule, attacks the globus major. Its invasion is usually unattended by any symptoms, except occasionally, when there is a slight sense of uneasiness in the part. The lesion consists of a smooth, hard, round, or oval and non-painful tumor, situated just above the testicle, usually about the size of a pea, but in some instances larger. It shows no degenerative tendency and cjuickly disappears under antisyphilitic treatment. The scrotum remains unaffected. ORCHITIS. Syphilitic orchitis is sometimes observed as early as the fourth or fifth month, but in the majority of cases it is a tertiary manifestation and appears several years after infection. One or both testicles may be involved, either at the same time or con tunica vaginalis. At the l)e<;innin<^ of the disease there may he litth- ])rojcr- tions n])on the surface of the testicle, due to syphilitic dej)osits, which, as the process continues, fuse together, forming a hard tumor, resembling almost exactly the shape of the normal testicle. In other cases the surface of the tumor is perfectly smooth from the beginning. The course of this affection is very slow. If untreated, it may result in partial or complete atrophy of the organ, or the parenchyma of the gland may degenerate into fibrous, cartilaginous, or even osseous tissue. As a general rule, suppuration does not occur, although it may occasionally follow the breaking down of gummatous deposits. The lesions may be difi'use or circumscribed. In the diffuse form the whole organ is increased in size, firm, hard, and resistant, and unless treated, becomes atrophied. There is also frequently a certain amount of hydrocele. The enlargement is imiform; the outline of the epididymis is often lost, although it may appear as a separate swelling, surmounting the larger mass; the normal testicular sensi- tiveness is decreased or lost, and the induration is of a peculiar "woody" character. The organ feels peculiarly and characteristically heavy. In the circumscribed form gummatous material is deposited in masses through the testicle. These masses have a ten- dency to undergo secondary degeneration and softening, thus causing inflammation and ulceration of the surrounding tissues, finally leading to syphilitic "fungus" of the testicle. It yields readily to treatment, if recognized at an early period. 286 SYPHILIS OF THE GEXIW-URINARY ORGANS The vas deferens usually remains normal in sy])hilitic orchitis, although it may \)c involved; this is true also of the vesiculffi seminales and ]:)r()stato gland. Tlie chief conditions to be ditt'erentiated are tuberculosis and malignant growths. In tuberculosis the disease begins most often in the epididymis instead of the testis proper; the vas deferens is involved early in the disease, and there is frequently a coincident implication of the prostate and seminal vesicles. Abscess and sinus formation are much more frequent. Malignant growths are sometimes hard to difi'erentiate, but, as a rule, the swelling is more nodular, its growth more rapid, and there is a marked tendency to cyst formation. Pain is also a more prominent feature. The Wassermann reaction is of great value in clearing up the diagnosis. The differentiation is important, as sypliilitic testes have not infrequently been removed by mistake. THE PENIS. Gummatous deposits may occur in tlie penis, especially near the coronal sulcus, and are also occasionally found in the corpora cavernosa. These syphilitic deposits gradually increase in size without giving rise to any pain, but soon cause deformity of the organ, especially during erection, owing to occlusion of the spaces of the erectile tissue. THE UTERUS AND ADNEXA. Syphilitic affections of the ovaries resemble those of the testes, but are rarely encountered. THE KIDNKYH 287 The symptoms are slight pain and increase in the size of the organs, with loss of the sexual appetite and sterility. The Fall()i)iiiii tubes are very rarely involved. Gummatous infiltrations and tumors of tJie uterus are occasionally rejoorted . Exulcerative hypertrophy of the cervix consists of an enlargement and hardening of the os, which becomes con- gested and ulcerated, the secretion from the ulcer Ix'inij; contagious, scanty, and mucopurulent in character. This lesion may occur at any time after infection, and runs a chronic course, but responds readily to local and const iln- tional treatment. THE KIDNEYS. In the kidneys of syphilitic subjects the same lesions may be met with as occur in the other organs, such as interstitial nephritis, to which the transient albuminuria met with in some patients is chargeable, gummatous tumors, and cica- trices, which latter result from the preceding affections. CHAPTER XXIX. SYrillLIS OF THE NERVOUS SYSTEM. Syphilitic affections of the nervous system are of frequent occurrence; they may appear as early as the second month or as hite as the twentieth year after infection, and are more frequent in men than in women. Nervous phenomena are more apt to occur in neurotic subjects and those addicted to alcohoHc excesses; also in those who have not received proper and sufficient treatment in the early stages of the disease. Brain-workers, and those who are mentally and physically exhausted, are especially suscei)tible to nervous manifestations; as are also those wlio have suffered from sunstroke, or antecedent meningitis. Arteriosclerosis, or any other condition causing cerebral congestion, also renders the patient liable to nervous affections. The Skull and Vertebrae. — Lesions of the bones may be situated on the inner surface of the skull or ^'ertebr8e•, and, by the pressure they exert, cause inflammation of the men- inges and secondary changes in the brain or cord. These lesions ma>' be periostitis, osteitis, nodes, exostoses, or necrosis. The Dura Mater. — The dura mater is very susceptible to syphilitic imasion. The changes produced in it are increase in thickness, roughening of its inner surface, and increased vascularity. It may be affected alone, or the disease may extend to the inner surface of the skull and the arachnoid, TlIK AH'J'KiaKS 2S\) or the dura mater may hv, secoiidarily invoked \)\ professes begimiing in tJio ])ia mater and arachnoid. The syphiloma may be diffuse or riicuniscriKcd. Sypliiln- mata of tlie S|)inid dura mater reseuihlc those ol the (cicliiid •in origin and course. The Arachnoid and Pia Mater. — An'eclions of the arachnoid and i)ia mater consist ot" con' be either continu(nis or intermittent in character. LOCOMOTOR ATAXIA 203 Locomotor Ataxia. It is now |)ositi\cly (IctfrmiiMd tluit locomotor iitaxiii, or lubes dorsiilis, is iii\;iriiil)ly the result of juitecedeut sypliilitie iiil'cetioii. The existence of u posi- tive Wassermanii reaction, at some time diirin^^ the course of the disease, either in the hlood or cerebrosj)in;d (hiid, becomes worse at nif^iit. Any of tlie joints may be attacked, but "generally the larger ones, usually the knee. In some cases the cartilages are in\aded, gi\ing rise to crepitation. Synovitis. — There are two varieties of syphilitic synovitis; the ftrst is a chronic effusion into the joints, without change in its structures; the second consists of effusion witJi thick- ening of the synovial membrane. The first variety occurs in the early stage. The affection begins slowly and painlessly and consists of an effusion and some stiffness of the articulation. The integument is not involved. The effusion may be slight or copious, and, in properly treated cases, is rai)idly absorbed, while in neglected ones it becomes chronic and very persistent. Suppuration or destruction of the joint does not occur. During this process firm pressure may elicit some pain, otherwise there is none. The second variety occurs late in the secondary and during the tertiary stage. The affected joint becomes slightly painful, enlarged, and its motion impaired. Tlie effusion takes place slowly and is accompanied by thickening of the synovial membrane and fibrous tissue. The lesion is due to gummatous infiltration into the syno- ^•ial membrane. In some cases the cartilages become more or less eroded, thus giving rise to crepitation. There is but little tendency to complete ankylosis. The knee-joint is the one most frequently affected. 20 CHAPTER XXXII. SYPHILIS OF THE EYE. The bones of the orbit may be attacked by either periostitis, caries, or necrosis, and present the same general symptoms as do simihir lesions in the other bones. The infianimatory process may extend from the diseased bones to the contents of the orl)it, causing a cellulitis, ifdiich, if untreated, is liable to result in abscess and partial or com- plete destruction of the eye. These lesions usually attack the orbital plate of the frontal and lacrimal bones. Syphilitic nodes can form upon any part of the walls of the orbit and, if deeply situated, cause protrusion of the eye, with more or less interference of vision. Affections of the lacrimal passages may occur at any period of the disease. In some cases they are limited to the mucous membrane and submucous tissue and consist of catarrhal inflammation, with edema and ulceration. In the majority of cases the process begins in the bones or periosteum and involves the mucous membrane secondarily. As the lacrimal passages become impervious, the tears collect upon the conjunctiva and flow over the face; puru- lent matter forms in the lacrimal sac and regurgitates, causing conjuncti\itis and inflammation of the puncta lacrimal is. If the i)rocess be very severe, an abscess may form in the lacrimal sac. TREATMENT ^-|07 lk;si(lcs the thorougli constitiitioiiiil treatment to \hi ])li()l)i;i iit first, l)iit these syiiii)t()ins o.sit.s ot* lym])li ill the retina, cause Ii(j;li1-(()l(tn(| palclie.s, heiieatli which i)ass tlie vessels oi" tli<' dioroid iiiid the retina. Retinitis is rather an nncoinmon nl;lnil'(^-^t;l1i()ll ;in- day. Moderate exercise in the fresh air and sunshine must be insisted n])on, as well as daily bathing in either warm or cool water, whichever is preferred; as by these means the secretory apj^aratus of the CONSTITUTIONAL I'HMAT M KNT OF SVl'flflJS :',\7 skin is koi)t fiiiKiioiiiiliii^' noriiuilly, wliidi is very essential in these eases. Jinssian and Turkish })a,tlis arc. heiicficiai in sonic eases, as are also |)iaJn hot, salt, or sea baths, prov idcd they are taken in moderation, and not followed by the cold \)\u])^(;, or shower, the shoek of whieh is very harmful and even danger- ous during the first month or so of the disease; the bath may be followed by massage. Surf bathing slionid never be allowed during the early months. In the primary stage of the disease — that is, before tiie appearance of tlie roseola or macular rash, the patient's general health must be thoroughly investigated, and he or she put in as good physical and mental condition as possible. The teeth and gums, as well as the mucous membrane of the nose, mouth, and throat, and also that of the entire gastro-intestinal tract, should be carefully and systematically examined, and put in thorough order, as congested mucous membranes, rough, dirty, and decayed teeth, and spongy gums cause more or less local irritation, whieh is the prime factor in the production and persistence of mucous patches, and is in many cases the underlying cause of salivation, when mercury is administered. The condition of the kidneys should always be investigated at this time, in order to enable us to differentiate between an ordinary, preexisting nephritis and that jjossibly due to the administration of mercury or arsenic. Should nephritis be present, these remedies must be administered with extreme care. Should anemia develop, as it may in the primary and the early part of the secondary stages, hematogenous drugs must be administered, such as iron and strychnin, and, if indicated, arsenic. 318 CONSTITUTIONAL TREATMENT OF SYPHILIS Before the use of salvarsau or neosalvarsan it is always imperative also that the eyes be carefully examined, to see that the fundus and optic disks are normal, as these structures are very susceptible to arsenic-containing drugs. ADMINISTRATION OF MERCURY. In using mercury it must not be forgotten that in certain instances it is apt to cause such disagreeable complications as salivation, stomatitis, and gastro-intestinal disorders, but fortunately such complications at the present time are very rare indeed, as the doses employed are exact, the preparations more carefully selected, and the gums, teeth, and mucous membrane put in good order when the disease is first diagnosed. ^Mercury may be administered by the mouth, by in- unction, by intramuscular injection, or by fumigation. Internal administration: If the drug is to be administered in this manner, the best preparations are the biniodide, protoiodide, or the tannate of mercury, given in i)ill form, and often combined with iron and arsenic. The dose of the biniodide or protoiodide is from a (juarter- to a half-grain, three times a day; while that of the tannate should be from a half-grain to a grain. If so desired, the salicylate or thymolacetate of mercury may also be used in pill form, in from half- to even three- quarter-grain doses; practically, however, these preparations have no advantages, nor are they even as efficient as those previously mentioned. It must be remembered, moreover, that the internal administration of mercury is much more liable to cause salivation and gastro-enteritis than the inunctions or injec- ADMINIHTIIATION Oh' MKIldJUY .''.10 tioiis, to wliicli it is Jar inferior in every resj)(;ct us rogjinJs the ultinijttc cure of the })Jiti(!nt, and tliat it is now [)nif;ti(;ally a thing ot" tlic [)ast, never to he used nnl(!ss it is, for some reason, absolutely iini)ossihlc for th(; [)atient to take any other form of treatment. Inunction: This is the most efficacious and rational mode of administering mercury, as by the inunction method we obtain not only the constitvitional, but also the local, action or effect of the drug, and at the same time sj)are the stomach. The best preparation is a 50 per cent, mercurial ointment made with fresh lard. The part to be rubbed should be thoroughly cleansed with alcohol. A fresh portion of integument is selected each time, and rendered clean as above described, as in this manner irritation of the integument (dermatitis) is in a great measure, if not wholly, prevented. For each inunction or rubbing from twenty-five to sLxty grains or more of the ointment are used, which is carefully weighed and put up in oiled papers or gelatin capsules, thus making the method an exact and accurate one as to the amount of drug used at each rubbing. The inunctions are best given by a professional rubber, although patients can rub themselves, if necessary. The average healthy adult will take about sixty grains of the 50 per cent, ointment at a rubbing, although there are some who can go as high as seventy-five and even eighty grains. Each rubbing should occupy from twenty to thirty minutes in order that the ointment may be well rubbed in, which leaves the skin of a grayish color,, and not markedly greasy to the touch. If the inunctions are given in this thorough manner, the treatment is not as irksome as it is described by some writers ; 320 CONSTITUTIONAL TREATMENT OF SYPHILIS in my own j)r;u'tu'e 1 c-xpcrifiKT little or no (liHicultx' from patients on this score when this method is employed. To protect tiie clothins;, tliese ])atients can wear tiic thin- nest kind of underclothes over the i)art last rubbed. A course of inunctions consists of cIcncii rul)l)in. Right half of back (from root of neck to but- tock, and from median line to axillary line). Region 7. Left half of back (from root of neck to l)uttock, and from median line to axillary line). Region S. liight thigh and groin. Region 9. Left thigh and groin. Region 10. Light leg and foot (dorsum and ])lantar surface). Region 1 1 . Lcftlcgand foot (dorsum and i)lantar surface). The rubbings should be given every other night, the first one not being washed off until just before the second one is administered, and so on throughout the entire course. ADMJNISTUATIOS OF MKh'CHHY 321 Wluwi one coiirsi! of imiiictioiis i^ (iiii.^licd (II riil)l>iiigs), treatment slionlfl he stopped for ;i few days and then resumed in the Siinu! rej^ional manner as ahoxc deserihed, the integument heini^; tiioronj^iily cleansed hy hot soap-and- water haths, (hirin<;- this jx-riod of rest. For rubhing the scalp and face, we employ the white precipitate or anunoniated mercurial ointment on account of the bluish-black color of the mercurial ointment. The.se parts are rubbed two or three times a week during the early secondary stage. Fumigation. — Fumigations are undoubtedly of great value in certain of the chronic, the localized, and especially the scaling and ulcerating, eruptions of syphilis, l)ut must not be employed as a routine method of constitutional treatment. The mercurial vapor is best generated from calomel and cinnabar placed on a Lee fumigation lamp. These treatments may be taken at home or at a regular bath establishment, whichever the patient prefers; the plnsician always prescribing the amount of drug to be used at each bath, and never leaving it to the discretion of the attendant. The purest calomel and cinnabar (red sulphide of mercury) must be employed, and the body or the part to be acted upon thoroughly washed, before the bath is given. The bath should be taken at night just before retiring, and about twenty grains of calomel and forty grains of cinnabar used; these are mixed and placed on the lamp. The patient, undressed and covered with blankets, sits on a cane-bottom chair, beneath which is the lamp; in a few minutes profuse perspiration comes on, the drugs being com- pletely volatilized in about twenty minutes, during which time steam is also produced from the water bath on the 21 322 CONSTITUTIONAL TREATMENT OF SYPHILIS lain]), \\hicli is tlien extinguished. The patient remains on the chair a few minutes longer, and then retires in the same blanket, ^vithout being rubbed. The bath may be given every night, or one to three times weekly, according to the strength of the patient and the amount of mercurial effect desired. The patient should be very careful not to catch cold after the treatment. While this method is of undoubted value in the type of lesions mentioned, it is now practically obsolete, owing to the readiness with which these lesions respond to the intravenous injections of salvarsan and neosalvarsan, com- *. bined with mercury. It is described here, therefore, rather for its historic interest than as a practical method. Intramuscular injections: The treatment of syphilis by intramuscular injections of mercury is very efficient; but its general adoption as a routine method of constitutional treatment cannot be recommended, as the injections are followed by more or less pain, soreness, indurated nodules, and in some rare cases by abscess formation. The ])reparations of mercury used may be either soluble or insoluble. Of the former the best is the bichloride in sterile, watery solution, ten minims containing | grain. The dose used varies from T2^ to j or even ^ grain, every three to five days. Of the insoluble preparations the salicylate is the best. It is put up for use in the form of a 10 per cent, suspension in sterile albolene, so that 10 minims equal 1 grain. The dose is from f grain to 1 grain every five to eight days. The mixture must be thoroughly shaken just before use. The injections are given with an all-glass (Fig. 129) hypodermic syringe, and a platinum needle about an inch and a quarter long. ADMINISTh'ATlON OF MERCJJfiY V>2'.'> The site of the iiij(icti()ii is sterilized l>,y jjiiiiitiiig it v\itli tincture of iodiii iiiul washing with 95 per cent, alcohol. The syringe und ncedh; an; l)()il(!d and th(; surgeon's hdiid- scruhlx'd and cleansed as for any operation. The patient slionid he on his side or ahdonien, with nniseles rehixed. The needle is inserted at right angles and deeply into the muscle and the solution injected slowly; the needle is then carefully withdrawn, and the puncture wiped o\\ with alcohol. No dressing of any sort is required, hut the injection site should be massaged with sterile gauze for a few moments. FiG. 129. — All-glass syringe and needle for intramuscular injections. The best place for making the injection is into the upper and outer part of the buttock. Iodide of Potash. — While probably not possessed of any direct effect upon the Spirocheta pallida itself, the iodide of potassium is a very useful adjuvant to combine with mercury and salvarsan or neosalvarsan, as it hastens elimination and assists greatly in the breaking down of syphilitic deposits wherever they may occur. It finds its greatest field of use- fulness, therefore, in the treatment of late secondary or of tertiary lesions, and in most cases is best given in the later stages of the disease. o24 CONSTITUTIONAL TREATMENT OF SYPHILIS The dose (»f tlie iodide of potash in the beginning should ))e t'roiii about fi\e to fifteen grains, three times a day, an hour after meals. This may be increased gradually to one himdred or even more grains daily. It is best to begin with ver\' small doses, diluted in water, or mixed with essence of ])ei)siii, elixir of lactoix^ptine, or milk of magnesia. In some instances it causes coryza, pain in the frontal sinuses, edema of the conjunctiva, swelling of the lids, irritation of the fauces, gastro-intestinal derangements, or eruptions on the skin, most commonly papules, acne pustules, or furuncles, which, as a rule, are situated ui)on the face, the neck, and the back. In large and long-continued doses, iodide of potassium may sometimes give rise to a condition known as iodism, which consists of a feeling of oppression in the head, tinnitus aurium, neuralgia, spasmodic muscular action, im])airment of voluntary motion, and sluggish intellect. All the above complications rapidly subside on the temporary suspension of the drug. Mixed Treatment. — By the "mixed treatment" is meant the internal administration of potassium iodide and mercury in combination. The indications for the use of the ''mixed treatment" are the same as for the internal treatment by pills, already mentioned. In other words, this method of administration should never be resorted to except imder conditions which absolutely preclude the use of inunctions or intramuscular injections of mercury and the intravenous administration of the new arsenical preparations. The following prescription for the "mixed treatment" is a good working formula, but may have to be somewhat ADMINIS'rh'A'riON OF MKIirUKY 32.') modified iiccordiiif^ to the siiseeptiMlity of t lie pnt iciit ;iiid 1 1n- requirements of eueli individual ease. I^ — Hydrarg. biiiiodid., Ki"- j-ij iij iv PottiHs. iodid., 7)Vi-Z^^-?>i-?>^ Tinct. gent, co., ad Jiv — M. Sig. — 3j (,() 5ij in a wineglass of waier, one f,o t,wo liour.s after each meal, Zittman's Decoction. There is always a small percentage of patients who, after undergoing antisypliilitie treatment with mercury and iodides for a varying length of time, begin to show signs of anemia and defective elimination, or by whom the regidar antispecific remedies are no longer well borne. In tliese eases the use of the following modi- fication of Zittman's decoction is often followed by marked improvement, the cathartic and tonic action of the mixture making it possible for the patient to resume regular antiluetic treatment. I^ — Alum pulv., 3ss Fl. ext. sarsaparilL, 5ij Glycerini, 5J Syr. sennse, Siss Sp. anisi, 3J Fid. ext. glj^cyrrhiz., Sj Aq. fcBiiiculi, ad Sviij Sig. — §j in a glass of water after meals. -M. During the time that this treatment is being employed patients should drink freely of any bland water. Salivation. — During a course of mercurial treatment some subjects are liable to become salivated, especially those with bad teeth and spongy gums, which conditions should have been corrected in the primary stage of the disease. The first symptom of salivation is soreness of the gums just behind the superior incisors, and in the lower jaw back of the last molars; the other symptoms are a metallic taste in the mouth, fetid breath, increased flow of the saliva, 326 CONSTITUTIONAL TREATMENT OF SYPHILIS tenderness of the teeth when elosed n])on eaeh other, swelHng of the tongue, which is marked by tlie teeth on its sides, edema of the nnieous membrane of tlie cheeks, gums, and lips, with difficulty and pain in articukition and de- glutition. In some cases the neighboring lymphatic glands may become enlarged and tender. Sometimes there is fever and diarrhea, accompanied by general malaise. In some verj' rare, extreme and neglected cases there is ulceration of the soft parts, which may or may not be followed by necrosis of the maxillary bones. Treatment. — The mercurial treatment must be stoj^ped im- mediately, the bowels freely opened with saline cathartics, and the patient given a hot soap bath, especially if taking inunctions or fumigations. The diet must be liquid and nour- ishing. For a gargle and mouth-wash we can use solutions of chlorate of potash and alum, with tincture of myrrh, which must be employed frequently. The line of juncture of the teeth and gums may be painted with equal parts of tincture of iodin and tincture of myrrh. In those cases in which the teeth and gums have been neglected, and are therefore in a dirty and spongy condition, thorough cleansing, at frequent intervals, with absorbent cotton on an applicator or a soft brush, is very useful. These patients must be kept in the open air and sunshine as much as possible and given tonics as indicated, with plenty of easily digestible, nourishing food. ADMINISTRATION OF SALVARSAN AND NEOSALVARSAN. The successful administration of salvarsan and neosal- varsan requires a careful technic, but one which is neither complicated nor difficult to master. HALVAIiHAN AND N EOS A LV A US AN 327 We shall lirst dcscrilK! tlic udMiiiiistration of the newer preparation, iieosalvarsiiii, as the stei)s in tlic jjroeechire are siini)l(T tlian, iiion^li siniihir to, those used in injecting salvarsan, and wiU make it easier to in)(hTsf;ind the iirl- ministration of the latter. Neosalvarsan may be administered either intr;iiiiu^fiil;irl,\- or intravenously. The intramuscular method is far inferior to the intra- venous, and is never employed by the author. Witii it both the absorption and the elimination of the drug are slow and uncertain; the procedure is no safer, and the injections are always followed by more or less pain, b}' edema, and by the formation of large, tender nodules in the tissues. In many cases the pain and swelling are so severe as to confine the patient to bed. The method of intravenous administration employed by the author is as follows: The necessary apparatus consists of two graduated glass jars or burettes, having a capacity of 50 c.c, resting in a suitable holder and coupled together by glass and rubber tubing, and a three-way stopcock, as shown in Figs. 130 and 131. By means of the three-way cock, fluid may be drawn from either jar alternately, as desired. In place of the burettes some operators use Record syringes of about 20 c.c. capacity, but the writer prefers the jars, as the fluid then enters the circulation by force of gravity only, and the pressure can be much more easily regulated. The common outlet tube, leading away from the tln-ee- way cock, ends in a metal nozzle which fits accurately into the socket of the needle through which the injection is made. There are various models of needle on the market; the 328 CONSTJTUTIOXM. TRKATMEXT OF SYPIIJUS author's i)ret'(.Tciicr hv'iu^ for tlie Schreiber needle, shown in Fiti'. V-V2. Xccdlcs iiuist he sharp and free from rust, ..^^..^^•C*! Fig. 130. — Salvarsaii gravity apparatus. SA L VA nSA N AND N /'JOS A L VA L'SA N 320 both inside and out, to Jivoid tin; risk ol" l;i(,(Tiitioij of the vein and cloffjiiinfi; ol' \\\v. flow of tlic drn^. J^'or this reason they should in)t he used more lh;ui once or twice, as corrosion is very liable to occur in old needles. "^Fhe most useful calibers are 18 and 20; IS, the larger, for esfjeeially larg(; and prominent veins, and 20, the smaller, for the average Fig. 131. — Autlior's three-way stopcock. man and for women and children. New needles should be thoroughly washed out with alcohol, before sterilization, to remove all traces of the oil with which they are often filled. The burettes, tubing and needle must be sterilized by boiling and then allowed to cool down to room temperature Fig. 132. — Schreiber needle. before use. The two jars are then filled with sterile, freshly distilled water, at room temperature, enough of which is run out, by manipulation of the stopcock, to completely fill the tubing and insure the exclusion from it of all air bubbles. The water in one jar is then run out, down to the mark zero, while the other jar is refilled to its full 3.30 COXSTITUriONAL TREATMENT OF SYPHILIS capacity. I'Accpt for the addition of the solution of neosalvarsan the apparatus is now ready for use. Tlie preparation of the patient should begin the day before. He should undergo a careful physical examination, which should include a urinalysis, a Wassermann reaction, if he has not lately had any antisyphilitic treatment, and an examination of the eyes, ears, nervous system and heart and lungs. Alcohol should be avoided for at least twenty-four or forty-eight hours. Dinner, the night before, and breakfast, on the morning of administration, nmst be very light and easily digestible. The use of tobacco, for twelve hours before, is also to be forbidden. The bowels should be opened, preferably by com})ound cathartic pills, in the evening, and a saline, in the morning. The. ])atient should rest for at least a half-hour before receiving the injection, and should drink water very freely both before and after. The apparatus having been prepared, as described above, the patient now lies down on an operating table, with head and shoulders somewhat elevated, and allows both arms to hang down over the sides of the table, so as to dis- tend the veins with blood. That arm is selected for the injection in which the superficial veins are most prominent. The usual site is into the median basilic or median cephalic vein, but any vessel which is sufficiently large may be se- lected. The site having been decided on, an area of several- square inches about the point of puncture is sterilized, either by washing with soap and water, followed by bi- chloride solution, or by painting with tincture of iodin and washing with alcohol. The arm is then covered with a sterile towel and left, thus protected, in a dependent position until ready for injection. The ampoule containing the drug, sterilized by soaking > disease in the father that the child will escape, even during the first year. The father transmits his disease through his sperm cells, which come in direct contact with the ovule f)f the female at time of fecundation. The mother may also transmit syphilis to the fetus, but her disease must be constitutional, as at that time her ovule is syphilitic, and the fetus is thus infected at the time of fecundation. The disease of the mother may be so modi- fied by constitutional treatment that the child will escape infection. In those cases in which the father and fetus are both syphilitic and the mother apparently healthy, though re- fractory to syphilitic infection, it can now be shown by the complement-fixation test that the disease is really present in the mother also, but in a condition of latency. The syphilis of the mother, acquired during pregnancy, may be conveyed to the fetus through the uteroplacental circulation, and the mother may also be infected by a sj^philitic fetus through the uteroplacental circulation. The course of the disease is chronic and very irregular in character in those cases where treatment is inadequate. Cutaneous, mucous, and visceral lesions may be present at the same time. The duration of hereditary syphilis depends upon the intensity of the disease and the treatment employed. The lesions respond as readily to modern treatment as do those 22 338 HEREDITARY SYPHILIS of the acquired form of the disease, but it is i^articuhirly difficult, in hereditary syi)liiHs, to render tlie Wasserniann reaction negative and keep it so. The mortaUty of syphihtic cliildren, althoug;h quite liigh, is not as great as in former years, owing to tlie improved methods of treating the parents, as a result of which the fetus may even escape infection, or, if infected, the disease itself he rendered less severe. Abortion. — Syphilitic women are very liable to abort, and generally do so between the fifth and seventh months unless adequately treated. Abortion caused by the death of the fetus takes place at about the sixth month. The fetus is usually macerated, of a purple color, with various visceral lesions and bulla? upon the soles and palms. Syphilitic stillborn children, or those dying soon after birth, frequently have no cutaneous lesions, but have a peculiar senile appearance. The majority of syphilitic children born alive look per- fectly healthy^ but at about the end of the third week the disease manifests itself; some, however, exhibit cutaneous lesions at birth. Prognosis. — ^The prognosis of hereditary^ syphilis is usually unfavorable, but depends greatly upon the condition of the parent or parents at the time of conception, the inten- sity of the disease in the child, and whether the infant and the infected parent or parents have received proper anti- syphilitic treatment for a sufficient length of time. The prognosis should therefore always be made in a guarded manner, and after a careful weighing of the above stated considerations. It is, however, not now as unfavor- able as in former years, owing to our improved methods of treatment, not only of the parents, but also of the child itself. CHAPTER XXXVI. LESIONS OF IIEliEDlTAllY SYPHILIS. THE SYPHILIDES. The commonest eruptions of hereditary syphilis are the erythematous, the papular, the vesicular, the pustular, tlje bullous, and the tubercular syphilides. The erythematous syphilide, or roseola, is the first erup- tion, and appears about the third week of life; it may be preceded or accompanied by coryza. Beginning upon the lower portion of the abdomen as pmk spots, the eruption finally invades the trunk, the face, and the extremities; the spots gradually assume a dull red, coppery color, which does not disappear on pressure, owmg to the pigmentation of the skin. As a rule, there is no elevation or desquama- tion of the spots, except in severe cases, or when they are situated upon the palms, the soles, or the nates. In some instances the spots coalesce, forming fissures which may or may not be painful. The eruption may be so faint in some cases as to escape observation. The Papular Syphilide. — This syphilide is sometimes the first to appear, or may be intermingled with the erythema- tous eruption. The lesion consists of large and small, flat papules, scattered over the body. Grouping is infrequent except at a late period, and then occurs about the joints and on the extremities. The papules are coppery red in color, and may exfoliate, especially when situated upon the palms or soles, 340 LESIONS OF HEREDITARY SYPHILIS Condylomata lata are really iiothiiii;' more than modifiefl j^apuies, which, being situated hetween opposed surfaces of skin, at mucocutaneinis junctions, or where\er there is mois- ture, become hypcrtro})hic. They vary in size and shape, are of a grayish-pink or brown color; the surface is flat, sometimes fissured and ulcerated, with an offensive and highly infectious secretion; they appear early, run a chronic course, and are most frequently encountered about the anus. ^Yith ])r()])er treatment they (lisai)])ear, leaving copper-col- ored pigmentations, which finally fade. The Vesicular Syphilide. — This syphilide is rare and occurs as an early manifestation. It appears in groups, situated upon the chin, about the mouth, upon the forearms, the nates, the hypogastrium, and the thighs, and is usually associated with a bullous or pustular eruption. The ^'esicles may be large or small, are situated upon an infiltrated base of a brownish-red color, and contain serum or seropurulent fluid. The Pustular Syphilide. — This syphilide generally appears before the eighth week; it may involve the entire body, but is usually most marked upon the thighs, the buttocks, and the face. The pustules vary in size and are situated on a thickened, deep red base; they sometimes rupture, leaving an ulcerated surface, which may or may not become incrusted. Those about the mouth have a tendenc}'^ to coalesce. Groups of pustules are liable to form in the palms or soles, or develop around the nails, and finally destroy them. If the scalp is invaded there is usually some resulting alopecia. The Furuncular Syphilide. — Furuncles are liable to appear as early as the sixth month, or as late as the third year, and may occur either alone or associated with other lesions. THE MUCOUS M EM B HANKS 'AW 'J'lioy roriii slowly iiiid without jiny si^ns of iiifliuinii;i,f ion, tlui biisc being ol" a. (•oj)p('ry-r('(l color. Snpcrficial nlccratioii occurs on the a,i)cx, Icavimg a deej) nicer, with excrlcd mar- gins, Jind a scanty, oil'ensive secretion. The bullous syphilide, or ])ern])higus, always indicates a severe and often fatal form of hereditary syphilis; it may occur at birtli, or from a month to six weeks afterward. '^riie j)ahns and soles are most frequently invaded, alt hough any portion of the body may be attacked. The bullse are conical, rounded, or flattened, and ctjiitain seropurulent fluid, which soon becomes purulent; the sur- rounding skin is thickened and of a copper color. After rupturing, their course, when untreated, is chronic like that of the pustules. The Tubercular Syphilide. — This eruption may occur as early as the sixth month, or even several years after birth. It begins as deep-seated nodules or papules; these impli- cate the integument, forming sharply circumscribed tiunors, which either disappear or break down into ulcers. The sur- face of the tubercles may be scaly, looking somewhat like psoriasis. They are usually found where the connective tissue is loose and abundant. Gummata and Gummatous Ulcers. — These manifestations of the disease usually occur between the third and the twentieth years. Their course is similar to those in the acquired form. THE MUCOUS MEMBRANES. One of the first symptoms of hereditary syphilis is 'snuf- fing, accompanied by a profuse or scanty serous discharge 342 LESIONS OF HEREDITARY SYPHILIS from the nostrils, which is duo to u structural change in the nasal mucous membrane. The secretion becomes purulent, bloody, offensive, and highly infectious, causing edema and excoriation of the nose and the ui)1kt lip, upon which crusts may form. The lesion begins as a simple erythema of the nnicous membrane, ulceration ensues, and the disease may then extend to the bony and cartilaginous framework of the nose, causing its destruction, with more or less resulting deformity (saddle-nose) . Mucous Patches. — These lesions are at first whitish in color, elevated, and surrounded by an erythematous border; the epithelium is soon remo\'ed, leaving a slightly depressed, red, and ulcerated surface. Mucous patches are most commonly situated at the angle of the mouth, upon the mucous membrane of the cheeks, the fauces, the tonsils, the sides and dorsum of the tongue, and on the gums, near the teeth. The secretion from the patches is free, serous in character, and highly contagious, so that great care must be exercised to guard against the infection of others, especially healthy ' wet-nurses, who would naturally be infected on the nipple or breast by nursing such children. It has been observed that a child suffering from hereditary syphilis, whose mother is api)arently healthy, may nurse at the mother's breast without infecting her. (Colles's law.) This has been taken as proving that the mother has become immune to the disease, though never infected. Present- day experience with the Wassermann reaction, however, suggests more and more strongly that such mothers are, in reality, syphilitic, but that, in them, the disease is in a con- dition of latency. 77//'; UMSI'lllATORY OUdANH 313 Gummatous Infiltrations. 'V\\v, k^sioiis {fcncnilly ofciir Ix,- twccii the lliini ;ui(l \\w. twclltli ycurs. They consist of w. cclliihir iiifiltriif ion of the nnicoiis mciii- l)riui(>, wliiclv at first bccoincs reddened and elevated, and finally devel()])s into well-marked tumors, wliieh nsnaliy break down into undermined ulcers, with a };reeni>li, thick secretion. Their favorite sites are the hard palate and the y)osterior l)haryngeal wall. THE RESPIRATORY ORGANS. Durmg the early years of syphilis the larynx may l)e the seat of simple hyperemia, of mucous patches, or of ulcera- tion, which involves either the mucous membrane alone or the cartilage beneath it. Gummatous infiltrations of the larynx belong to the later stages of the disease. Upon the surface of the lung, and scattered through its substance on the smaller vessels and bronchi, numerous nodules, differing in size, and varymg in color from a grayish pink to a light yellow may occur; the pleura near these nodules becomes opaque and thickened. An entire lung, or only portions of a lobe, may be involved. The morbid process begins by congestion, followed by cell-proliferation around the bronchioles and in the walls of the capillaries, causing partial or complete occlusion of their lumen, and destruction of the function of the lung. The nodules consist of connective-tissue cells, of fibrinous and of gummatous tissue, and may undergo fatty or caseous degeneration. True gummatous nodules do some- times occur. 344 LESIONS OF HEREDirARY SYPHILIS These lesions are most frequently encountered within the first eighteen months of iifi-. THE ALIMENTARY CANAL. It is thought by some observers that the chronic diarrhea met with in syphilitic children is due to an erythema of the gastro-intestinal mucous membrane, similar to the erythema occurring in the mouth and pharynx. The liver may be the seat of a connective-tissue infiltra- tion, which renders it hard, lobular, and hypertrophied ; these changes are either circumscribed or general. This new indurated tissue causes the capillaries to become obliterated, and the caliber of the larger vessels to be diminished, and also compression of the cells of the acini, with cessation of the flow of bile. Gummatous hepatitis occurs either as numerous small tiunors, scattered through the substance of the liver, or as one or more isolated larger masses. During the early stages of the disease the spleen may become more or less hypertrophied, but this enlargement yields readily to constitutional treatment. The enlargement is very great, rapid in its course, and most marked in cachectic children, and those in whom the disease is of a severe type. The pancreas may become enlarged and firm in consistence. The interstitial connective tissue is increased, especially between the larger lobules, causing compression of them, with atrophy, and fatty degeneration of their epitheliinn. 77//'; NAILS 345 THE GENITO URINARY ORGANS. In the kidneys the lesion consists of a cliH'use or eireurn- scribed infiltration of small romul or fusiform-shaped cells into the connective-tissue framework, followed hy compres- sion or destruction oC the tuhnles ;ind colloid dc<^rciicratif)n of their ei)ithelium; the organs are at first enlarged, hut gradually become greatly reduced in size. The suprarenal capsules sometimes become enlarged, owing to the proliferation of young connective-tissue cells. When the testicles are afl'ected the disease consists of a chronic, painless enlargement of one or both organs, gener- ally accompanied by hydrocele and hyperemia of the scro- tum. The epididymis and cord are sometimes invoKed. The lesion consists of a connective-tissue proliferation, either interstitial or diffuse. If commenced at an early date, constitutional treatment causes speedy resolution; but if neglected, atrophy or degener- ation with abscess-formation, followed by fungous protrusion of the testicle, may occur. In all probability the ovaries are affected in a similar manner. THE NAILS. Affections of the nails are not so common in hereditary as in acquired syphilis. There are two forms of onychia: the ulcerative and the non-idcerative. Ulcerative onychia usually occurs during the first and second years of the disease, but may appear much later. It is the most common form, and begins at the side or base of the nail as a papule or pustide, which ulcerates and 346 LESIONS OF HEREDITARY SYPHILIS extends along the base or margins of thr nail, and finally involves the matrix, which results in the loss of the nail, thus leaving an imhealthydooking ulcer, with sanious dis- charge. The terminal phalanx becomes red, enlarged, and painful. The nails of the fingers are more liable to be attacked than those of the toes. Cicatrization of the ulcer, without the formation of a new- nail, sometimes follows, or a deformed and useless one may grow. Non-iilccraticc onychia is a later and more chronic mani- festation. It commences as a coppery-colored swelling at the margin or base of the nail, which soon becomes thickened, fissured, and brittle, dirty white in color, with hyperemia of the matrix and adjoining tissues. There is usually some de- formity of the phalanx, which may or may not be permanent. THE TEETH. The permanent teeth in hereditary syphilis may present certain peculiarities, especially the upper central incisors of the second set, which are known as Hutchinson's teeth. (Fig. 133). In describing these teeth Hutchinson says: "As diag- nostic of hereditary syphilis, various peculiarities are often presented by the other teeth, especially the canines, but the upper central incisors are the test teeth. When first cut these teeth are usually short, narrow from side to side at their edges, and very thin. After a while a crescentic por- tion from their edges breaks away, lea^'ing a broad, shallow, vertical notch, which is permanent for some years, but Tlll<: liONICH 'Ml between twenty Jind thirty usually becomes oMiteruted l>y the premature wenring down of the tooth. The two t(;eth often coiiverg(^ and sometimes they stiind \\id(l.\ ;\\r,\r\. In certahi instiinccs in wliicl) tlie noteiiing is either wholl\' absent or but slightly marked, there is still a peculiar color and a narrow squareness of form, which are easily recognized by the practised eye." The first or temporary set of teeth do not show this mal- formation, and many children sufi'ering from hereditary syphilis have perfectly normal permanent teeth. Fig. 133. — Hutchinson's teeth. THE HAIR. Affections of the hair in hereditary syphilis are very like those in the acquired form. They occur with lesions of the scalp, especially the pustular syphilide. THE BONES. Osteochondritis. — This affection occurs either in the first months of the disease or as late as the twelfth year, and is a very constant manifestation of untreated hereditary syphilis. 348 LESIONS OF HEREDITARY SYPHILIS It most coniinouly attacks the bones of the forearm, the leg, the arm. and tlie thigh, but the clavicle, the sternum, the ril)s, the metacarpal and the metatarsal bones may also be involved. The lesion is situated at the diaphyso-epiphyseal jniiction, and consists of a ring-shaped swelling around the end of the bone. In some cases the entire epiphysis may be enlargetl, with or without the ring-formation at its junction with the shaft. If two bones are att'ected, as those of the forearm or the leg, they appear to be fused together by this j^rocess. The distal ends of the bones are more frequently attacked than the proximal. The lesion develops slowly in some cases, and rapidly in others; causes but little pain, interferes only slightly with motion, and disappears under proper treatment. The in- tegument is not involved unless the mass be very large, when it is rendered tense and painful. The joints may be secondarily invaded, especially the elbow- and knee-joint. In some cases the lesions degenerate and break down, causing ulcerations of the integument; the epiphysis may be separated from the shaft and destroyed, likewise the cartilage. In other cases resolution of the swellings occurs, and the bone returns to its normal condition; but if the intermediate layer of cartilage be destroyed, the bone is usually shortened. Periostitis is a later affection, and usually appears between tiie fourth and nineteenth years. Any of the long bones may be affected, and in some cases those of the skull also. The bone becomes tender, enlarged, and curved anteriorly; the process may invohe the entire length of the shaft, or be localized and i)roduce nodes. One or both limbs can be thus afi'ected. 77//'; i']Yi<:>H :i19 Dactylitis. 'V\\v lesions consist of swcllinji; ol' (he |)li;il;iiif^('s, iind of (he metacarpal or metatarsal bones in lliee;irl.\- niontlis ol" the (lisetise, or even n,s late as the tvv<;ntieth ye;ir. The proximal i)lialanges are more often attacked than tli(' distal ones. The course of this affection is chronic, unless treated. THE SHEATHS OF THE TENDONS. The sheaths of the tendons may become swollen and iilled with fluid, the overlying skin being distended and reddened. This affection comes on rapidly, is not readily influenced by antisyphilitic treatment, and runs a chronic course. THE JOINTS. In some cases of osteochondritis there is a serous effusion into the neighboring joint, which becomes slightly painful on account of the tension ; resorption and complete recovery usually ensue. The elbow, the wrist, the shoulder, the knee, and the ankle are most frequently involved, although almost any articulation is liable to invasion. In the latter years of syphilis the larger joints may be affected either primarily or secondarily to lesions of the bones. The process is slow, the joint being greatly distended and slightly painful; the surrounding skin remains normal. With the proper treatmen.t resolution generally takes place, leaving a good articulation. THE EYES. In hereditary syphilis the eyelids and the eye itself are liable to all of the lesions which occur in the acquired form, 350 LESIOXS OF HEREDrTARY SYPHILIS andAvhich have already been described iiikUt that heading. These affections may a])iH'ar at a very early date. THE EARS. The occurrence of suddiii deafness in children who have hereditary syphilis is (juite common. It is apparently due to disease of the nerves, or of their distributions in the laby- rmth. The changes in the external parts, or the membrana tympani, are not sufficient to account for the deafness; the Eustachian tubes also remain normal. Deafness, when it occurs, is usually observed from about the tenth to the twentieth year. The prognosis is, as a rule, unfavorable. THE NERVOUS SYSTEM. In hereditary syphilis inflammation of the meninges and endarteritis have been observed; also gummata upon the membranes. Chorea sometimes occurs, and is either mild or severe in character; it may be accompanied by hemiplegia or epilepsy. In these cases it is thought that hemiplegia is caused by obstruction of the middle cerebral artery; that chorea is due to occlusion of its small distal branches, and that epilepsy is occasioned by thickening of the meninges or by gummata in or near the corpus striatum. Epilepsy may occur alone, and has been observed as late as the fifteenth year. There is sometimes paralysis of the cranial nerves. TREATMENT OF II ICIilChlTA llY SY I'll I LIS '.\.)\ HEMORRHAGIC SYPHILIS IN NEWBORN CHILDREN. Tliis coiidilioii exists at l)irtli, or not later than the first iiiontii of life, and is frwiiiently tlu^ only rnanifestution of the disease, l)ut it may he accompanied hy otlier lesions. In some cases there is a sniajl, subcutaneous iicinorrhage in parts exposed to friction or pressure, while in other cases it occurs in or upon mucous membranes and viscera, or from the umbilical vein, and may be profuse or even fatal. TREATMENT OF HEREDITARY SYPHILIS. If a pregnant woman is syphilitic, she should immediately be given the constitutional treatment outhned in the chapters on Acquired Syphilis, and this should be continued in a care- ful and methodical manner during her pregnancy, and there- after until she is pronounced free from the disease. The mother's genitals must be kept in a healthy, clean condition, and, if lesions exist upon or around them, should receive active and appropriate local treatment, by means of hot bichloride douches, calomel dusting powders, and, in some cases, applications of mercurial ointment, if indicated. When these measures are taken early enough in the preg- nane}^, infection of the fetus may usually be avoided. After the fifth or sixth month, however, the child is very liable to contract the disease, and even if apparently perfectly healthy at birth, should be considered as possibly syphilitic and kept under careful observation, with repeated blood examinations, and a vigilant watch for the development of lesions. If the father was syphilitic at the time of impregnation or showed any manifestation of syphilis before it, then the 352 LESIONS OF HEREDITARY SYPHILIS mother must litive antisyphilitic treatment in the maimer above described for its beneficial etl'cct both on the fetus and herself. In treating syphilitic infants great care must be used, as the use of inunctions is sometimes difficult on accoimt of the delicacy and irritability of tlie skin, and the development of gastro-intestinal irritation. Treatment of the child by means of the milk of the mother or nurse is known as indirect treatment. Although some of the drug may be eliminated through the milk of the nursing woman, it is at best an uncertain and inaccurate method of treatment^ and one not to be relied upon. It must not be forgotten that a healthy wet-nurse is very liable to infection on the breast or nipple by nursing such children. The direct treatment of the child should be intermittent and not continuous in character; during the intervals of treatment it is well to admhiister tonics, and to do all in our power to build up the general condition. As in the case of adults the treatment should include the compoimd use of salvarsan or neosalvarsan, mercury and iodide of potash. The dosage of salvarsan in the case of an infant should run from 0.01 to 0.02 gm.; that of neosalvar- san may be slightly higher, and these should be cautiously re])eated at intervals according to the condition and suscep- tibility of the child. For inunctions we employ 50 per cent, mercurial oint- ment, using from 10 to 20 grains every day, or every other daj', according to the age and condition of the child. The administration of mercury by intramuscular injection is too painful a method tb be employed for children. Potassium iodide is best administered in the chikl's bottle of milk. The dosage for an infant is from 0.5 to 1 gr., or TUEATMI<:NT of ll/'Jh'/'JD/'I'Ah'V SY I'll I LIS '.\')'.\ even more, lliree limes ii diiy. In hnjisl-lcd inl'iinls it ni;i\' 1)0 given dissolved in water, with a little sngar oi' milk. The internal adnn'nistnition of merenry m;iy oeeasionally have to be resorted to, hnt, iis in iidnlls, this method is neither satisfactory nor a(l\'is;d)lc, iind slionid only he nsed when no other is possible. If the syphilides are very persistent, jnucii benefit is always derived from their local treatment by fumigations, ointments, lotions, or baths containing mercury; at the same time keep- ing the lesions scrupulously clean. Constitutional treatment should always be employed for at least two years, and continued for several months after all manifestations of the disease have disappeared; the Wassermann reaction being taken at intervals for several years thereafter. 23 INDEX. Abscess, cuiiiplicating stricture of urethra, 131 periurethral, 56 of prostate, 64 rupture of, 64 situation, 64 symptoms of, 64 treatment of, 67, 68 Adenitis complicating urethritis, 61 Albargin, 45 Alimentary canal, syphilis of, 344 Allis's clamp, 172 Alopecia, 263 prognosis of, 263 symptoms of, 263 varieties of, 263 Anus, syphilitic lesions of, 274 Argyrol, 45 Arnott's grooved director, 167 Arthralgia, 304 Arthritis, gonorrheal, 107. See Gonorrheal arthritis. Aspiration of bladder, 180 B Balanitis, 51 diagnosed from acute gonorrhea, 30 treatment of, 51 Balanoposthitis, 51 diagnosed from acute gonorrhea, 30 infected, 231 Bladder, aspiration of, 180 diverticula of, complicatingstrict- ure of urethra, 131 Jiloodvessels, sy])hilis of, 283 Bones, syphilis of, 301, 347 Bougies, 140, 144, 153 h boule, 141 method of passing, 144, 149 care of, 189, 190 filiform, 141, 152, 153, 165 care of, 190 method of passing, 149 olivary, 140, 152, 153 Bronchi, syphilis of, 280 Catheter carriers, 193 fever, 185. See Urinary fever. Catheterization, retrograde, 174 Catheters, 182 bicoude, 181, 182 blunt, 178 bulbous, 46 care of, 191 coude, 181, 182 instillation, 96 olivary. 178, 182 sUver, 183, 191 with prostatic curve, 183 soft-rubber, 46, 87, 191, 192 tunnelled, 180, 191 ureteral, 194 woven, 191 Chancre, 228. See Syphilis, initial lesion. diagnosed from chancroid, 235 differential diagnosis of, 235 extragenital, 229 genital, 229 hard, 228 Hunterian, 228 356 INDEX Chaftoro of meatus or urethra, iliagnoscd from acute gonor- rhea, 30 soft, 208. See Chancroid, synonyms of, 228 Chancroid, 208 characteristics of, 209 compUcations of, 211 adenitis, 212 lymphangitis, 211 lUlTerential iliagnosis of, 212, 235 abrasions, 213 chafes, 213 exulccrated bahmitis, 212 fissures, 213 gonorrhea, 31 hard chancre, 212, 235 herpetic vesicles, 212 duration of, 210 etiology of, 208 bacillus of Ducrey, 209 infection of, 208 direct, 208 mediate, 208 prognosis of, 213 scat of, 210 treatment of, 213 of adenitis, 217 first method, 217 second method, 218 general, 213 of the sore, 214 beneath prepuce, 215 of urethra, 214 varieties of, 210 echthymatous, 211 follicular or acneforni, 210 phagedenic, 211 Chordee, 26 to relieve, 43 Circulatory organs, syphilis of, 282 Circumcision, 205 Clamp, Hayden's, 206 Colles's law, 342 Condylomata, 240, 268, 340 Congenital syphilis, 336. See Hereditary syphilis. Cowperitis, 59 suppurative, 60 treatment of, 60 Crede's method of treating gonor- rheal ophthalmia, 105 Cystitis, 80 gonorrheal, SO symptoms of, 81 acute, 81 chronic, 81 subacute, 81 urine, 81 treatment of, SI acute stage, 81 chronic stage, 82 irrigations, 82 Dactylitis, 298, 349 varieties of, 298 Digestive organs, syphilis of, 2()9 Dilatation of ureters complicating stricture of urethra, 132 of urethra, 152-156 continuous, 154 gradual, 153 complications of, 154 instruments, 153 medication, 154 rapid, 154 Diverticula of bladder complicat- ing stricture of urethra, 131 Divulsion, 156 Dressings in acute gonorrhea, 37, 39, 40, 41, 42 E Kars, syphilis of, 314, 349 Electrolysis, 156 Endoscope, 97-101 care of, 189 Endoscopy, 97 indications for, 97 method of, 101 Epididymitis, 71, 284 lesions of, 284 symptoms of, 72 treatment of, 73 Epididymo-orchitis, 71 dressing for, 74 symptoms of, 72 treatment of, 73 Episcleritis, 309 INDEX '.\r{i IOr'(u'.M()iis, piiiiil'iil, 'J(') l(} r(!li(!vo, 4.'i l<:rytlierna, 'i.'iS, 2(57, 2(i!), 27:i, 27S Esophagus, sy[)liilit.ic lesions of, 274 ■ Extravasation ol' urine, 182 (lauses of, 132 regions of, 132 symptoms of, 133 constitutional, 133 local, 133 treatment of, 136 Eye, syphilis of, 306, 349 Fever, catheter, 185. *See Urinary fever. syphilitic, 236 urethral, 185. S&e, Urinary fever. urinary, 185. See Urinary fever. Filiforms, care of, 190 to pass, 149 to tie in, 179 Fistula}, complicating stricture of urethra, 131 Folliculitis, 57 paraurethral, 58 penile, 57 preputial, 57, 58 treatment, 58, 59 Fluhrer's urethrotome, 159, 160 G Genito-urinary organs, syphilis of, 284, 345 Glaus penis, affections of, 198 Gleet, 84. ^ee Gonorrhea, chronic. Glycerin as a lubricant, 195 Gonococcus, 19, 20 progress of, 22 staining of, 20, 21 Gonorrhea, 17 acute, 24 anterior, 24 complications of, 51-62 stages of, 25 acute, 25 declining, 26 Gonorrhea, acute, .uiUirior, Hta^faj of, pro(lrotii;il, 25 symptoms of, 25 incubation, 24 opacity of urine, I'O two-glass test, 28 tr(!atm(!n(, of, 32, 37 abortive!, 32 of declining stage, 43 dressings, 37, 39, 40, 41, 42 hand-injections, 43 internal medication, 43 irrigations, 43 Janet's method, 35 anteroposterior, 24 diagnosis of, 30 posterior, 27 complications of, 63-83 prognosis of, 31 treatment of, 48 two-glass test, 28 retention of urine during, 177 chronic, 84 anterior, 84, 86 symptoms of, 86 treatment of, 90 irrigations, 90 sounds, 92 anteroposterior, 84 causes, 84 lesions, 84 posterior, 87 symptoms of, 88 treatment of, 92 instillations, 95 irrigations, 93 amount of fluid, 94 solutions, 94 treatment of, 89 varieties of, according to loca- tion, 84 anterior, 84 anteroposterior, 84 posterior, 84 urethrocystitis, 84 complications of, 25 com-se of, 24 definition of, 17 diagnosis of, 30 differential, 30 balanitis, 30 358 INDEX il)taiiiiiifi, Cion6rrlu>:i, diagnosis of, diiTeriMi- cntial rhaiK'ie, 30 cIiaiKToid, ;U etiology of, 19 diploc'occ'us, 21 goiioc'occus, 19, 20. Sec Cioiio- C'OCCUS. otlior microorganisms, HI localities, 17 Dcriirrcncc, 17 jjathology, 22 ))rogiiosis, ol smear, metlitxl of 20 of staining, 21 when cured, 101 Gonorrheal arthritis, 107 bacteriology of, 107 cause of, 107 diagnosis of, 111 frequency of, 108 joint lesions of, 109 muscles, 111 liathology of, 108 symptoms of, 109 treatment of, 112 vaccines in, 113 flakes or shreds, 86 anterior urethra, 87 ])<)sterior urethra, 87 ophthalmia, 104 cause of, 104 prognosis of, 105 symptoms of, 104 treatment of, 105 rheumatism, 107. See Clonor- rlical arthritis. Ciouley's bistoury, 159 tunnelled catheter and guide, 180 sound and filiform, 155 Cunnnata, 255. 257, 341. See Syi)hilide, gummatous, of soft palate, 273 of tongue, 271 Gummatous ulcers, 258, 341 Hairs, syphilis affecting, 263, 347 Hand-injections, 43 Hanover urethral syringe, 44 Ilayden's l)ladder sj'ringc and coupler, 33 briilge for inflameil testicle, 73 circumcision clam]), 206 doulile-currciit irrigation tubes, 65 for cpididyino-orcliitis instillatidii syringe, 34 sovmd, 139 statT and liliform, 165 three-way stopcock, 329 trocar and caimula, 181 urethral forceps, 193 uretinoscope, 99 Hemorrhagic syphilis in newboiii children, 351 Hereditary syi)hilis, 223, 336 abortion, 338 appearance of symptoms, 336 Colles's law in, 342 course of, 337 definition of, 336 derivation of, 336 duration of, 337 hemorrhagic, in newborn clul- dren, 351 lesions of, 339 alimentary canal, 344 bones, 347 condylomata, 340 dactylitis, 349 ears, 350 eyes, 349 genito-urinary organs, 345 gummata, 341 gummatous infiltrations, 343 ulcers, 341 hairs, 347 joints, 349 kidneys, 345 larvnx, 343 liv('"r, 344 I lungs, 343 mucous membranes, 341 ! nasal, 341 jxitches, 342 nails, 345 nervous system, 350 chorea, 350 epilejjs}', 350 INDEX '.'y')\) llcrcililMU-y H.ypliilis, lesions of, ner- vous syst,!!tn, hciiiipli'- inciiiiigos, .'350 ptinilysis ol' cniniiil nerves, 'Mi{) osteochondritis, 'Ml, ^W.) piincreas, 'MA periostitis, ;M8 respiratory organs, 'M'i spleen, :i44 syi)liili.les, 339-341 bullous, 341 erythematous, 339 furuncular, 340 papular, 339 pustular, 340 tubercular, 341 vesicular, 340 teeth, 346 tendon sheaths, 349 testicles, 345 mortality, 338 prognosis of, 338 snuffling, 341 transmission of, 337 treatment of, 351 direct, 352 fumigations, 353 intramuscular injections, 352 mixed treatment, 352 neosalvarsan, 352 salvarsan, 352 duration, 353 father syphilitic, 351 indirect, 352 pregnant woman, 351 Herpes progenitalis, 198 cause of, 198 diagnosis of, 199 lesion of, 198 prognosis of, 199 symptoms of, 199 treatment of, 200 Hutchinson's teeth, 346, 347 Instillation catheter, 96 Instillations, 95 Instrumentation, 195 Instrutnetits, ISS. Sec I'retlirai instrunierils. Intestines, sypliilitic lesifjiis fif, 271 Iritis, :',();» acute, :',)() chronic, 31 I parenchymatous or suf)f)urative, 310 serous, 310 simple or plastic, ^jIO Irrigation, 33, 43, 46, 82, 90, 93 solutions, 91 Jankt's method of treating acute gonorrhea, 35 Joints, syphilis affecting, 301, 304, 349 Kollman's dilators, 155 Keratitis, 308 diffuse, 308 punctate, 309 Kidneys, syphilis affecting, 345 Larynx, syphilis affecting, 278, 343 Litholapaxy tubes, care of, 191 Lithotrites, care of, 190 Liver, syphilis affecting, 275, 344 Lubricants, 194 glycerin, 195 lubrichondrin, 195 olive oil, 195 white vaseline, 195 Lubrichondrin as a lubricant, 195 Lungs, sj'philis affecting, 280, 343 Luy's urethroscope, 98 Lymphangitis complicating ureth- ritis, 61 M Macular syphilide. 238 Maisonneuve's urethrotome, 158, 159 360 IXDEX Meatotoiny, lo7 Meatus souiul, 157 Mixed sore, '2Vi Moutli, syphilis of, 2l)9 Mucous papules, '2(37. See Mucous patches, pat dies, 2t)7. 342 complications of, 268 of larynx. 279 lesions of, 2l)S of toiiffue, 2l)9 \vithii\ the month, 2{i8 Myositis, 291) N Nails, .syphilitic lesions of, 263i 34o Neosalvarsan, 320, 352 Nervous system, syphilis affecting, 288, 350 Nose, syphilis affecting, 278 Olive oil Us a lubricant, 195 Onychia, 264, 345 non-ulcerative, 346 separation of the nail, 264 sicca, 264 ulcerative, 345 Opacity of urine, 30 Ophthalmia, gonorrheal, 104. See (loiiorrheal o))hthalmia. neonatorum, 104. Sec Gonor- rheal ophthalmia. Orchitis, 284 circumscribed, 285 course of, 285 differential diagnosis of, 286 diffuse of, 285 site of, 284 symptoms of, 285 Osteochondritis, 347, 349 Otis's perineal drainage tube, 169 urethrometer, 141 urethrotome, 160 P.\L.\TK, guinmata of, 273 Pancreas, syphilis affecting, 277, 344 Paraphimosis, 53 treatment of, 54, 55 Paraurethral folliculitis, 58 Perineal .section, 173 Perionj'chia, 265 non-ulcerative, 265 ulcerative, 265. Periostitis, 348 Periurethral abscess, 56 treatment of, 57 Pharynx, syphilitic lesions of, 273 Phimosis, 52 accjuired, 52 congenital, 52, 205 sci-ssors, 215 Prepuce, affections of, 198 Preputial folliculitis, 58 Pro.state, abscess of, 64 treatment of, 67, 68 congestion, 63, 68 inflammation, 63, 68. See Pros- tatitis. Prostatitis, acute, 63 sj^mptoms of, 63 treatment of, 64 chronic, 68 diagnosis of, 69 symptoms of, 69 treatment of, 70 Protargol, 45 Pus in urine, 29 Pyelitis, 83 Pyelonephritis, 83 Pyuria, 29 R Radlsh finger. 111 Rectal electrode, 71 Respiratory organs, syphilis affect- ing, 278, 343 Retention of urine, 176 causation, 176 effects on mucous nieml)rane, 177 treatment of, 177 INDf'JX 301 liclciil-ioii of iiriiii', I rc'i.tincnr oC, ;is|)ir;i.t,ii)ii, ISO (lui'injj; ;i,(;ul.c H()]\()iy\]ci\., 177 wIk'm <;;iiis(mI by si rid mc, 17S vvlien due, l.o prosl.alic hy- ]K:rl.n)|)liy, \Ki Rctrogrado ciiUu'tcri/i.'il.ion, 171 Rheuiiiahisin, }i;()iK)iTh(!al, 107. Sac Gonorrheal arthi-itis. Rupia, 252 cicatrices, 25;:5 lesion, 252 varieties, 252 Salivation, 325 synii)toms of, 325 treatment of, 32() Salvarsan, administration of, 326, 352 gravity apparatus, 328 Scale plate, 138 Schreiber's needle, 329 Seminal vesiculitis, 76 acute, 76 chronic, 77 Serum in treatment of gonorrheal arthritis, 114 Silk bulbous instillation catheter, 96 Smear, to take, 20 Smoker's patches or plaques, 269 Snuffling, 341 Soft palate, gummata of, 273 Sounds, 92, 140, 189 care of, 189 meatus, 157 method of passing, 144 Spermatocystitis, 76. See Seminal vesiculitis. Spirocheta pallida, 221, 222 refringens, 222 Spleen, syphilis affecting, 276, 344 Stricture of the urethra, 115 complications of, 130, 154 abscesses, 131 diverticula of bladder, 131 extravasation of urine, 132. See Extravasation of urine. Slnt-liirc III IIk; iir'cl lir;i, (;oiriplif;i- tioD.M of, listiila;, K'jI uret(!r.s, dilatation of, K>2 diiignosis of, l.'iX idHtnuMcntH, \'.W incthod of passing a sound, 144 preliminary examination, 142 urethral exploration, \'V.', etiology f)f, 118 forms of, 125 ainiular, 125 congenital, 118, 119 irregular, 125 linear, 125 semifibrous, 121 soft, 121 spasmodic, 126 tortuous, 125 traumatic, 118 gonorrheal, 118, 120 number, 120 pathology of, 121 seat of, 119 region, 119 symptoms of, 127 time of occurrence of, 121 treatment of, 151 bevond penoscrotal junction, 152 congenital, 151 dilatation, 152, 153 continuous, 154 gradual, 153 rapid, 154 divulsion, 156 electrotysis, 156 meatotomy, 157 near the meatus, 152 penile urethra, 152 perineal section, 173 retrograde catheterization, 174 traumatic, 151 urethrectomj", 157 urethrotomy, 158, 163. See I'rethrotomj-. Suspensory bandages, 8 Svnovitis, 305 Svphilides, 237, 339 bullous, 253, 341 course, 238 362 IXDEX Sypluliilos, orytheinatous, 2:^8, 339. Sec Erythema. lesion, 23'J site, 239 synonyms, 23S f!;innmat<)us, 255 precocious, 255 varieties of, 255 tertiary. 255 Miacular, 23S niaculopapular, 213 nuiliiiiiant ])ref'ocious, 2l)l ileliaition of, 2(jl occurrence of, 261 symptoms of, 261 varieties of, 261 I)apular, 241, 339 conical or miliary, 241 lenticular or flat, 242 lesion, 241 scaling of palms and soles, 245 course, 245 varieties, 241 l)ip;mentary, 260 forms of, 260 IHistuhir, 248, 340 acncform, 248 ectliymaform, 251 imj^etigoform, 249 variolaform, 250 rupia, 252. See Rupia. serpiginous, 250, 259 deep, 260 superficial, 259 tubercular, 253, 341 forms, 253 Syphilis, 221 acquired, 223 adenitis, 234. See Syphilitic adenitis, arthralgia, .304 of bloodvessels, 283 of bones, cartilages, and joints, 301 of bronchi, 280 of circulatory organs, 282 congenital, 336. See Hereditary syphilis, constitutional treatment of, 316- 335 baths, 317 diet and daily habits, 316 Syphilis, constitutional, treatmiMit of, duration, 334 iodide of potash, 323 iodism, 324 merciuT, 318 com] )licat ions of, 318 fumigation, 321 iTitraiiiuscular injections, 322 inunction, 319 regions, 320 by mouth, 318 mixed treatment, 324 neosalvarsan, 318, 326, 352 intramuscularly, 327 intravenously, 327 primary stage, 317 anemia, 317 salivation, 325. See Saliva- tion, salvarsan, 318, 326, 332, 352 Wassermann reaction, 335 Zittmann's decoction, 325 contagion, 224 cutaneous manifestations, 237. See Syphilides. of digestive organs, 269 of ear, 314 external auditory canal, 314 internal car, 315 middle ear, 314 of esophagus, 274 etiology of, 221 Spirocheta pallida, 221 of eye, 306 choroid, 312 ciliary body, 311 conjunctiva, 307, 308 cornea, 308. See Keratitis, eyelids, 307 iris, 309. See Iritis, lacrimal glands, 307 passages, 306 muscles, 308 nerves, 313 optic nerve, 313 orbit, 306 retina, 312 sclerotic coat, 309 of fingers and toes, 298. See Dactylitis, of geni to-urinary organs, 284 INDEX Syphilis of t^cnilo-uiiiuiry orf^ans, epididymis, 'JSl. Sec I'lpi- (lidyrnilis. kidiK^ys, 12.S7 |)(!nis, '2S(') testicles, 2S1. Hcc Orcliitis. uterus iuid adiiexa, 2(S() of hair, 20;-5. Sec, Alopecia, of heart, 2S2 lieinorrhaffic, in ncwhoru ciiil- dren, 351 hereditary, 223, ;i3(). .S'ec Hered- itary syphilis, incubation period, 223 infantile, 33(5. See Hereditary syphilis, infection, 225 direct, 225 mediate, 225 initial lesion, 228 duration of, 232 induration of, 231 parchment, 232 relapsing, 232 origin of, 228 seat of, 229 secretion of, 232 termination of, 231 treatment of, 233 local, 233 varieties of, 231 insontium, 225 of joints, 304 arthralgia, 304 synovitis, 305 of larjaix, 278 chronic inflammations, 279 deep ulcerations, 279 erythema, 278 ■ mucous patches, 279 superficial ulcerations, 279 tertiary lesions, 279 vegetations, 279 late osseous lesions, 302 osteomyelitis, 304 osteoperiostitis, 302 of liver, 275 of lungs, 280 lymphangitis, 235. See Syphil- itic lymphangitis, of maxillary bones, 304 of mouth, 269 Sy[jliilis ol' iiioiilli, cryl liciiia, 2(19 mucous pat(;li, 2i>7 of toiifiue, 2tJll (hiTcMviitial diagnosis of, 271 carciuonia, 272 guinmata, 271 initial lesion, 271 tubercular ulcers, 272 erythema, 2ti9 fissures, 270 gunnnata, 271 mucous patches, 269 sclerosis, 270 deep, 270 . superficial, 270 of trachea, 280 Syphilitic adenitis, 234 situation in relation to chancre 235 symptoms, 234 erythema, 238 fever, 23(3 lympliangitis, 235 symptoms of, 235 roseola, 238 Syringe for bladder, 33 instillation, 34 urethral, 44 Taylor's phimosis scissors, 215 Teale's gorget, 167 Teeth, Hutchinson's, 346 syphilitic lesions of, 346 Thompson's two-glass test, 28 Tongue, syphilis of, 269, 271 U Ulcers, gummatous, 258 Ureteral catheters, care of, 194 Ureteritis, 83 Ureters, dilatation of complicating stricture of urethra, 132 Urethra, anatomy, 115 Urethra, caliber. 118 divisions, 119 length, 117 portions, 116 bulbous, 116 fixed, IK) memliranous, 1 Ki narrow, 1 17 l)enile or i)enduious, 116 prostatic, 116 shape, 118 stricture of, 115. See Stricture of the urethra, structure of, 115 Uretliral and bladder irrigation, 47 fever, 185. See Urinary fever, forceps, Ilayden's, 193 instillation, 95 instruments, 188 care and use, 188 sterilization, 188 bougies i\ boule, 189 catheters, 191 silver, 191 soft-rubber, 191 tunnelled, 191 ureteral, 194 woven, 191 cystoscopes, 193 endoscopic tubes, 189 filiforms, 190 lithotrites, 190 olivary bougies, 189 sounds, 189 tunnelled, 189 syringes, 193 urethrotomes, 190 .sj'ringes, 44, 193 Urethrectomy, 157 Urethritis, catarrhal, 19 n()ii-si)ecific, 19 specific, 17. See Gonorrhea. Urethrocystitis, 78 acute, 79 chronic, 79, 84 symptoms of, 79 treatment of, 80 Urethrometer, 141 method of u.se, 150 Urethroscope, 97 Hayden's, 99 Luy's, 98 INDEX 'M\ri Urethrotoiiio, fiun; of, I 'JO Fluhrcr's, 150, HiO Maisoiiiiciivci's, I^S, If)'.) Otis'H, IGO Urethrotomy, 158-175 external, 163 bladder drainage, 1(>J indications, 1(J3 method, Ki^J indications, 103 perineal section, 173 indications, 173 preparation of patient, 163 retrograde catheterization, 174 with a guide, 165 without a guide, 171 internal, 158 indications, 158 instruments, 158 urethrotomes, 158 Fluhrer's, 159 Maisomieuve's, 158 Otis's, 160 operation, 162 preparation of patient, 161 ITrinary fever, 185 etiology of, 186 prophylaxis in, 186 treatment of, 186 varieties of, 185 Urine, extravasation of, 132. See Extravasation of urine, retention of, 176. See Retention of urine. Vaccines, in treatment of gonor- rheal arthriti.s, 113 Vaseline as a lubricant, lO.j Vegetations, 200 diagnosis of, 203 lesion, 201 treatment of, 204 Venereal wart.s, 201. Sm Vegeta- tions. Vesical tenesmus, 28 Vesiculitis, 76 abscess formation, 77 chronic, 77 diagnosis of, 78 symptoms of, 77 treatment of, 78 diagnosis of, 76 , symptoms of, 76 treatment of, 77 W Warts, 200. See Vegetations. hard, 202 soft, 201 Wassermann's reaction, 233, 271, 276, 286, 295, 330, 335, 342, 353 Zittmann's decoction, 325 •. -iajj?* jzaic ' CZOf H^ \^\Q) H3 ^ Coo. ^le.i/1 "Rcio^ \^\b H ^2 copA r